Essex Partnership University NHS Foundation Trust

Updated 12 July 2023

We inspected Essex Partnership University NHS Foundation Trust (EPUT) because we received information and had concerns about the safety and quality of services.

We carried out an unannounced comprehensive inspection of 6 core services:

• Wards for people with a learning disability or autism
• Acute wards for adults of working age and psychiatric intensive care units
• Mental health crisis services and health-based places of safety
• Wards for older people with mental health problems
• Substance misuse services
• Community-based mental health services for adults of working age

We also inspected the well-led key question for the trust overall.

We chose to inspect acute wards for adults of working age and psychiatric intensive care units to see how many improvements had been made following our inspection in October 2022 where we rated the safe domain as inadequate and issued a warning notice. We chose to inspect 3 core services based on their ratings at comprehensive inspections in 2018 and 2019 to see if the trust had made improvements to quality and safety. We chose 2 core services that were rated as good in 2018 to check if the trust had sustained the quality of care delivered.

The trust provides the following mental health services, which we did not inspect this time:

• Child and adolescent mental health wards
• Community mental health services for people with learning disabilities or autism
• Community-based mental health services for older people
• Forensic / secure wards
• Long stay/rehabilitation mental health wards for working age adults
• The trust provides community health services, which we did not inspect this time:
• The trust delivers the following community health services:
• End of life care
• Children and young people’s services
• Inpatient services
• Adult services

Our rating of services ​went down​. We rated them as ​requires improvement​ because:

• We rated safe, effective, responsive and well-led as requires improvement. We reduced the overall rating for caring from outstanding to good because this is a more accurate reflection of how the trust are currently performing overall. Our overall rating considered the current ratings of the 5 mental health core services and 4 community health core services we did not inspect at this time.
• The governance and safety culture of the trust did not always support the delivery of high quality, person centred care. Issues with timeliness in responding to lessons and inaccurate data impacted staff's ability to support people appropriately. Three core services had declined in their quality. Wards for people with a learning disability or autism and community based mental health services for adults of working age went from good to requires improvement and acute wards for adults of working age and psychiatric intensive care units went from requires improvement to inadequate. Two core services – wards for older people with mental health problems and mental health crisis services and health based places of safety had remained requires improvement overall. One of the 6 core services we inspected had improved from requires improvement to good overall: substance misuse services. The trust had plans or had recently launched new strategies to address key safety concerns for example around staffing vacancies and patient safety observation, but many were very new and not yet embedded.
• Across the 6 core services we rated 30 domains associated with the key questions. In 9 examples there was an overall reduction from good to requires improvement. In one example there was a reduction from requires improvement to inadequate. In 1 examples ratings remained the same. In 3 examples domains had improved from requires improvement to good and in 1 example the safe domain improved from inadequate to requires improvement.
• The most concerning ratings were for acute wards of adults of working age and psychiatric intensive care units. We rated safe and well led as inadequate, the other domains as requires improvement which means this service is still inadequate overall. The trust failed to ensure that all the concerns highlighted in the warning notice issued in October 2022 had been achieved consistently across all wards. For example, on some wards staff still applied blanket restrictions. Examples included searching all patients returning to wards and preventing patients from accessing fresh air freely.
• There remained ongoing challenges with staffing wards consistently and we identified problems with staff completing patient observations safely and in line with trust policies. The rating for safe had remained inadequate, the same rating applied during the inspection in October 2022. CQC recognised Trust wide plans to address issues such as staffing. However, several aspects of these plans were not fully implemented embedded to impact care on all the wards yet.
• We also saw a reduction in the quality of care staff provided in wards for people with a learning disability or autism and community based mental health services for adults of working age. Both services overall ratings had reduced from good to requires improvement.
• Whilst there were still improvements required across a number of core services and leadership did not always support the delivery of improvement at pace, the trust recognised this and were in the early stages of implementing various programmes and processes which would drive the quality of care up. The leadership team had been increased to support executives in driving quality improvement. The CQC reflected the need to ensure pace and priority for this work and the trust agreed and committed to this.

