Avon and Wiltshire Mental Health Partnership NHS Trust

We gave an overall rating for community mental health services for people with learning disabilities or autism of good because:

• The services conducted assessments, including specialised risk assessments, at the appropriate time. Teams considered physical health needs and monitored them. Care plans were patient focused and staff were respectful of people using the service. Information was available in an accessible format and there was a patients forum that inputted in to the service that people could attend.

• There were good staffing levels and caseloads were appropriate. There was clear eligibility criteria and a referral pathways.

• The services regularly reviewed their practice; we saw evidence of learning from incidents, including changes in working practices. The intensive support team was reviewing their operating policy and referral procedure to ensure it met the needs of the people accessing the service. The forensic team had developed interventions from an evidence base, which met the identified needs of the people accessing the service.

However:

• The intensive support teams electronic record system did not have active risk assessments or contain all the required risk information. There was no effective procedure in place to mitigate this. Not all intensive support team care plans were uploaded on the electronic record system. Some people using the forensic service had not received their care plan in a timely fashion.

• Services did not have a full range of mental health professions in their teams.

• There were no recognised outcome measures in place and staff did not routinely give people information on how to make a complaint.

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

• There were not sufficient staff numbers to meet the needs of people using the services. There was a high level of qualified nurse vacancies on some wards with no psychology input.

• Levels of emergency response training and practical patient handling training were low.

• Staff did not consistently adhere to Mental Health Act legislation and standards described in the Mental Health Act (MHA) 1983 code of practice.

• Staff completed mental capacity assessments but did not document decision specific assessments.

• Staff were inconsistent when reporting of incidents.

• Staff did not always follow agreed actions or involve patients in care plans.

• Staff did not all use the health of the nation outcome scales for over 65s. They were not consistently monitoring patient’s outcomes.

• Multidisciplinary team meetings did not all have a full range of professions.

• The standard of the environments was variable. They were not all “dementia friendly”. Safety alarms were of variable quality or were not available. Some bedroom windows did not protect patient’s privacy and some patients slept in dormitories.

However:

• There was a recruitment plan in place to address shortages of qualified nurse vacancies.

• Staff met the mandatory training targets set by the trust in most subjects.

• Medicines management was effective throughout the services. Where medicines were kept on site, they were stored, monitored and audited safely.

• All patient files contained holistic, patient centred care plans.

• All wards had access to physical health care for patients. Staff assessed physical health on admission and monitored it frequently.

• Staff were very caring and demonstrated a high level of positive regard and respect to people accessing the services.

• Staff confirmed that they felt comfortable raising concerns with managers and were able to use the trusts whistle blowing process.

We rated specialist services as good because:

• The specialist services of Avon and Wiltshire Mental Health NHS Trust provided care and support for adults at a range of locations across the trust catchment area. Specialty services included: New Horizons, mother and baby unit and SpecialistEating DisorderService (STEPS), both based at Southmead Hospital.

• We found areas of good practice in both teams we inspected. In particular, we found that the inpatient eating disorder unit and the community teams were delivering specialist intervention work, and working together to ensure a smooth transition from referral through to aftercare in the community.

• The specialist mother and baby unit, New Horizons, had identified, through learning, that there was a need for a community team to support them with referral, access, discharge and aftercare. They were in the process of setting up this service within Bristol.

• Staff undertook research and accreditation programmes which resulted in service improvements. Learning also took place through incidents.

• The staff teams were consultant psychiatrist led and came from a range of appropriate disciplines. Each environment was appropriate for the specialism and was suitably adapted. However, the time given by some of the multi-disciplinary team was limited. For example, at STEPS, all staff and patients we spoke with told us that they could use more time with a dietician. At New Horizons there was no psychologist, however, the team worked closely with individual patient’s psychologist in the community and continued to support the relationship while the patient was on the unit.

• The activities on offer were varied and rehabilitative in approach. New Horizons had an occupational therapist who worked with every patient in a therapeutic way and used evidence based approaches. The building been purpose built as a mother and baby unit to meet the specific needs of the patient group and their babies.

• Each unit offered a comfortable, homely, and non-clinical environment with a focus on stepping back in to the community and involved family members.

• Staff appraisal, mandatory training and supervision rates were high. There was a commitment from the trust in continuing professional development, career progression, specialist training for their staff but it was limited due to budget.

• Staff used evidence-based tools to assess, monitor, and manage individual patient needs and risks. Assessment and planning was thorough and considered the patient’s physical and mental health. Family, carers and other professionals were involved in the patients’ treatment.

Are services safe?

We rated safe as good because:

• Both units were clean, homely and well maintained.
• There were risks, for example, ligature risks; however, these were managed through risk assessment, and action planning. There had been no recorded incidents relating to ligatures on either unit.
• There were two vacancies at the time of inspection and a recruitment process in place. All shifts were managed in advance, which allowed managers to ensure staffing levels were sufficient. There was an approval system in place and bank and agency staff were only used when necessary.

• There was an out of hours system in place, which was accessible to patients.

• Staff used de-escalation techniques to reduce the need for restraint.

• Risk assessments were completed for every patient on admission then regularly reviewed.

• Staff could identify what would constitute a safeguarding concern and knew how to alert the local authority or trust safeguarding team.

• Pharmacists and technicians regularly visited the wards to audit patient records and identify errors in line with the trust medication policy.

• Staff reported incidents. Managers ensured learning was shared following incidents.

Are services effective?

We rated effective as good because:

• Patients had a comprehensive assessment on admission, which included mental and physical health. On-going assessment was evident.

• Patient records were on a shared electronic record system that staff from other directorates could access at any time.

• Care plans were personalised, holistic and recovery orientated.

• Each ward was consultant led with junior and specialist doctors.

