All inspections: Livewell Southwest CIC

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

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the young people and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of young people on the wards. Managers ensured that these staff received training, clinical supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
Staff treated young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs of young people. They actively involved young people and families and carers in care decisions.
Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

The provider did not have a blanket restrictions policy and although had lifted the blanket restrictions found during our last inspection, were not allowing young people outside unsupervised due to a perceived risk of absconsion.

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

We rated all five of the key questions ‘are services safe, effective, caring, responsive and well-led’ as good. Our rating for the organisation took into account the previous ratings of services not inspection this time.
Staff in the organisation had worked hard to address concerns we had raised in the last inspection. Two services that were previously rated as requires improvement at the last inspection were now rated as good. Community end of life care and child and adolescent mental health wards had both improved.
Livewell Southwest had strong leadership who had the appropriate range of skills, knowledge and experience to deliver community health and mental health services. Staff felt they were visible and approachable. There was a rolling programme of visits scheduled to services by the executives. Executives used these visits to engage with staff and also listen to their views on the services.
There was a positive, open and honest culture throughout the organisation. Staff at all levels of the organisation were proud to work at the organisation and morale among staff was very good. both leaders and staff across the organisation put patients at the centre of everything they did.
The organisation had recently refreshed and published its new strategy which had been coproduced with staff and stakeholders. The organisation had worked hard to ensure it forged strong strategic alliances with partner organisation. Its contribution to the wider health economy was highly valued by partner organisation and it was now seen as equal partner.
Livewell Southwest had effective systems and processes in place to support delivery of the services it delivered. There was an appropriate sub board committee structure and escalation to board through the structure. Non-executive directors (NEDs) chaired committees and were confident to raise any concerns or challenge to the executive team. The organisation was financially stable and there was relevant financial expertise among the executives and NEDs.
There was a strong emphasis, from both leaders and staff across the organisation for putting patients at the centre of everything they did.
There was also a strong emphasis on listening to staff and providing opportunities for staff at all levels to develop and a strong emphasis on Quality Improvement. The organisation had appointed two Freedom to Speak Up Guardians (although there is no requirement for a CIC to do so). The organisation were using innovative ways to develop its existing staff and to attract new staff.
Staff treated all patients with compassion, respect and kindness. The privacy and dignity of patients was maintained at all times. Patients were supported by staff to understand and manage their care and treatment. Staff actively involved families and carers of patients in their care appropriately.
Across the organisation clinical areas and premises where patients received care were clean, well equipped and maintained.
Services had enough medical and nursing staff. Teams in the organisation had access to a full range of specialists required to meet the needs of patients in their care. Care was planned and provided in a way that met the needs of local people and the communities it served. Staff met the needs of patients with a protected characteristic. Staff supported patients with communication, advocacy and cultural and spiritual support.
Generally, staff across the organisation knew their roles and responsibilities under the Mental Health Act 1983, Mental Health Act Code of Practice and the Mental Capacity Act 2005. Staff assessed and recorded capacity clearly for those who might have impaired mental capacity.
The organisation managed incidents well and staff understood how to report them appropriately. Incidents were investigated, and lessons learned were shared with staff.
The organisation treated concerns and complaints seriously. The organisation investigated concerns and complaints and shared lessons learned with staff. Patients were included in the investigation of their complaint.

However:

Patients on Cotehele ward, part of the wards for older people with mental health problems service, did not have access to their bedrooms during the day without a staff member escorting them. This limited their ability to be as independent as possible, which is important for older people in hospital. There were also blanket restrictions in relation to the time patients went to bed in the evening which meant that patients had to go to bed at set times.

Staff did not undertake a risk assessment of patients at the time of referral to the community mental health teams and did not monitor patients on the waiting lists prior to their initial assessment. This meant that they did not know whether a patient’s mental health deteriorated whilst waiting for an assessment. Staff assumed the GPs would monitor them but there was no agreement in place as to who should monitor patients on the waiting list.

In the community health services for inpatients staff on South Hams ward were not assessing pressure ulcers and wounds adequately and in line with the organisation’s policy. Some staff were also unaware of the organisation’s policy on safeguarding in relation to the development of pressure ulcers and when notifications should be made to the Care Quality Commission.

There was further work needed by the organisation on equality and diversity.

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. Staff managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
The organisation was piloting a primary care mental health team to fill a gap in mental health provision who don’t meet threshold to receive support from secondary mental health services but require more support than GPs can offer. Stakeholders provided unanimously positive feedback about this service and praised the team’s ability to work with patients promptly and effectively as well as providing support to local GPs.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The service was well-led and the governance processes ensured that that procedures relating to the work of the service ran smoothly.

However:

Staff were not assessing risk prior to patients accessing the service. Patients were not risk assessed at the point of referral, therefore staff could not prioritise patients waiting for an initial assessment based on level of risk. A basic risk assessment was completed during initial assessment and only when accepted to the service did patients receive a comprehensive assessment. Staff did not monitor patients who were waiting for their initial assessment. Staff told us that it remained the responsibility of the patient’s GP to monitor and contact the service if the patient deteriorated further during this wait.
The duty team reviewed the suitability of referrals for the community mental health team but were concerned that they were rejecting a high number of referrals due to pressures in the service to keep waiting lists down. Feedback from local GPs who weren’t able to access the primary mental health team stated that a high number of their referrals were being rejected. There was no auditing process to ensure referrals were not being rejected incorrectly.
GPs who had referred into the service were not always receiving a rationale for why their patient had been rejected from the community mental health teams. Some received advice to signpost patients to other services however GPs commented that often their patients had already accessed those services and required further support.
Not all staff had completed training in Mental Capacity Act and Mental Health Act.

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

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Edgcumbe ward had cared for a patient on the end of life pathway so that the person did not have to be moved to a different ward potentially causing confusion and distress. The ward demonstrated an ability to be flexible and responsive the needs of the patient and family allowing the experience to be a peaceful and dignified as possible.
The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Patients on Cotehele did not have access to their bedrooms during the day or the main ward area overnight and were all taken to their rooms at a set time of the day.
Patients complained that they were disturbed by staff shining torches on them during the checks overnight and staff could be overheard talking, disturbing patients.
The garden areas on Cotehele ward were not fit for purpose.
Some patient files were not being securely stored on Edgcumbe ward.

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

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

There was room for improvement with the recording of patient wishes, including the use of treatment escalation plans (TEPS) and do not attempt cardiopulmonary resuscitation (DNACPR) orders, and supporting patients with advance care planning.
Not all staff were familiar with the end of life care strategy and how this applied to them in their work.

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

The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. The service controlled infection risk well. Staff managed medicines well.
Staff provided good care and treatment, gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

Managers did not ensure that management and reporting for incidents of pressure ulcers was completed in line with policy. Staff at South Hams ward did not fully assess and document care plans for patients with pressure ulcers. Staff did not raise pressure ulcers as a safeguarding concern and did not document discussion and decision making in relation to this. Managers did not submit notifications of serious injury to the Care Quality Commission for pressure ulcers grade 3 and above.