Our inspection identified the following areas where further improvement was needed:

• The arrangements for governance, assurance and performance management did not operate effectively. The CQC recognised the timing of the inspection meant there were multiple examples of new strategies, systems, roles and approaches that were in the early stages of implementation. Examples included the trust safety strategy, the appointment of directors of quality and safety and the implementation of ‘Time to Care’ and safety dashboards. All of these required further embedding to directly impact the quality of care people received. The pace of change remained a concern along with ongoing and repeated breaches of regulation identified in services that had been highlighted to the trust during previous inspections dating back to 2019.
• The approach to service delivery and improvement was reactive and the trust were in the early stages of implementing more robust assurance arrangements to support a proactive response to improvement. There remained work to be done to ensure quality improvement initiatives were present in services and making an impact on the services people received.
• Staffing remained a challenge. Bank and agency use was higher than the trust targets. Managers described ways they attempted to book staff familiar with the wards and patients, but staff and patients told us unfamiliar staff were an issue, especially during evenings and weekends. Sickness was rated as ‘amber’ on the trust risk register at 6%. There were challenges in recruiting to roles, vacancy rates for qualified staff were 21%. We continued to find issues with how staff observed patients, with examples of staff sleeping and not interacting in a therapeutic way. However, it was recognised there were some early programmes of work which may have a positive impact in the future, such as the recruitment programme for internationally trained nurses.
• Data quality affected the trust’s ability to monitor and mitigate against poor performance, risk and poor quality. Data provided about key elements of service performance from executive level did not match with information we found at ward level. An example that supports this can be found in the report for acute wards for adults of working age and psychiatric intensive care units relating to supervision and appraisal data. There was a lack of pace relating to over 10 items reflected on the board assurance framework. From October 2022 – January 2023 there were 7 strategic and 8 corporate risk items that had shown no movement is their score. We identified issues with quality audits not highlighting gaps in the quality of care being provided, an example of this related to governance systems providing false assurance to the board about the quality of patient observations being delivered on wards. There were issues with inpatient services having low bed occupancy despite community teams having increased caseloads and waiting lists. An example of this was seen in acute wards for adults of working age and psychiatric intensive care units and community home treatment teams, this had not been robustly addressed by the trust.
• The trust were due to launch their new data strategy following the inspection to build on their digital strategy. This would provide focus on how best to utilise data to provide robust intelligence and information to improve patient outcomes. Electronic systems and data quality required attention and pace. The trust have been using 7 different electronic patient record systems since the merger in 2017 and 6 years later are in a position of having funding approved to develop and implement a single system for the trust. In August 2019 we highlighted to the trust issues with training data, performance data and staff difficulties with multiple electronic recording systems. However, the health information exchange (HIE) remained in place to support record sharing between teams.
• Medicines optimisation and management across the trust required improvement. Pharmacy workforce challenges affected the quality and sustainability of medicines services. Pharmacy teams operated with a 45% vacancy rate overall. Organisational restructures and reporting lines meant Pharmacy teams felt removed from operational decision making. There were issues with medicines management on wards and the capacity of Pharmacy teams to audit and offer support was compromised by staffing challenges. The trust continued to advertise Pharmacy roles but had trouble in recruiting.
• Leaders did not always support staff effectively. Supervision and appraisal rates did not consistently achieve the trusts target meaning not all staff had regular access to this support. Meetings and opportunities to share learning did not take place consistently and regularly. This applied at all levels in the trust and minimised lessons and learning influencing strategy and practice. Feedback from staff about their engagement with the trust varied greatly, some staffing groups felt disconnected and that leaders did not listen to or recognise their concerns, whilst other groups were mainly positive. Forty two percent of the focus groups expressed some level of concern regarding their ability to express concerns and engagement with the organisation.
• Long standing complaints required attention to ensure complainants received responses in good time and knew what was happening with their case. One example showed a complaint being made in August 2021, not resolved and the most recent contact recorded as April 2022. Whilst recognising the very recent implementation of a new complaints process, we were not assured that there was enough focus on resolving long standing complaints.

