Trust Headquarters

One inspector and one pharmacist inspector visited the CRHT teams in Barnet, Enfield and Haringey over two days. We spoke with staff in all of the teams, including unqualified nursing staff, medical staff, pharmacists, nurses, deputy team managers, team managers, service managers, the assistant director for the service and the Executive Director of Nursing, Quality and Governance. We looked at documentation on site and asked the trust to provide us with information following the inspection which we examined.

We checked the management of medicines in the Barnet, Enfield and Haringey CRHT teams. We found that all of the areas of non-compliance with Regulation 13 of the Health and Social Care 2008 (Regulated Activities) Regulations 2010 had been addressed, such as recording when staff supervised medicines in the community, training for non-nursing staff who supervised medicines, safe storage and transportation of medicines, and auditing of medicines management. We found that medicines were now stored and transported securely, and there was regular temperature monitoring of medicines storage areas in all three CRHT teams, which showed that medicines were being stored at the correct temperatures to remain fit for use.

We found that prescription charts were now completed fully and clearly, which meant that there was evidence that people were receiving their essential prescribed medicines. We found that staff who transported, supervised and prompted people to take medicines had received appropriate training to do so. We found that the CRHT teams were now following trust policies regarding management of medicines. Therefore the CRHT teams were now compliant with Regulation 13 of the Health and Social Care 2008 (Regulated Activities) Regulations 2010.

Staff told us that they felt supported. Additional staff had been recruited into post since our previous inspection. All staff had received supervision. There were regular team meetings and additional local and service-wide clinical governance meetings where issues including complaints, concerns and incidents were discussed so that learning could be disseminated at all levels. Staff in all the teams and at all levels across the service demonstrated enthusiasm and commitment to providing a good service to people in Barnet, Enfield and Haringey.

For this inspection, we visited the Crisis Resolution and Home Treatment Teams in Barnet, Enfield and Haringey on consecutive days. These teams had reconfigured in November 2013 and were working in a different way to the teams that we visited in the previous inspection.

We found that staff had been through a period of adjustment to their new roles. We were told by staff that "things are settling down" after a period of initial bedding in. We spoke with people who used the services in the three boroughs. Most people were positive about the support they had received from the services. One person told us "I was cared for really well and given options". Another person told us the staff were "very caring and listening". Other people told us that sometimes their visits were not at the times they were expecting or that they had been cancelled. Overall, we found that there had been an improvement in the feedback we received from people who used the service from the previous inspection.

We checked the management of medicines in the teams we visited. We found that some actions, which had been identified in action plans sent to us by the Trust after our previous inspection, had not been completed, such as training for non-nursing staff who supervised medicines. We also found that some issues relating to medicines management, which had been identified by the trust in audits in September 2013, had not been addressed in practice, such as regular temperature monitoring of medicines storage areas in the Enfield and Barnet teams. We found that there were some gaps in the prescription charts in the Haringey and Barnet teams which meant that there was no evidence that people had received some doses of their essential prescribed medicines, which may have placed them at risk. We found that the trust was not following policies it had in place regarding management of medicines. This meant that the service continued to be non-compliant with Regulation 13, management of medicines, and the Trust had not made the changes which were indicated in the action plan that they sent to us following the inspection in May 2013.

Staff in the teams we visited told us that there had been a difficult time when the teams were established but they felt that there was improvement in the services which they were delivering. There had been significant absence rates due to sickness and vacant post. We found that through this change process staff had not been sufficiently supported as they had not received regular managerial and clinical supervision or specific training in relation to their roles.

We checked records in the three teams we visited. We found that there had been an improvement in the recording since the previous inspection. We saw that most care plans and risk management plans were reviewed regularly and progress notes were kept up to date and provided a record of the work which was carried out in the team which ensured a safe service.

Comments from people using the service included 'nurses have been extremely polite and professional. Very happy with the treatment I have received,' 'everyone has been so wonderful and given as much support as they possibly can' and 'I have always been treated well with pleasant staff. The only thing I would suggest is try for more staff. The nurses are always busy.'

We spoke with the divisional manager and the area manager for District Nurses. They told us that a staff skill mix review had taken place using a caseload monitoring tool. Following this exercise, an increase in staffing numbers was agreed and recruitment was then undertaken. The divisional manager told us that all district nursing vacancies were now filled. Some posts had been filled but some nurses had not yet come into post or completed their induction.

Some nurses told us that the staffing situation had improved and there were many more nurses in their teams. One nurse commented 'I can see the light at the end of the tunnel.' Other nurses we spoke with were not so optimistic. They told us that they had yet to see any improvements in the staffing levels of their teams. We were assured by the divisional manager that posts would be filled as pre-employment checks were completed.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system to regularly assess and monitor the quality of service that people received and to identify, assess and manage risks to the health, safety and welfare of patients and others.

There was evidence that learning from incidents and investigations took place and appropriate changes were implemented. The provider took account of complaints and comments to improve the service.

People were mostly positive about the staff treating them. Some comments were; 'I am treated with dignity and respect. They also cheer me up which is important' and 'Their general attitude is helpful and friendly and they seem to care a lot.' People using the Haringey Home Treatment team were less positive about the service. Some felt that there was a lack of consistency in staff visiting them, they were unable to choose when staff visited and staff did not spend enough time with them.

Haringey users were not protected from risks associated with medicines because the provider did not have appropriate arrangements in place.

The teams we inspected worked well with other teams in the Trust and with other providers. We found good examples of joint working with substance misuse teams, inpatient wards, GPs, social care providers and other hospitals. The Trust was working to improve joint working with GPs as they had identified this as an area which needed improving.

Systematic governance arrangements were in place. Where risks had been identified, the Trust had carried out audits and internal and external reviews then produced action plans to make improvements. We found that action plans were monitored to check progress.

Up to date records were not always maintained.

Despite the low staffing levels in District Nursing, people's needs were assessed and care and treatment was planned and delivered in line with their individual care plans in all three services we reviewed. District Nurses were able to do this because they were working extra hours and prioritising patient care above all other requirements placed on them. This situation was not sustainable and there was a risk that this could impact on patient care.

The provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening although further training was needed to ensure staff could use the Mental Capacity Act in their work to protect patients who may not be able to make decisions about their care and treatment.

The Trust was working to improve co-ordination with other providers such as the local hospitals, because District Nurses did not always know about people discharged from hospital into their care.

Staff supervision and appraisal systems were in place but supervision levels were inconsistent between the teams we inspected. Training was often difficult to access and did not always take account of staff's working patterns. Some training needs identified had not been carried out.

Systematic governance arrangements were in place but did not always flag up key risks, such as low staffing levels, lack of access to non-mandatory training and difficulties co-ordinating care with other providers. Where risks had been identified, such as the new IT system, completion of mandatory training and applying learning from Paediatric Occupational Therapy to Enfield Community Services as a whole, their resolution was slow, despite the production of action plans and monitoring of progress. Governance systems did not effectively manage key risks to service users and others.