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

Leadership was lacking on the ward. There was poor supervision records, with some staff members not having supervision for several months at a time and some staff not knowing who their supervisor was. Only half the staff had had an appraisal meeting in the last 12 months. Team meetings were not happening on a regular basis and the meetings that did occur were not recorded so that sharing of information and learning could be disseminated.
Care plans were not specific and contained missing or incomplete information. For example there was limited information regarding antecedents, triggers or planned actions following an event.
Risk assessments were not specific to the overall risk profile. They did not include possible triggers or detailed action plans in the event of a risk occurring.
Recording and sharing of information about young people such as changes in medication, therapy plans or recent mood/behaviour was poor. There were no regular formal team meetings, with no minutes and therefore sharing of information was further limited.
The recording of fridge temperatures was poor and there was no recorded action taken if the temperature was not within recommended limits. This was in all fridges on the ward.
Staff had not received Mental Health Act training. Only 11 staff had received training, but they had good knowledge of and applied the Mental Health Act well.
There were blanket restrictions applied on the young people and no documented rationale provided for these restrictions. For example young people were not allowed to keep mobile phones on their person and were not allowed electronic devices in their bedrooms.
Young people were not offered or given a copy of their care plan.
Staff and management were not confident in their knowledge of Gillick competence. This included explaining the rights of informal patients to leave. The Gillick competencies were being applied, however, staff were not aware that this was the framework they were following. . Mental Capacity Act training was well attended, however staff and management were not aware of Gillick competence.

However:

Leadership was visible and the young people knew the staff and management well.
The young people felt cared for and told us the staff were always approachable.
Staffing levels were good and young people rarely missed activities or leave.

Livewell Southwest CIC is an independent social enterprise organisation that provides community health and social care services for the people of Plymouth, South Hams and West Devon.

End of life care was provided by community nursing teams and on inpatient wards in three community hospitals (Mount Gould hospital, South Hams hospital in Kingsbridge and Tavistock hospital). In addition there was a dedicated end of life care multi-visit team made up of healthcare assistants who worked with specialist charity carers to provide end of life care in patients’ own homes. Specialist palliative care was not provided as part of Livewell Southwest but they worked closely with local hospice and other services to ensure collaborative care delivery.

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

There had been very little improvement on the completion of treatment escalation plans and do not attempt resuscitation form on the inpatient wards. No quality improvement programmes had been delivered for the patients in the community and no audits to monitor quality or effectiveness.

Health care assistants had no end of life specific training to equip them to safety identify deteriorating patients or communicate effectively and with compassion to patients and those close to them at their end of life.

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

Patients received a safe, effective, caring, responsive and well led service.

Patients were protected from abuse due to the training, policies and procedures that were in place to support staff to recognise and deal with suspected abuse.

Staff reported incidents and the provider took action to investigate and reduce the risk of such incidents reoccurring.

The community hospitals were clean and hygienic in appearance and staff promoted the control of infection when delivering care and treatment to patients.

Staff maintained accurate and up to date records which reflected the care and treatment provided to patients whilst at the community hospitals.

Discharge planning was detailed and supported by the multidisciplinary team. This assisted patients to experience a well-planned discharge with the appropriate care and support to enable them to get home safely.

Patients were supported to receive their medicines in a manner suitable for them and when necessary staff followed safe systems to administer medicines.

The nutritional and hydration needs of patients was assessed and patients were provided with a varied menu. When required assistance was given to patients to ensure they were able to eat and drink adequate amounts for their needs.

Clear evidence supported that staff worked well together in multidisciplinary teams to provide continuity of care and good outcomes for patients on the wards and within the theatre department at Tavistock hospital.

Written and verbal consent was obtained from patients prior to the delivery of care and treatment. Mental capacity assessments were carried out to ensure that treatment plans were delivered in the best interests of the patients, particularly if the patient did not have capacity to express their wishes.

Staff demonstrated compassion, kindness, empathy and showed patients respect when delivering care and treatment. Patients were included in the planning of their care and treatment plans and independence was promoted. Patients were provided with sufficient information to make informed choices regarding their care and treatment.

The service responsive to the needs of local people and additional services, such as weekend theatre lists, were planned to meet those needs. The organisation worked with commissioners and stakeholders to develop the services in response to identified needs.

The leadership of the organisation was open and transparent and staff felt supported and valued. The provider had knowledge of the service and key issues due to the governance and risk management frameworks in place.

However:

Staff had not always taken prompt action when potential safeguarding concerns had been identified.

Patient records did not consistently direct and inform staff of the action they are required to take to meet the assessed care and treatment needs for each patient. Patient monitoring documents were not always completed in full.

Patient medicines were not stored securely at all times. We observed there were medicines left on tables in the dayroom and bedside which meant other patients and visitors to the ward potentially had access to these.

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

On both wards staff had built good relationships with patients. Staff gave patients information about the service and what treatments were available. The information was provided in a number of formats and was available to patients and upon their request at any later date.
The service had been re-designed with regular fortnightly ward rounds that focused on multi-disciplinary and multi-agency working. There had been recruitment on the wards to improve staffing numbers since our last inspection in 2016. New staff were provided with induction and a personal development program with regular reviews with managers and supervisors.
Both ward used staffs from clinical support team to cover sickness and vacancies. The clinical support team work across the service to fill shifts.
Staff assessed the needs of patients. Assessments were updated regularly.
Staff assessed and managed physical health through weekly monitoring.
Patients said that staff were kind and caring. They said they felt safe on the wards.
Staff had access to services in the organisation and external services to help meet patients’ needs. These included regular visits by the independent Mental Health Act advocacy service (SEAP – Support Empower Advocate Promote).
Staff understood safeguarding and when to report safeguarding and followed the organisation's safeguarding policy.
There was good leadership from ward managers.

However:

There was no adapted bathroom or toilet facility for people with physical disabilities at Syrena house. The showers were 'walk in' showers, but there was no other adaptation for people with impaired mobility.
Visitors, including children could only meet with patients in communal areas or staff meeting rooms on the female ward.
Patients care plans at Syrena House were not holistic and lacked patients views and involvement.

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

The care plans and risk assessments were comprehensive, holistic, recovery orientated and up-to-date. They were regularly reviewed and updated as required.
Staff were open to patient and carer feedback, and had used it to improve their quality of care.
The wards had sufficient numbers of skilled and experienced staff to deliver the service. Staff came from a variety of professional disciplines and this helped them to meet a wide range of patients’ needs.
Staff spent quality time with patients to ensure they provided the highest quality, person centred care. Staff treated patients with respect, dignity and were passionate about their roles
During our inspection of Cotehele ward in October 2016, there was a blanket restriction on patients accessing their bedrooms during the day. This has been resolved.

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

During our previous inspection in June 2016 we rated mental health crisis services and health-based places of safety as good overall. We rated safe, caring, responsive and well-led as good and rated effective as requires improvement. In 2016 the provider was not meeting all requirements under Regulation 17 HSCA (regulated activities) Regulations 2014 (good governance). We found that the provider had met these requirements during this inspection.

The policies for both adults and young people’s health-based place of safety had not been updated since the revised Mental Health Act Code of Practice had been introduced in April 2015. During this inspection this had been rectified.