Our inspection identified a number of areas where improvements had taken place:

• There was a full recognition by the trust of the need to continually improve the culture of the organisation. The freedom to speak up guardian, although in an interim post, had worked hard to increase their visibility and share the importance of speaking up. Many of the staff we met during the inspection talked about the improvements in the workforce culture, although there were still pockets of poor morale, mainly due to staffing challenges and some issues identified via an internal inquiry following a television broadcast. The trust board displayed positive role modelling behaviours which they demonstrated throughout the well led review. The trust made sure learning featured at different levels in the organisation from the executive level learning sub- committee group through to learning newsletters displayed on wards and in services. Executives made themselves available to staff via ‘grills’ where staff could directly challenge leaders about their concerns or any issues. The trust appointed 500 engagement champions who could access the CEO directly, however there remained challenges with capturing the voice of staff working on inpatient wards. The trust set expectations about staff behaviour and developed a behaviour framework to outline clear boundaries about unacceptable behaviour and consequences for those behaviours. This was initially driven by the need to support staff who experienced racial abuse (identified at the CQC inspection in November 2022) but was not limited to this issue.
• The trust was actively involved work across the systems relevant to Essex. Three members of the executive team served 3 integrated care boards (ICB’s) relevant to the trust’s portfolio. The trust was part of four integrated care systems and were involved in 6 place based alliances. The trust also engaged with 3 local authorities which served different areas to those associated with the ICB’s. Trust leaders understood the need to design, plan and develop effective services to meet the needs of the local population. A priority for the board was to ensure that the trust faced outwards and developed a reputation of transparency and openness. The trust opened their committees to governors to increase challenge and accountability and support the work of the non-executive directors. Feedback from people was integral to planning and reviewing services. The patient experience team developed multiple ways for people to provide feedback on their experiences by working with local teams to understand what fitted their demographic. This included the use of text messages, quick response (QR) codes, paper ballot boxes and forms. The work on creating a variety of feedback methods contributed to an 800% increase in feedback from August 2022 – January 2023. Work was ongoing to ensure that patients and people who use service featured as a key stakeholder. The ‘your voice’ community provided challenge and feedback to the board and the trust launched ‘I want great care’ in January 2022. The patient experience annual review from November 2022 demonstrated positive results for involvement including 92% growth in the recruitment of volunteers (from 126 in 2021 to 243 in 2022) and a 720% growth in recruitment to the lived experience team (from 10 in 2021 to 82 in 2022).
• The trust participated in the early adoption of the patient safety incident response framework (PSIRF). This sets out the NHS’s approach to developing and maintain effective systems and processes for responding to patient safety incidents. The purpose is to develop a culture of learning to improve patient safety. The patient safety team engaged regularly with the national team to support the re-design of materials to improve their quality. The trust made a commitment to PSIRF despite the fact it was promoted as a cost neutral programme but has needed investment. Responses to patient safety incidents demonstrated compassion and answered all questions and concerns put forward by families and carers.
• The trust was the lead provider for the COVID-19 vaccination programme and was integral to ensuring people of Essex had access to this. They set up multiple vaccination sites quickly, delivered 1.6 million vaccinations and worked with local systems and partners to offer vaccinations to hard to reach and marginalised groups. The trust used creative ways to increase vaccination uptake such as vaccination busses and home visits.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about each of the core services.

During the inspection visits, we:

• Visited 29 wards, 17 teams and 4 health based places of safety
• Spoke to 224 staff performing a wide range of roles
• Spoke to 104 patients and 17 relatives or carers
• Looked at 182 individual patient records
• Looked at over 116 medication records
• Attended 29 meetings including staff handovers, multidisciplinary meetings and patient community meetings. We observed 5 examples of patient care by sitting and watching from patient areas.
• Attended 4 home visits
• Held 12 focus groups with staff of all grades on a variety of topics
• Looked at records, policies and procedures involved in the day to day operation of the services.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke to 104 patients and 17 relatives and carers across the services we inspected. Patients and carers gave largely positive feedback about the way staff treated them and the support they offered. Patients and carers gave examples of staff treating them as individuals and involving them in their care.

On acute wards for adults of working age and psychiatric intensive care units, most patients told us staff working day shifts treated them with kindness and helped them to be independent. Patients liked the choice of food and the fact they could have snacks and drinks throughout the day. On wards for people with a learning disabilities and/or autism people told us staff treated them with kindness and that staff provided activities that they enjoyed such as cycling and colouring. Staff supported carers to attend the ward for visits and clinical meetings and involved them in planning the care and discharge of their loved one. On the wards for older people with mental health problems patients told us that staff listened and helped them to understand their care. Patients felt safe, valued and respected.

In the community-based mental health services for adults of working age, patients and carers praised the staff for making sure everyone was involved in care decisions and that staff looked at physical and social needs alongside their mental health. They felt the service responded to their needs quickly and involved other services which could help. Patients liked the frequency of their appointments and the fact that there was a team approach so they could be seen by others if their worker was on leave or absent and didn’t have to repeat their care story. In the mental health crisis services and health-based places of safety, patients said staff treated them kindly and offered flexible appointments to meet their needs. Patients felt staff offered them opportunities to be involved in their care and did everything they could to provide care in the community and help people stay out of hospital. In substance misuse services, people felt staff had an excellent knowledge of substance misuse and this helped them feel supported. They described staff as being available when they needed them and making every effort to involve people in their care.

There were however some areas for improvement identified by people who used the services. On the acute wards for adults of working age and psychiatric intensive care units’ patients and carers described issues with staff working nights. This included 5 patients describing staff falling asleep at night, 3 patients told us that staff talked in different languages during night shifts and were ‘uncaring’. Four patients told us that staff observing them did not engage with them. One patient described issues with the food portions and 11 patients told us that the coffee was decaffeinated so staff could support them with good sleep hygiene. On wards for people with a learning disabilities and/or autism there had been an issue with a walk being cancelled due to staffing shortages and not all carers had a copy of their relative’s care plan.

In the community-based mental health services for adults of working age, some people told us they would like more definite goals and to see the Doctor more often for reviews.

Updated 26 July 2018

We rated community health services for adults as good because:

• The service managed patient safety incidents well. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service planned for emergencies and staff understood their roles if one should happen.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• The service provided care and treatment based on national guidance and evidence of effectiveness. The service monitored the effectiveness of care and treatment and used the findings to improve them.
• Staff of different kinds worked together as a team to benefit patients.
• Staff understood their roles and responsibilities under the Mental Capacity Act 2005.
• Staff cared for patients with compassion, involving patients and those close to them in decisions about their care and treatment. Staff provided emotional support to patients to minimise their distress.
• The trust planned and provided services in a way that met the needs of local people. The service took account of patients’ individual needs. People could access the service when they needed it. Response times and waiting times were monitored and senior staff took action to improve access to the service.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action, developed with involvement from staff, patients, and key groups representing the local community.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers across the trust promoted a positive culture that supported and valued staff.
• The trust had a systematic approach to continually improve quality and safeguard high standards of care and treatment by creating an environment in which excellence in clinical care would flourish.
• The service had effective systems for identifying risks and planning to eliminate or reduce them. The trust collected, analysed, managed and used information well to support all of its activities, using secure electronic systems with security safeguards.
• The trust engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.