The adult place of safety was separate to the children and young people place of safety. Staff in both services managed risk well both in the environment and clinically. Staff knew patient risks and managed them appropriately. There were robust lone working procedures in place.
The home treatment team caseloads were significantly reduced since the previous inspection, making the workload more manageable for the team. Managers reviewed and monitored caseloads regularly.
Care records showed that patients received good care. Staff completed risk assessments and comprehensive assessments based on their needs.
Staffing levels were good in the health-based places of safety and the home treatment team. Managers used a robust model to ensure staffing levels met the needs of the service.
There was good medicines management practices in all locations. All teams had access to medical support out of hours.
Staff followed the Mental Health Act Code of Practice when receiving and assessing patients detained in the health-based place of safety. They also ensured patients understood the reason for their detention. Both units collected regular data on response times for all section 136 (MHA) information.
Staff in all teams demonstrated good knowledge and skill in their relevant field. Staff had opportunities to develop. Staff received annual appraisals and regular supervision.
Staff in the health-based place of safety demonstrated good partnership working with relevant agencies. Regular multi-agency meetings were held to ensure robust partnership working.
The teams were caring and compassionate and treated people with dignity and respect. Patients in the home treatment team described their care and support as positive and kind.
The home treatment team provided 24 hour a day, 7 days a week support to people. Other professionals could access the service for advice and the team worked well as part of the wider crisis pathway. The children and young people’s health-based place of safety was due to undergo a refurbishment to provide a purpose built suite.
There was good, clear leadership on both health-based places of safety. The overall manager was enthusiastic and driven to provide a quality service. The leaders in the home treatment team were knowledgeable and experienced and were supportive of the team. Managers provided supervision and appraisals, which was a requirement following the previous inspection.

However:

The home treatment team was located in an environment that was clean but not ideally suited for their purpose. Access to security was poor, particularly out of hours.
Patients were not always involved in the development of their initial care plans.
Due to inability to recruit to additional posts, this specific service could not provide the enhanced crisis service out of hours. Their model was to work as part of a partnership between the CMHT and the mental health liaison service to provide this service.
There was confusion within the home treatment team around their identity and overall place in the wider crisis pathway. Staff told us they did not feel involved in discussions around the teams’ future.
Discussion around risk within multi-disciplinary meetings was not structured.
Identified risks were not consistently translated to care plans.

We rated four of the key questions, ‘are services safe, effective, responsive and well-led’ as good and the key question, ‘are services caring’ outstanding. Our rating for the organisation took into account the previous ratings of services not inspected this time.

Staff took the time to interact with people who used the service and those close to them in a respectful and considerate way. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.

Staff demonstrated understanding of patient’s care needs and wishes and showed an encouraging, sensitive and supportive attitude to patient’s and their relatives / representatives.

Patient’s were encouraged to be involved in the development of the service and were involved in their care planning, and carers were also involved where appropriate. We saw excellent examples of patient centred care.

Patients and carers gave positive feedback about the care received.

In the majority of the services we inspected, we found that staff managed access to and discharge from the service well. This was reflected in the time it took for patients to receive an assessment and then their treatment, and in the way the inpatient staff in the majority of the services we inspected worked to help patients to be ready for discharge.

The organisation’s senior leadership team had the skills, knowledge, and experience necessary to successfully oversee a large organisation. The board were actively working hard to ensure a positive approach to the closer working relationship with Plymouth Hospitals University NHS Trust. A new chief executive had been appointed in March 2018 whose focus was ensuring an appropriate balance between working towards the working relationship and the day to day strategic management of the organisation. The chief executive and vice-chair both had a clear understanding of the challenges and strategic direction of the closer working relationship with University Hospitals Plymouth NHS Trust.

The provider had worked hard on its recruitment and retention plan with some success. For example, there was now a fully recruited district nursing workforce.

We saw some examples of excellent leadership at all levels with many dedicated, compassionate staff who were striving to deliver the best care for their patients.

However,

We rated two services as requires improvement, the child and adolescent mental health inpatient ward and community end of life care.
On the child and adolescent mental health inpatient ward, improvements were needed to the governance of the service, care plans and risk assessments.
Whilst we noted some improvements within community end of life care. further work was needed to ensure consistency in record keeping and training for staff.

We re-rated community-based mental health services for adults of working age as good overall because:

During our re- inspection in October 2016, we saw that the services had made substantial improvements against the breaches to:

Regulation 12 (1)(2)(a)(b)(c)(g) safe care and treatment.

Regulation 17 (1)(2)(a)(b) good governance.

Regulation 18 (1)(2)(a) staffing.

Since that inspection we have received no information that would cause us to re-inspect these areas of the warning notice. During our most recent inspection in May 2017, we found that the services had addressed the issues that were outstanding from the re-inspection in October 2016. The community based mental health services for adults of working age were now meeting all of the requirements under Regulations 12, 17 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014: The South and West teams had reduced their nurse vacancy rate from 33% and 15% down to 0%. The management teams had introduced systematic changes to their recruitment and retention processes which resulted in decreased staff turnover, a single point of

reference from start to finish of the recruitment process, increased staff morale and regular reviews of team capacity. The provider had reviewed and made systematic changes to reduce caseload sizes. As a result, the teams had reduced their wait times significantly, and had reduced their allocation list from 50 patients last October 2016 down to two. These two patients had been referred on the same day as the inspection. The provider was auditing their allocation lists regularly

and assessing any breaches with the MDT in weekly meetings to ensure they met their target waiting time.

Overall, we rated the urgent care service as good because;

Safety performance and risks were assessed, managed and monitored. Quality and safety reports were sent to senior managers on a monthly basis. Openness and transparency about safety was encouraged.
Practitioners were well qualified and demonstrated the skills that were required to carry out their roles effectively and according to best practice. They worked collaboratively with multidisciplinary teams from community services and acute services at neighbouring hospitals
Staff used evidence-based guidelines in order to ensure effective treatment was delivered.
The learning needs of staff were identified at regular clinical supervision sessions and at annual appraisals.
We observed staff taking trouble to maintain people’s privacy, dignity and confidentiality. They demonstrated empathy towards people who were in pain or distressed and were skilled in providing reassurance and comfort.
Feedback from patients and those close to them confirmed that staff were caring and kind.
There were relatively few delays for treatment. The average wait across all units was 42 minutes. Ninety nine per cent of patients were treated, discharged or transferred within four hours.
The needs of people with complex needs were well understood and addressed appropriately.
Clinical leaders were respected by staff. They were knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them.
Integration of the three units was at an early stage but obvious progress had already been made.
There was a strong sense of teamwork between all staff. There were shared values of delivering high quality patient care

However:

There was no record of how many staff had received training in life support for children.
There was no risk assessment of resuscitation facilities at isolated units.
Healthcare assistants carried out initial clinical assessment of patients before being assessed as competent to do so. If a unit closed at short notice they would assess the seriousness of injuries and advise patients on treatment. They had not been trained to do this.
There was no x-ray service at South Hams and Tavistock during weekends and bank holidays.
Plymouth Healthcare did not have a strategy for the integration of Tavistock and South Hams hospitals. As a result, there was no agreed plan for the integration of the three minor injuries units.