However:

• Staff had not always completed mandatory training provided, to the trust’s target.
• Equipment was kept on the floors of large storage cupboards, which reduced effective cleaning of these areas to prevent healthcare associated infections.
• Patient records did not demonstrate that all patients received timely risk assessments such as malnutrition universal screening tool and Waterlow risk assessment.
• Records provided by the trust showed compliance with staff appraisal did not meet the trust’s target of 90%.

Updated 26 July 2018

We rated community health services for children and young people as good because:

• Staff kept children and young people safe from harm and abuse. Staff understood and followed procedures to protect all children and young people including those that were vulnerable. Staff assessed and monitored individual patient risk.
• Staff had appropriate skills, knowledge and experience to deliver effective care and treatment. There was effective multidisciplinary working across the service and care was delivered in line with national and best practice guidelines. Staff planned and delivered services to meet individual needs.
• Staff cared for children, young people and families with compassion, dignity and respect. Staff involved patients and carers in decisions and their care and treatment.
• There was a strong, visible person-centred culture and staff are highly motivated and inspired to deliver care that is kind and promotes children and young people’s dignity. Parents and children we spoke with valued their relationships with the team and felt that staff often went the ‘extra mile’.
• Staff supported the children and young people to minimise their distress.
• Complaints were effectively managed and the outcomes used to improve the quality of the service.
• The service had governance frameworks, risk management plans and quality monitoring systems in place to improve patient care, safety and outcomes.
• There was a systematic programme of clinical audits across the service to reassure senior staff of the safety of the service.
• There was a child friendly patient satisfaction survey to provide feedback.
• Staff were given opportunities for further learning and development. Several staff members described how they had developed and progressed within the organisation. Managers spoke of succession planning.

Updated 26 July 2018

We rated community health inpatient as good because:

• Patient safety was prioritised, which was reflected in the running of the service.
• Care and treatment was delivered effectively by competent staff.
• Patients were involved in their care, and were shown compassion by the staff working with them.
• The service was planned based on the needs of local people, and new initiatives were set up to improve the service.
• There was an open and transparent culture with engaged and experienced leadership.

Updated 9 October 2019

Our rating of this service improved. We rated it as outstanding.

The summary for this service appears in the overall summary of this report.

Updated 29 July 2022

Essex Partnership University NHS Foundation Trust provide community health, mental health and learning disability services for a population of approximately 1.3 million people across Bedfordshire, Essex, Suffolk and Luton.

Essex Partnership University NHS Foundation Trust provides child and adolescent mental health inpatient services to young people and their families living across the country where a community setting would not be a safe or appropriate place for children and young people’s treatment. The child and adolescent mental health inpatient service consists of three wards located across two sites at the St Aubyn Centre, Colchester and Rochford Hospital.

We carried out this unannounced focused inspection to follow up on the conditions placed on the Trust’s registration after our previous inspection. The conditions included restricting the service from admitting any new children and young people without the prior written agreement of the Care Quality Commission and a condition to ensure all three wards are staffed with the required numbers of suitably skilled staff to meet the new children and young people’s needs and to undertake children and young people’s observations as prescribed.

During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. As result of this, the imposed conditions have now been removed.

At this inspection, we inspected all three wards of the child and adolescent mental health service; Larkwood ward, Longview ward and Poplar adolescent unit.

The St Aubyn Centre accommodates Larkwood ward and Longview ward. Larkwood ward is a ten bedded, mixed sex, locked psychiatric intensive care unit. It provides acute and intensive psychiatric care and treatment for young people between the ages of 13 and 18, who are experiencing acute, complex and / or severe mental health problems.

Longview ward is a 15 bedded, general psychiatric mixed sex ward, providing inpatient assessment and treatment for young people aged 13 to 18 years.

Rochford Hospital accommodates Poplar adolescent unit, a 13 bedded general psychiatric, mixed sex ward providing inpatient assessment and treatment for young people aged 13 to 18 years.

All three wards had education facilities on site, providing education and vocational opportunities in line with the national curriculum.