Overall we rated the organisation as requires improvement for community end of life care services because:

Treatment escalation plans (TEPs) that included do not attempt cardiopulmonary resuscitation (DNACPR) decisions were not always completed in line with organisational policy. This included poor records of discussions relating to DNACPR and a lack of clarity on whether discussions were taking place with patients and family members. Incomplete mental capacity assessments relating to DNACPR meant that it was unclear that mental capacity was being considered when decisions were made.
Poor records management following reviews of TEPs and DNACPRs resulted in duplication of forms and had the potential to cause confusion about whether a patient was or was not for resuscitation.This presented a risk of a resuscitation decision not being followed.
There was a lack of holistic evidence-based end of life care guidance in use across the organisation.
It was unclear how the service was monitoring patient outcomes specific to end of life care.
Not all nursing staff delivering end of life care had received syringe driver training or competency assessments.
There was no completed strategy for end of life care.
There was no lay person or non-executive director overseeing end of life care and end of life care was not discussed at board level meetings.
Quality measurement in relation to community end of life care services was limited and there was no clear plan for measuring or improving the quality of end of life care in relation to patient outcomes.

However;

Equipment for use at the end of life, including syringe drivers, was readily available and there was good use of anticipatory prescribing and monitoring of symptoms for patients at the end of life.
There was good evidence of incident reporting, learning and improvement and staff were consistently aware of reporting procedures. Lessons were learned from incidents and were shared with all staff.
We saw evidence of outstanding practice in the development of innovative projects relating to improving the quality of end of life care for people living in vulnerable circumstances. The organisation had developed a resource of end of life champions.
Feedback from patients and relatives told us that staff treated people with dignity and respect and we observed staff caring for patients in a way that built rapport.
There were examples of staff going the extra mile to support patients and their relatives at the end of life and to promote individual choices about care.
Services were planned and delivered to meet people’s needs and Plymouth CIC staff were actively engaged with other providers within the locality to improve services
There was clear, motivated and enthusiastic leadership at service delivery levels within the organisation.
There was good collaborative working with other providers to improve end of life care through joint working within the locality.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

Despite rating Plymouth Community Healthcare CIC as good overall, we had concerns about the safety of patients accessing the Community Mental Health Teams for adults of working age. It is our view that the provider needs to take significant steps to improve the quality of this service and we find that they are currently in breach of regulations. We issued a Section 29 warning notice on 15 July 2016 which told the provider they must make significant improvements.

Following the June 2016 comprehensive inspection we issued the provider a section 29 warning notice which gives a strict timescale for them to improve. This related to the services provided by Plymouth CIC's community-based mental health services for adults of working age.

In October 2016 we carried out an unannounced focussed inspection of Plymouth CIC's community-based mental health services for adults of working age. This was to see if the provider had met the concerns raised in the warning notice. We found evidence of progress and improvement and at this time we will not be taking any further enforcement action. We will continue to monitor the provider's compliance with the warning notice. Further details can be found in the community-based mental health services for adults of working age core service report.

At the comprehensive inspection in June 2016 we found the service provided by Plymouth CIC to be good because:

Across the inpatient and community services we saw that staff worked with patients and their families to deliver individualised care. Care plans were holistic, they documented detailed assessments of both the emotional and physical needs of patients, were patient centred and most had a strong recovery focus.
We observed good assessment and management of risk throughout most services. For example ligature risk assessments were in place and well managed either by rectifying the issues identified or by actively managing the areas where risk was identified to reduce the risk to patients.
Generally the wards and community environments were clean, bright and well furnished. The provider was committed to refurbishing environments which required it. For example, it had managed the refurbishment of the Glenbourne well; with particular focus on safety and patient involvement in the re-design.
The provider had robust infection control policies and procedures and staff adhered to these across all environments.
In the community team for learning disabilities and autism, staff understood the importance for patients of being close to their friends and family. The team had won an award for bringing patients who were staying in hospitals out of the area, back home to Plymouth.
We observed that staff delivered care and treatment to patients in a kind, caring manner that respected their dignity. Where concerns had been expressed by patients and carers we saw that this had been addressed appropriately and in line with the expectations of duty of candour.
The great majority of the patients that we spoke with on the wards were positive and complimentary about the support they received from staff. Staff interacted with patients positively and respectfully. They demonstrated that they knew the patients well in their interactions with patients and in their responses to them. Where it was appropriate we saw that carers and family members were involved in the care planning process and care plans documented patients’ wishes and feelings about their treatment.
Patients told us that food was good and there was a wide choice available to them. The Provider had been awarded five stars for food hygiene by South Hams district council on 29 August 2014, Mount Gould had received a five star rating for food hygiene by Plymouth City Council on 28 January 2014 as part of the scores on the doors rating system.
Most staff had received training in and had a good understanding of safeguarding procedures.
There was a wide range of activities on the wards throughout the week that patients could benefit from.
There were separate health based place of safety (HBPoS) for adults and young people. Staff in the HBPoS manged risk well, including environmental risks and safeguarding concerns. There had been a gradual reduction in the use of police custody for section 136 purposes for adults and since the introduction of the place of safety for young people, there had been no use of police custody for this patient group.
Staff were positive about working for the provider as an employer and said they encouraged individual services to improve and had a ‘no-blame’ culture. Staff knew who senior managers and said they were visible. Senior managers and executive board members had visited all locations. Non-executive directors had a good understanding of the provider’s strategy and presented appropriate challenge to the executive team.

However:

In some clinical areas, the provider had not ensured that staff had the necessary skills or training. It had not always assessed whether healthcare assistants in the community hospital were competent before they were allowed to carry out initial clinical assessment of patients. Healthcare assistants were re-directing patients to other services before the patients had been assessed by a registered practitioner. Although all staff had received recent training in immediate life support for adults, there was no record of how many had received training in life support for children.
The provider had processes in place to identify and report serious incidents. For example, we observed assessment and management of risk with locally held risk registers and use of a risk rating tool that identified problems and escalated these issues for action. However these were not used consistently across all core services, we saw that adaptations required following an incident on the older persons wards had not been made 12 months after the incident.
Not all staff were receiving regular supervision in line with the providers’ policy.
There were some instances where the provider had not assessed or managed risk well. Staff had not conducted a risk assessment of child and adult resuscitation facilities at South Hams and Tavistock to ensure they were suitable for an isolated unit.
Staff in the community mental health teams for adults did not always provide care and treatment in a safe way. Not all patients on waiting lists for treatment had been thoroughly risk assessed.
Staff in the community inpatient team did not adhere to the medicines management guidance such as the use of patients own medicines as stock medicine.
In the 'end of life care service treatment escalation plans' and 'do not attempt resuscitation decisions' forms were not always appropriately completed and recorded in line with organisation’s policy.
MHA training was considered essential for some teams and appeared to be regularly delivered and accessed by staff. However, there was no record of this held locally or at provider level to ensure the right staff had received the correct level of training.
At South Hams hospital the provider did not always provide appropriate X-ray facilities when they were required by patients with suspected fractures.
The staffing levels and skill mix within the district nursing service was not always safe, and staff were not always appropriately supported.
The provider was not always adhering to the safeguarding policy and was not consistently raising safeguarding alerts to the Local Authority safeguarding team and the Care Quality Commission.
Cothele ward had a blanket restriction in place which restricted the reasonable movement of patients.
The provider did not always act in a timely way to implement learning from incidents.

We rated the community health services for adults as good overall because:

There were effective incident reporting systems in place and staff reported they received feedback and learning from these.
Staff had good knowledge of safeguarding procedures and felt supported in raising any safeguarding concerns. Staff had a good understanding of consent and deprivation of liberty safeguards. Consent to treatment was gained in line with legislation.
There were good medicine management systems in place to keep patients safe.
Relevant equipment was available, had been checked and was serviced regularly.
Good infection control systems were in place and staff were seen adhering to them.
The community adult’s service provided care in line with best practice guidance. Staff were given time to attend mandatory training and reported that this was supported by the organisation
Multi-disciplinary and collaborative working was evident throughout the service. Working in the same building as other teams and social care colleagues had improved information sharing.
Feedback from patients was positive.
Patients received care from staff who treated then with dignity and respect. Staff ensured that options were explored to respect the patient’s wishes and requests
The needs of patients were taken into account when planning and delivering services. Staff were flexible
Teams worked together to provide the most appropriate care at the most appropriate time for patients. Care and treatment was coordinated between the community adult services.
Patients were given information about how to make a complaint or raise a concern. There were systems in place to investigate complaints and systems in place for disseminating learning.
There was strong leadership in place. The executive team was visible and staff felt comfortable in approaching them.
A positive culture was evident in nearly all the services we visited.
Staff felt they had a voice and we heard examples of when changes had been made following discussions and involvement of staff members.

However:

Staffing levels were an issue across the community teams and had an impact on staff’s ability to manage caseloads, waiting times and morale.
There was variable access to information and connectivity via the IT system.
There were issues with the waiting times and waiting lists in some specific areas
Since patient records had been completed using the electronic patient record system there had been no consistent audit of the records.

Overall rating for this core service Good

We rated this service as good because:

Plymouth Community Healthcare CIC provided support for children, young people and their families to promote healthy choices. They provided information in a way people could understand and supported families to access health care when they needed to. They identified vulnerable families and offered specialist support for them.
Safeguarding processes were in place and followed by staff with children and young people’s health, wellbeing and safety at the heart of the workforce.
There was a positive attitude among the staff who learned from incidents and comments to improve their service where they could.
Risks were identified and reviewed by senior managers for their action.
Staff were appropriately trained to ensure they were competent to provide care for children, young people and their families and displayed skill and compassion to engage them in their care.
Staff were open and honest with their clients and ensured they were informed of options for their care and helped to make their own choices.
Staff worked with other agencies to support families and ensured appropriate advice was available. Care pathways supported families to access the right support at the right time.
Nationally approved guidance was used to ensure services were safe and effective.
Technology was provided for staff to maintain their safety and share information securely in a timely way.
Professional supervision was available for staff to ensure they were supported in their practice.
Staff engaged with opportunities to contribute to planning how their services were delivered

However

Health visiting staffing levels were decreased in 2016 to meet financial constraints that had been imposed by commissioners. Some health visiting teams with high caseloads were unable to offer vulnerable families additional support using the Maternal and Early Childhood Support Home visiting programme.
School nursing and children’s speech and language therapy services did not assess the acuity of their caseload to determine how many staff were needed to meet the needs of the children they provided care for.

We rated community health services for inpatients as good overall because:

The organisation had a strong track record of safety performance. Openness and transparency about safety was encouraged and incidents and near misses were reported, monitored and learned from.

The service had enough staff to care for the number of patients and their level of need. Treatment was planned and delivered using guidelines and best practise. Staff were well-trained, received regular appraisal and had access to further training and development. Teams worked well together to deliver a high standard of outcomes for patients, which audits showed were above the national average.

Staff consistently demonstrated a person-centred culture where patients and those close to them were involved in their care and treatment. Feedback from people using the service and those close to them was very positive. It demonstrated staff treated them with kindness, dignity and respect.

The service was planned and delivered in a way that took account of different people's needs, and offered flexibility and choice. Complaints and concerns were monitored and well-managed.

Staff were engaged in delivering the vision and strategy for the service which was driven by quality, safety and the experience of people receiving and delivering services. Quality and safety were well monitored and there were effective processes in place to identify, monitor and address, current and future risks. The organisation worked well with its stakeholders. Leaders were respected, visible and approachable and staff felt well supported by them. Staff told us they felt respected, valued and were proud to work for the organisation, and there was a strong culture of supporting others. Staff were encouraged to develop and improve services and worked well with local communities, voluntary organisations and stakeholders, to develop the service.

However:

We identified some variation in the supply, storage and management of medicines across the organisation.
Patients told us they felt confident to raise a concern about their care, should they wish to do so, but few people knew how to make a complaint about the service.

We identified some concerns about the environment on Skylark Ward, Plym Neurological Rehabilitation Unit and at Tavistock hospital.

We rated community mental health services for people with a learning disability or autism as outstanding because:

The team had won a national award for their successful repatriation of patients.
Feedback we received from patients, carers and stakeholders described staff going the extra mile and providing compassionate, focused, respectful and attentive patient care. The team asked for feedback from patients and responded to the feedback. Surveys showed high levels of satisfaction.

The service was fully staffed. Staff worked together across a range of disciplines to provide holistic and individualised care to patients.

Staff were well trained and experienced. They were up to date with mandatory training and were able to access specialist training.

Patients could access urgent care when they needed it through bespoke out of hours packages, crisis plans or by contacting the team and requesting help. Patients that needed it were assessed urgently and psychiatrists were available for ad hoc consultation.

Waiting times were within the target for the service of 18 weeks. The team could assess patients sooner if they felt they could not wait although there was no target for providing urgent assessments. However, staff did not monitor patients for potential increases in risk while they were waiting for an assessment. Patients who were care coordinated by another agency did not always have a risk assessment produced by the team. A new practice of producing threshold assessment grids for every patient was addressing this.

Care planning was highly individualised, holistic and person centred. Patients and carers were actively involved in care planning.

The team used medicines and psychological therapies that were recommended by the National Institute for Health and Care Excellence. Psychological therapies were adapted to make them accessible to the patient group.

Staff had good knowledge and understanding of the Mental Capacity Act.

The service had good working links with a wide range of teams and services inside and outside of the organisation. This enabled patients to receive holistic and joined up care and to have access to mainstream services. The team carefully planned transitions between services as patients came into or left the service.

Staff were respectful, caring and compassionate. They treated patients as individuals and provided care that was tailored to meet individual needs.

Carers were supported to be involved in patients care. They were offered group and one to one support.

The team made it easy for patients to access the service by seeing them in the city centre, at home or in other familiar places. They made documents easy for them to understand by including pictures and using easy to read language.

Team morale was good and staff were happy. They were supported by accessible and approachable managers and had regular appraisals and supervision.

There was a strong commitment to quality improvement and staff were encouraged to be innovative. The team took part in research and audits. They also trained others in working with people with learning disabilities and mental health difficulties.

We found the following areas of good practice:

The clinic room used by the staff but was managed by the co-located organisation, was kept locked and was very clean and tidy.

No agency or bank staff were used at this service.
Risk assessments were completed on referral and reviewed regularly.
All staff worked to the National Institute for Health and Care Excellence guidance in regards to their detoxification practices.

Mandatory training rate for staff was 100%.

All staff used Skyguard lone worker protection devices.

All care records reviewed had a comprehensive assessment.Care plans were reviewed and updated every three months.

All staff had line management supervision every six weeks with group supervision quarterly this was led by the clinical lead. All staff had staff development plans.

The interactions between staff and people using the service were friendly, respectful and kind.