The Care Quality Commission have registered this service for the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983.
• Treatment of disease, disorder or injury.

Our rating of services improved. We rated the service as requires improvement because:

• The service did not manage the disposal of medicines and sharps safely. The service did not dispose of out of date stock items as required.
• Staff did not always follow the Trusts’ policies and procedures with regards to the use of mobile phones and wearing personal protective equipment.
• The service did not ensure children and young people had access to snacks at all times without being dependant on staff.
• Not all staff respected children and young peoples’ privacy and confidentiality. Staff did not give carers information on how to find the carer’s assessment.

However

• The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well and followed good practice with respect of 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 children and young people and in line with national guidance about best practice.
• The ward teams included or had access to the full range of specialists required to meet the needs of children and young people on the wards. Managers ensured 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. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.

How we carried out the inspection

For this inspection we reviewed all the key lines of enquiry; safe, effective, caring, responsive and well led.

The inspection team visited all three wards between 1 March and 29 April 2022 and completed off-site inspection activity during this time. We returned to Poplar adolescent unit twice during this time following concerns raised during the inspection. During the inspection we:

• Visited the service and observed how staff cared for children and young people
• Visited the Poplar adolescent unit at night and observed how staff cared for children and young people
• Viewed eight extracts of CCTV from Poplar adolescent unit
• Viewed five pieces of body camera footage from Poplar adolescent unit
• Toured the clinical environment
• Spoke with nine children and young people who were using the service
• Interviewed 23 staff members and managers
• Spoke with five carers
• Observed one community meeting
• Reviewed 11 children and young people care records
• Reviewed 15 prescription charts
• Reviewed policies and procedures relevant to the running of the service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with nine children and young people across all three wards.

One young person told us not all staff knock on their door before entering.

One young person told us some staff ignore them and don’t engage with them. Four children and young people told us they do not always know the night staff, they were always different, and this makes them feel uncomfortable.

Two children and young people told us they never meet with their named nurse.

Three children and young people from either Longview ward or Larkwood ward, told us their leave had been cancelled due to the wards being short staffed.

Two children and young people told us there is a lot of restraint on the wards and one young person told us they feel non-regular staff panic and don’t de-escalate incidents as often as they should. One young person told us they felt they were restrained more than they should have been.

One young person told us some staff talk about other children and young people in front of them.

Five children and young people from Larkwood ward or Longview ward told us snacks are on a timetable and they cannot access fruit or snacks when they want.

Five children and young people told us they did not like the food and the quality of the food is poor. Two children and young people told us the level of choice was limited.

Three children and young people told us staff were nice, kind, respectful and felt like they cared.

Two children and young people told us they knew all about their medications and side effects.

Two children and young people told us education was good and had helped them.

We spoke to five children and young peoples’ carers. Two carers told us they were not involved in their relatives’ care and it is left to the young person to phone them to inform them what is happening.

Three of the carers we spoke to had not been asked to give feedback on the service.

Three carers told us they had not been informed about the carer’s assessment.

Updated 26 July 2018

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

• Staff completed comprehensive assessments of risk that they updated when risk to patients changed. Staff ensured that if a patient suffered a crisis, there was a plan in place for the patient and carers to follow to reduce risk. Staff monitored patients on waiting lists and allocated patients according to priority of risk.
• Staff completed mandatory training and teams met the trust target for this. Managers provided regular supervision and yearly appraisals of staff’s performance. Staff had access to a trust wide leadership and development programme to increase their skills and support career development.
• Staff knew how to report incidents and what to report. Staff were trained in safeguarding and knew how to make a safeguarding referral.
• Care records were personalised. There was evidence that patients were given pictorial and easy read care plans. Staff made records of physical health assessments in the patient notes and kept GPs informed of care plans.
• We saw evidence of mental capacity assessments and best interest meetings had been held where necessary.
• Staff were caring and passionate about the care they provided. Patients we spoke with told us they were pleased with the service that they received. Carers told us the team went above and beyond to support their relative. Staff were inclusive of patients’ needs and those in the children’s service involved parents and children in the care planning and risk assessment process.
• Staff provided a rapid response to support patients who experienced sudden to deterioration in physical or mental health. Carers told us that if they called the adult’s community learning disability team, they would get a response back the same day.
• There was evidence of parents evaluating the children’s learning disability service provision at the exit interview when children were discharged.
• Staff received feedback from complaints at team meetings and supervision.
• Manager’s had an open-door policy and aside from this there was a two hour protected time slot twice per month where staff could meet with the associate director and raise any issues.
• Service users were involved in recruitment.