From accepting a referral, a client was seen within one week by a care manager. At the time of inspection, there was no waiting list for services.

The building had electronic door access for people with restricted mobility.The service had a lift for people with mobility issues that allowed them to access the waiting room and interview rooms.There was an adapted toilet that people were easily able to access.

Staff informed us that they thought the team worked well together and everyone was willing to help and support each other.Staff thought morale was very high within their team and they were all very happy to work there.

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

Staff had completed mandatory training. Staff updated their mandatory training on an annual basis. Staff received supervision every 12 weeks, in line with the organisational policy and staff appraisals were up to date.
All care records we reviewed had comprehensive, up to date risk assessments were in place. Staff updated risk assessments regularly. Staff had completed comprehensive assessments of all those using the service. Care plans were holistic, personalised and included a crisis plan.
All staff were aware of safeguarding procedures, what would constitute a safeguarding alert and how to make a referral. Staff shared lessons across the whole service following incidents. Staff practice had changed as a result of learning from incidents.
Psychological therapy was available to people using the service. People using the service had access to a psychiatrist for diagnosis and medicine reviews. The prescribing psychiatrist carried out high dose anti-psychotic monitoring. Staff considered the physical health care of people using the service.
The staff team included nurses, physiotherapists, occupational therapists, psychologists and psychiatrists. Social workers were employed by the organisation, but they were not located within the team. In order to access social workers staff made referrals to the adult social care department of the organisation.
The multidisciplinary team meetings were comprehensive and considered the needs of carers as well as those of people using the service. Staff from the Alzheimer’s Society were based in the team office which ensured good relationships and joint working.
Staff demonstrated a dedicated approach and put the needs of those using the service first. We observed staff demonstrating kindness, dignity and respect to all people using the service. Carers spoke very highly of the service and reported that they felt consulted in care planning and treatment. Care records we reviewed showed that people using the service had an active role in the care they received.
Staff completed assessments in a timely manner. Staff from both pathways were meeting the organisation’s target waiting time of 18 weeks from referral to treatment. Staff saw urgent referrals within 24 hours, or sooner if required and responded promptly to any deterioration in the mental health of anyone using the service. Each team provided duty cover during working hours. The memory service pathway introduced additional memory assessment clinics to reduce the waiting list.
The teams had good governance systems in place. For example, team managers had systems in place to ensure mandatory training was up to date, supervision and appraisals were completed within organisational timescales and incidents were reported and learnt from. The team manger had good administrative support.
The complex dementia service was involved in research into diagnoses of Alzheimer’s disease in people aged under 65 years old.

However:

The functional team was on the organisation’s risk register due to the high level of staff sickness. The manager had submitted a request to the executive team to recruit agency nurses to cover absences due to sickness.
Social workers were not fully integrated into the service.
Staff did not demonstrate knowledge of the organisation’s values. Staff reported feeling disconnected and removed from the wider organisation.
Staff reported the organisation made changes to the service without any form of consultation. Staff did not know when they would be moving to permanent premises.

We rated wards for older people with mental health problems as requires improvement because:

Patients on Cothele ward had limited access throughout the day to their bedrooms except for an hour at lunch time. Patients also had to comply with agreed times to get up and go to bed. This was agreed to enable staff to safely monitor the wards which were on two different levels in the building.
Wards did not have access to doctors employed on the ward outside the hours of 9am to 5pm from Monday to Friday. The wards also did not have access to the provider’s junior doctor rota.
Not all staff had completed basic life support mandatory training.
Staff did not initial and date when they made changes to the the frequency of modified early warning scores on Edgcumbe ward.
Staff did not always update care plans following incidents with patients.
On Cothele ward, doors on patients’ bedrooms were not fitted to open in both directions.
Staff did not monitor the clinic room temperature on Edgcumbe ward to ensure that medicines stored there were kept below the manufacturer’s required maximum temperature.
The wards’ ligature assessments did not list dates when work was to be completed to remove risks.
Staff on Cothele ward had not escalated health findings for two patients to doctors for action, even though the escalation treatment protocol indicated they should.

However:

The wards were clean, bright and well furnished.
Staff delivered care and treatment to patients in a kind, caring manner that respected their dignity.
Staff developed care plans for patients. These included outcomes from assessments for anxiety and memory issues.
Staff adhered to strong infection control principles and equipment across the wards was well maintained.
Patients and their families told us they felt safe and cared for on the wards.
We saw good evidence of clear leadership on both wards. Managers were visible and supported staff when required.
Staff had received training and had a good understanding of safeguarding on the wards.
There was a wide range of activities on the wards throughout the week.
Patients told us that food was good and there was a wide choice.
Staff worked with patients and their families to deliver individualised care.
There was a wide range of professionals in the multidisciplinary team providing treatment and care to patients.

We rated forensic inpatient/secure wards overall as Good because:

Staff were actively involved in clinical audit on the ward.

We observed good medication management on the ward.
We saw that the service listened to staff and patient feedback and made changes to the way the service was delivered.
The ward areas were visibly clean and well maintained.
All staff and patients told us they felt safe on the ward and felt that the number of staff was suitable to meet the needs of the patient group.
We observed positive and caring interactions between the staff and the patients. Staff were courteous and responsive to patients’ requests.
Patients were risk assessed on admission and had up to date risk assessments which were linked to their care plans.
Care plans showed good evidence of involving patients in their care.
Staff supported patients to complain and helped them to resolve complaints.
Patients spoke positively about their regular contact with the chaplaincy service who visited the hospital on a weekly basis or more frequently if required.
Ward systems were effective in ensuring that staff had received appropriate mandatory and statutory training and local guidance to enable them to undertake their roles effectively.
The ward was also committed to reducing the impact of restrictive practices.
Staff felt confident to use the whistleblowing procedure and to raise concerns with their colleagues and line managers.

We rated long stay/rehabilitation mental health wards for working age adults overall as Good because:

The environments were clean, staff completed environmental audits each week. All known ligature risks (a ligature risk is a fixture or fitting that could be used for self-harming) were rated and mitigated by staff observation. There was an action plan in place to remove all ligature risks on Greenfields ward.
We reviewed the staff training records on each ward, and noted that mandatory training was up to date for all staff; this encompassed safeguarding training for adults and children, record keeping, physical intervention training, conflict resolution and first aid training.
All medicine charts were inspected and all medication doses were within the parameters set by the British National Formulary. All medicines were administered in accordance with consent to treatment forms.
The quality of caregiving and interaction was good. Staff were polite, caring, courteous and respectful towards patients. Patients and carers reported feeling involved in the delivery of care.
Both wards reported difficulties in preventing some patients using illicit substances previously referred to as legal highs. This was addressed through educational means rather than restricting patients’ leave. Patients known to be at risk were provided with one to one educational guidance with regard to how these substances could impair their judgement and interfere with their recovery plans.
The services were responsive towards the needs of the patients. There were a range of activities available on Greenfields ward. Patients at Syrena House could access facilities in the local community.

However:

Staff on Greenfields ward had not been raising safeguarding alerts when appropriate to do so, or ensuring that alerts were escalated to the Local Authority safeguarding team and the Care Quality Commission, this is a breach of regulation.
Both wards had staff shortages, 21% of registered nursing posts were vacant, these posts had remained vacant in the service for the past three months. This resulted in daily use of bank and/or agency staff. Two patients told us they felt unable to approach staff that they were not familiar with.
The wards had higher than national average sickness rates.
Although patients at Syrena House had access to an occupational therapist, this had not led to the development of dynamic recovery programmes based upon comprehensive assessment of occupational need.
Syrena House did not have regular administrative support and staff reported fulfilling administrative duties rather than being with the patients.

We rated child and adolescent mental health wards as good because:

The building was purpose built and well designed in terms of layout for observation and ligature risk. The building was designed with ligature free fittings, such as showers and wardrobes. There were spacious and well designed facilities to promote comfort and dignity for children and young people. All rooms were ensuite with a female only lounge and a further room that could be used flexibly to create a male lounge. The ward complied with the Department of Health guidance on same sex accommodation. There was a range of therapy rooms, a relaxation room, and games rooms and outside space. There was access to a well-designed courtyard and garden. The seclusion room was a shared facility with the children’s and young people’s place of safety unit, both of which were rarely used, although there was an episode of seclusion during our inspection.
The ward was clean and well organised and there were regular environmental audits and safety checks. There were additional fire safety checks in place prior to essential building works and staff who carried these out had received up to date fire safety training.
The service was commissioned to provide inpatient care to children and young people in the peninsula: 11 of the 12 children and young people were from the catchment area. Although the service was full with high occupancy rates, beds were always available to young people returning from leave.
Transitional arrangements were in place for transferring young people from children’s and young people’s specialist services to adult in patient care services, such as eating disorders.
Staffing levels were agreed with the specialist commissioners for the service and there were good staffing levels on each shift which could support the needs of the patient group.
Risk assessments and care plans were detailed, and had a recovery focus. There were individual pathways, such as the eating disorder pathway and care planning included the young people’s views. There was evidence of recording and updating records for obtaining consent to treatment.
Access to psychological therapies was good including family therapy and cognitive behaviour therapy. All families were offered family therapy.
Staff were up to date with mandatory training, including safeguarding and fire safety.
Training in the Mental Health Act (MHA) and Mental Capacity Act (MCA) was not mandatory. Despite this we found a good understanding of MHA and MCA. Staff described good support and guidance from the Mental Health Act office. Section 17 leave records, for patients who were detained under the MHA Act were kept up to date.
Most children and young people and all parents we spoke with reported that staff were kind, respectful and caring. There was a good rapport between some of the young people and staff. We saw positive interactions with young people. For example, the daily community group where all young people were encouraged and supported to be involved. There was reciprocal warmth between some staff and young people. The service was in the process of improving user and carer engagement in service development and there was an involvement officer in post to support this.
The service had an effective performance management tool in place to monitor the service and there were regular reports to the specialist commissioners and there had been no recent formal complaints.

However:

There was not a clear mechanism to learn from informal comments and complaints.
There were gaps in the daily recording of fridge temperatures in the treatment room. Room temperatures were also not recorded to ensure the room was kept below recommended limits when storing any medicines outside the fridge.
Staff were not confident with tasks that were carried out infrequently such as seclusion. The seclusion area was a shared facility with the children’s place of safety which meant that during the seclusion there was no access to the children’s place of safety unit in the area.
Recent staff vacancies and leadership changes had affected the morale of the team and some staff did not feel confident to raise concerns. This had also resulted in some systems falling behind such as; mandatory training for some staff, and business meetings to share learning, and local and service wide information.

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

An agency worker was working with children and young people without a disclosure and barring check.
Waiting times to access most services were very long for many patients. The provider was not transparent in the way it reported waiting times for treatment.
The complaints process was not promoted to people effectively and concerns of parents and carers were not always listened to.
Staff were not following the lone worker policy consistently.
When assessments of mental capacity for young people aged 16 and over were required, these were not properly recorded and compliance with the Mental Capacity Act was not monitored.

Some carers felt they had been ignored and this had led to them making a complaint.

However:

Services were provided by well trained staff with a wide range of specialisms.
Effective systems were in place to make sure that the most urgent needs were dealt with quickly.
Managers and staff were committed to improving the service through new therapies and better relationships with other services.
The provider showed evidence of learning from incidents that affect patient safety.
Care plans were prepared in partnership with young people and their carers

We carried out an unannounced focussed inspection on 17 October 2016 to see if the provider had met the concerns we raised in a section 29 warning notice following our comprehensive inspection of the provider in June 2016.

We found evidence that Plymouth Community Healthcare CIC had made progress and improvements. At this time we will not be taking any further enforcement action but will continue to monitor the provider's compliance with the warning notice, this is because:

Between 21 and 23 June 2016 we inspected the services delivered by the community mental health teams for adults with mental health as part of the comprehensive inspection. During the inspection we found that the provider was not meeting the standards expected in this service as it did not have appropriate processes in place to monitor and prevent avoidable harm, or the risk of avoidable to harm to patients using the service.
We found that the provider was in breach of Regulation 12 (1)(2)(a)(b)(c)(g) safe care and treatment, Regulation 17 (1)(2)(a)(b) good governance and Regulation 18 (1)(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a warning notice on 15 July 2016. We told the provider to achieve compliance with the above regulations by the 19 August 2016. The provider sent us a comprehensive response and evidence demonstrating their compliance to all the concerns raised in the warning notice.
We carried out an unannounced, focussed inspection of the South and West teams on 17 October 2016 to assess if the provider had addressed the concerns and to check the progress that had been made. During our inspection we spoke with 12 staff, including the South and West locality managers and reviewed six care notes.
The provider had implemented processes to regularly monitor and assess the risk of patients on the waiting list and prioritise them in order of risk. All six records we sampled had been reviewed, had details of each client’s key risks and contained a crisis and contingency plans with identified triggers and early warning signs. However, we still found that the South and West teams had over 50 patients on their waiting lists. At the time of inspection the longest a patient had been waiting was 26 weeks.
We found that the provider’s medicines management had improved. Audits showed that staff were taking action to address the high fridge and room temperature in the South team’s clinic room. The clinic room was clean and all medicines were in date.
The provider had recruited more band six nurses; the South and West teams were less reliant on agency staff. However, at the time of inspection the teams were still carrying eight vacancies.
Data provided by Plymouth CIC showed that all staff had received recent supervision. Staff we spoke to told us that supervision was now happening and they were receiving better management.
As a result of actions taken by the provider staff told us they that a safer service was being delivered to patients, although they still felt stressed by the pressures from vacant posts and waiting lists.
Overall, we found evidence of progress and improvements being made across all the concerns raised in the warning notice although this was not enough to remove the warning notice. The provider had put in place several positive changes that were improving the safety of the service delivered. However, the provider had not addressed all concerns relating to waiting lists and vacancies. At this time we will not be taking any further enforcement action but will continue to monitor the providers’ compliance with the warning notice.