However:

• There was no medical cover outside the hours of 9am to 5pm for this core service. Patients care plans instructed them to telephone the police or attend local accident and emergency departments if their safety was in danger.
• There continued to be long waits for psychology and Asperger’s assessment and treatment.

Updated 26 July 2018

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

• Overall, staffing levels were good. The trust determined staffing levels across the service and the number and grade of members of the multidisciplinary team required at each service. Overall, staffing levels were sufficient to meet the needs of the patients. Repeat appointments were held at appropriate intervals and were rarely cancelled.
• Staff could get access to psychiatrists for patients if urgently required. Staff responded promptly if they identified deterioration in a patient’s health and staff could refer to dementia review support teams, or to dementia intensive/crisis support teams.
• Staff monitored patients on waiting lists to detect and respond to increases in levels of risk. Staff used a red, amber and green traffic light system to highlight patient’s risk levels.
• Staff provided a range of care and treatments to patients. Staff held wellbeing groups for carers and patients. Kingswood Centre held a weekly dementia café in the community for patients, carers and members of the public interested to learn more about dementia. Patients were provided with information and support with employment, housing, benefits and interventions that enable patients to acquire living skills.
• We observed effective working relationships with other teams in the organisations. A newly funded role for care liaison looked to diagnose patients in care homes with dementia, and to support hospitals to prevent unnecessary admission to inpatient wards.
• Staff involved patients in care planning and risk assessment. At Brentwood and Basildon teams staff used ‘my care and my support’ plans with patients to gain the patient’s view of their needs. Examples of patient and carer involvement across the services included inviting patients and carers to care plan approach reviews. Staff knew patients’ needs and responded in a timely way.
• The buildings that accommodated the teams were clean, except one for one area that was dusty. They had good furnishings and were generally well maintained throughout. The trust had systems for cleaning, and adhered to control of substances hazardous to health guidelines. Staff followed infection control principles, including hand washing.
• Managers completed environmental risk assessments, including ligature risk assessments, except one. Patients were not left unattended in any of the rooms at all services. Staff had access to alarms when using interview rooms and staff were on site to respond to alarms.

However:

• There was a lack of oversight by managers and the wider trust in the managing of medicines and equipment on the older people’s mental health community services. Staff at the Basildon team had not checked and disposed of out of date medication. We found that four types of medication had expired, including four depot injections. This posed a risk that medication would not be effective for patients.
• We found some equipment had passed its use-by date in teams posing a risk that it would not be effective if staff used it with patients. For example, at the Harland team there were electrocardiogram pads which had expired in 2008. At Thurrock the blood pressure cuff and blood glucose strips had expired. The blood glucometer had no calibration date.
• Staff had not assessed ligature risks at Brentwood, which meant risks to patients had not been identified or mitigated.
• Across teams, patient care records were limited in information and detail. Three patient records reviewed had no care plan.
• Staff across teams did not have a consistent approach for completing physical health annual reviews and checks and records were difficult to find.

Updated 12 July 2023

Updated 12 July 2023

Updated 26 July 2018

Our inspection was announced (staff knew we were coming) to ensure that everyone we needed to talk to was available. Before the inspection visit we reviewed information that we held about these services and information requested from the trust.