During our comprehensive inspection of the provider in June 2016 we rated community-based mental health services for adults of working age as inadequate because:

The service had substantial difficulties with recruitment and retention of staff. This included doctors, nurses, and allied health professionals such as social workers, psychologists and occupational therapists. Difficulties with staffing had been known to the service for at least 12 months prior to our inspection. There was very high use of agency and locum staff in the south and west teams, and teams had difficulty covering for sickness, leave or vacant posts. Two serious incident investigations had highlighted concerns about safe staffing. Staff in the south and west teams were stressed and morale was low.
Waiting lists for allocation of a care co-ordinator and lack of staffing were impacting on effective handover between teams within the organisation and some of the community mental health teams. Patients told us that they saw lots of different doctors, that there was high use of agency staff and that they did not always know who they were going to see. Staff told us that appointments were cancelled due to staff shortages. 2,444 appointments had been cancelled by the west, south and east teams between 1 June 2015 and 31 May 2016.
All teams had waiting lists for patients waiting for allocation of a care co-ordinator. Although waiting lists were reducing, referrals into the service remained higher than the numbers of patients being discharged. Three patients had been waiting between 31 and 35 weeks. This was in breach of 18 week targets, and two people who had been waiting since October 2015 were potentially high risk. Although there was some monitoring of patients on the waiting lists, this was not sufficiently robust. Risk assessments that were carried out at first assessment were too basic and did not provide sufficient information to give staff a baseline risk against which to monitor, there was no waiting list monitoring tool to ensure consistent review of people waiting for a care coordinator, and waiting lists were not rated by severity of risk. One-third of risk assessment were not up to date.
We had concerns about clinic and medication management in two of the three teams. This included clinic room and fridge temperatures not being recorded, out of date medications and an unlabelled medication in the medication cupboards. The wrong depot medication had been administered by another community mental health team in June 2015, and poor medication management increased the risk of medication errors.
Staff had not been trained in STORM suicide risk assessment training, despite the need for this being highlighted in a serious incident investigation, and the action having been signed off as completed. No agency staff had received STORM training. One agency worker had not received duty training before working as the duty worker and had been involved in a serious incident whilst on duty.
The quality of care plans varied and not all were personalised, holistic or recovery orientated. Staff were not trained to provide psychological therapies and there was a one year waiting list for cognitive behavioural therapy and a five month wait for psychotherapy. The provider was not meeting targets for improving physical health for people with severe mental illness, and the providers own audit showed that only 11% of patients in the south had not received annual physical health checks. Referral to assessment and treatment data was only available for the 18 week target and therefore the provider could not demonstrate that it was seeing urgent patients in a timely manner.
Information about advocacy was not made widely available and patients and patients and carers had limited ability to contribute to the running of the service.
Governance and leadership were inadequate. The provider had not undertaken a thorough analysis of the service in order to fully understand the root causes of the difficulties in employing and retaining substantive staff. There was no workforce strategy for community mental health teams despite issues with recruitment and retention having been ongoing for at least 12 months.
The provider did not have a clear plan to reduce the waiting lists, maintain reduced waiting lists, or ensure those on the waiting list were effectively monitored for deterioration in their mental health.
Staff had to access a number of different documents, some of which were draft copies and contradicted each other, in order to ascertain guidance on operational procedures. There was a draft operational policy for adult community mental health teams. The service specification was also a draft. Guidelines for prioritisation of referrals did not relate to the draft service specification and aims and objectives of the service were not defined.
Systems to monitor supervision and training of staff were not effective, lessons and recommendations from internal investigations of incidents were not always implemented and some serious incident investigations took too long. This meant that the there was a risk of similar incidents happening again. Some actions that the provider had taken as a result of complaints were unlikely to effectively reduce complaints as we found that contributory factors such as staff shortages, waiting lists and use of locum doctors were still present. This meant that patients were still likely to have cause for complaint.

However:

Staff tried to ensure that essential tasks to ensure patient safety were undertaken, psychiatrists were available when needed and patients had numbers to contact if needed.
Staff were aware of the problems in the service and wanted it to improve. Patients told us that staff were kind, respectful and friendly.
Team managers ensured staff received induction and were trying to improve access to supervision by using supervision groups. Staff told us that they felt supported by team managers and locality managers.

We rated Plymouth Community Healthcare’s home treatment team and health based places of safety as good because:

There was a separate place of safety for adults and young people. Staff manged risk well, including environmental risks and safeguarding concerns.
Care records showed that patients received care based on their needs. Staff had completed risk assessments and care plans that reflected the patient’s individual needs.
The places of safety had a clear policy on how the patient pathway was set out. There had been a gradual reduction in the use of police custody for section 136 purposes for adults and since the introduction of the place of safety for young people, there had been no use of police custody for this patient group.
There was evidence of good multi-agency working including shared forums for reviewing issues, strategic meetings, addressing continued service improvements and positive relationships within operational services.
Patients mostly gave positive feedback on the service and said that staff were supportive and listened to them. When we spoke with staff, they reported feeling well supported by their management team.

However:

There were some environmental issues with the places of safety, including a missing clock which meant that the patient could not maintain awareness of time and the quality of the environment in the suite for children and young people.
The caseload for the home treatment team (HTT) was higher than normal due to having community mental health team (CMHT) patients on their caseload. This was due to their concerns over the quality of service that the four CMHT’s provided. This placed additional pressures on the team impacting on the frequency of both management and clinical supervision available to staff and the frequency of team meetings.

We rated acute wards for adults of working age as outstanding because:

The Glenbourne Unit was well-led with a positive, supportive and motivated management team who ensured their passion for improving mental health services for patients was shared with the team members.
Patient records were of very high quality. Care plans and risk assessments were up to date and thorough.
The wards kept blanket restrictions to a minimum and ensured any blanket restrictions in place were justified by risk assessments.
The 2015 mental health inpatient survey had rated nurses at the Glenbourne Unit highest in the country for treating patients with dignity and respect.
All of the patients we spoke with were extremely positive and complimentary about the support they received from the ward staff.
Patients were involved in their care and treatment plans, their opinions were respected and their views were recorded.
The redesign and refurbishment of the unit was well thought through, prioritised improving patient care and the patient experience on the unit and had delivered a greatly improved ward environment.

We found the service provided by the community sexual health service to be good because:

Risk was managed and incidents were reported and acted upon with feedback and learning provided to staff. Staff adhered to infection prevention and control policies and protocols.
Treatment and care were effective and delivered in accordance with best practice and recognised national guidelines. There was excellent multidisciplinary team working within the service and with other agencies.
Patients were at the centre of the service and the priority for staff. Innovation, high performance and the high quality of care were encouraged and acknowledged. Patients were respected and valued as individuals. Feedback from those who used the service had been exceptionally positive. Staff went above and beyond their usual duties to ensure patients received compassionate care.
Care and treatment was delivered in a compassionate, responsive and caring manner. Patients spoke highly of the approach and commitment of the staff who provided the service.
Patients received excellent care from dedicated, caring and well trained staff who were skilled in working and communicating with patients.
Staff understood the individual needs of patients and designed and delivered services to meet them.
There were clear lines of local management in place and structures for managing governance and measuring quality. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.
All staff were committed to patients and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the unit as a place to work. They spoke highly of the culture and levels of engagement from managers.
There was a good track record of lessons learnt and improvements when things went wrong. This was supported by staff working in an open and honest culture with a desire to get things right.

However:

Clinical supervision was not being provided on a regular three-monthly basis in line with the organisation’s policy.
Administration staff did not have any written advice about how to manage clinical telephone queries during periods when a clinician was not on site to deal with the caller.
There was no formal system in place to follow up patients and those considered to be particularly at risk if they missed their appointments.

All Inspections