Between 1 and 3 May 2018 the inspection team visited all seven forensic wards in Essex. We inspected the two forensic wards in Bedfordshire on 15 and 16 May. During both visits the inspection team:

• visited all nine wards and looked at the quality of the ward environment and observed how staff were caring for patients
• spoke with 51 patients who were using the service
• spoke with seven carers of people who were using the service
• interviewed the managers for each of the wards and one senior manager
• spoke with 62 staff members; including nurses, doctors and an occupational therapist
• attended and observed two handover meetings and five multidisciplinary clinical meetings
• looked at 46 care and treatment records of patients
• carried out a specific check of 110 medication charts
• Looked at a range of policies, procedures and other documents relating to the running of the service.

We rated Forensic inpatient or secure wards as good because:

• Staff completed individual patient risk assessments. They only searched patients who they had assessed as posing a high risk. Staff locked some rooms when not in use and maintained a presence in patient areas.
• Ward areas were visibly clean, had good furnishings and were well maintained. Staff had access to protective personal equipment, such as gloves and aprons in accordance with infection control practice. Posters advising staff of the principles of effective handwashing techniques were on display on all wards. Wards had fully equipped clinic rooms with examination couches and accessible resuscitation equipment, which staff checked regularly. Staff maintained equipment; stickers were in place specifying when it had been cleaned.
• Managers calculated the number of staff required to cover shifts, the staffing rotas showed there was the appropriate number of staff on each shift. Ward managers reported that they could adjust staffing levels to take account of increased clinical need. The number of nurses and healthcare assistants matched this number on all shifts. The ward manager could adjust staffing levels daily to take account of case mix.
• Staff identified and managed specific risk issues and gave examples where they provided specialist equipment to meet the needs of a patient who was terminally ill to prevent pressure sores. Staff identified and recorded changing risks on the risk assessment form in the electronic care record. Staff had access to ligature cutters in all areas in the event of an emergency occurring.
• Staff followed National Institute for Health and Care Excellence guidelines in relation to practice and when prescribing medications. These included regular reviews and physical health monitoring. Staff described applicable NICE guidelines and how they used these with patients. Psychologists used a variety of treatments including offence based therapy and an offending behaviour groups.
• Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw staff responding to patient's needs in a discreet and respectful manner. Staff treated patients with dignity and supported them to engage in a variety of meaningful activities, including education and employment. Staff interacted with patients in a timely way and at a level that was appropriate to individual needs.
• Patients had their own bedrooms, they could personalise these, for example with artwork and photographs. Patients stored their possessions in lockers adjacent to their bedroom. Wards had sufficient rooms for patients to access 1-1 time with nursing staff, to receive visitors or to participate in ward based activities.
• Wards had information boards detailing the staff on duty and staffing levels. These informed patients of the staff available for care and treatment for that day. Managers and staff facilitated weekly community meetings, these allowed patients to raise concerns and provide feedback about the wards. The minutes of the meetings showed that actions taken following the meetings, for example purchasing games and equipment for patients to use. Patients told us they had met with senior leaders when they visited the wards.

However:

• The kitchen fridge on Dune and Alpine wards and at Edward House contained open items of food. However, labels were not in place indicating when the food had been opened and when it should have been consumed by.
• Staff told us that one patient on Alpine ward was being cared for under the trust long term segregation policy and at times the patient also required periods of seclusion. We reviewed the records and found staff had not implemented the appropriate trust documentation when seclusion commenced. Staff had not completed the checks required for secluded patients under the Mental Health Act Code of Practice.
• We reviewed two seclusion records at the Robin Pinto unit. We found gaps in the recording of two hourly nursing and four hourly medical reviews. We also found that one patient had not had a medical review for 11 hours which is not in line with the Mental Health Act Code of Practice.

Updated 9 October 2019

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

The summary for this service appears in the overall summary of this report.

Updated 12 July 2023

Updated 12 July 2023

Updated 12 July 2023

Updated 12 July 2023