• Both units had received Quality Network Accreditation.

• Each unit carried out a number of audits, which involved clinical staff to help improve quality and make improvements when needed.

• Services were involved in research projects to help improve services and provide an evidenced approach.

• Mandatory and specialist training was supported and delivered to encourage professional growth for the benefit of patient recovery. There was scope for career progression.

• All staff received mandatory management and clinical supervision and staff appraisals were completed within timescales.

• Each ward had access to a multi-disciplinary team. A pharmacist attended wards weekly.

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• Both units had good connections with the general hospital.

• Staff knew, understood and observed the principles of the Mental Health Act and Mental Capacity Act.

Are services caring?

We rated caring as good because:

• All patients and carers we spoke with told us that staff were caring, kind and compassionate.

• Relatives and carers were welcomed and supported in continuing support to their loved ones while on the unit.

• Patients and carers were given welcome packs on admission. Visits on to the ward took place before admission and all patients and their carers were orientated on to the ward.

• Patients were offered treatment choices and they were fully involved in care decisions and given a copy of their care plan.

• Patients were involved in community meetings and had the opportunity to give feedback on the service they received and make suggestions for improvements.

• Patients who were discharged could give feedback and comment on their stay on the units.

Are services responsive to people’s needs?

We rated responsive as good because:

• Patients were assessed for appropriateness for access and discharge. This was considered as a multi-disciplinary team and could involve commissioners. There was an introductory period before admission and a local orientation for patients upon admission.

• Patients were prioritised within area and staff had relationships with other units to work together to find the right placement if an out of area was a consideration.

• Following discharge, patients received aftercare and follow up by the community team.

• Each unit had good links with local hospitals to support physical health needs of patients. They also had scope to increase staffing numbers if a patient required more intensive care.

• STEPS had communal and gender specific rooms. This enabled patients to mix with each other, partake in different activities, or spend time in quiet areas.

• Each unit had an activity room equipped with various activities such as crafts, games, jigsaws and activities of daily living kitchen.

• Patients were encouraged to spend time with their relatives, including children and we saw this happen on each unit.

• Patients were made aware of their rights on assessment, during their stay, and there was information on display on notice boards on each unit.

• There were activities at the weekend. Patients used community meetings to decide on activities and groups. Patients on each unit were supported in having home leave at weekends to spend with their families.

• There was a ‘you said, we did’ board and patients were encouraged to contribute to service developments at community meetings. There was scope to contribute outside the meetings, with anonymity, in the form of a comments box.

Are services well-led?

We rated well led as good because:

• Staff on each unit demonstrated the trust’s values and were proud of the job they did.

• There was an open culture of discussing issues arising within the units. Staff told us that they had respect for each other, that they worked well together and had the support of their managers.

• The trust, managers, and staff were committed to regular supervision and there was performance management in operation. Staff were appraised and supervised regularly and reflection groups facilitated by psychology were available to help staff reflect, learn and develop.

• Managers made use of part time staff who increased their hours to cover shifts to avoid using agency staff.

• There were governance meetings every fortnight led by the modern matron.

• There were care planning quality forums to improve quality; encourage patient led care plans, and discuss what makes care plans meaningful.

• The units worked closely with the local services, including hospitals to share resources and good practice.

• Working rotas were planned at least six weeks in advance but were not always as flexible as staff would have liked.

• Staff had access to some specialism training but this was limited. Staff told us they would benefit from wider range of options to gain the skills needed to work with their speciality.

We rated long stay/rehabilitation mental health wards for working age adults as good

because:

• Staff maintained the environment across all wards. We saw clinic rooms that were clean and arranged in a way that protected privacy. Information was freely available specific to independent living. For example, activity programs, educational opportunities and advocacy.

• The wards were staffed by a full multi-disciplinary team. This was reflected in the care plans and the majority of staff received regular supervision, appraisals and training.

• Staff were very caring and demonstrated a high level of positive regard and respect to people accessing the services. Staff attitudes towards people were warm, kind, non-judgemental and thoughtful.

• Medicines management was effective throughout the services. Where staff kept medicines on site, they were stored, monitored and audited safely. Three out of four wards had emergency drugs and resuscitation equipment present and documentation showed staff checked these regularly.

• Each ward had up-to-date, robust ligature risk assessments (environmental features that could support a noose or other method of strangulation), and management plans. Each ward had up-to-date environmental checks and clinical audits, including learning from incidents and improving standards, and reliable systems and practices to keep people safe.

However:

• The doors on Alder ward and Whittucks Road that separated male and female corridors did not have privacy glass. This meant male patients could clearly see into the female corridor.

• Staff on Elmham Way could not tell us where the ligature cutters were. This meant there might be a delay in responding to an incident.

• At Whittucks Road and Windswept, risk assessments did not link in with the appropriate care plan, and there was limited information about patient and carer involvement.

• Whittucks Road had some blanket restrictions in place that were not appropriate. These included, a notice asking patients not to watch the television after midnight, staff asked patients not to leave the premises after 10pm and staff kept the main kitchen locked at all times.

• Staff at Whittucks Road also managed the intensive service at night. This made staff feel vulnerable and meant that patient safety on Whittucks Road could be at risk because staff had to answer crisis calls when then should be working with patients on the ward.

We rated forensic inpatient/secure wards as good because:

• We noted significant improvements across both the medium and low secure units at this inspection. On entering the units, particularly Fromeside, there was a different atmosphere. Staff were visibly more relaxed and confident. We found issues we had raised previously had been comprehensively addressed and a considerable amount of quality improvement had taken place, with more planned.

• There were safe systems of work in place with good environmental security and good individual patient risk assessments. The introduction of ‘Safer’ staffing levels had reduced the usage of agency staff and improved relational security by using staff who knew patients. All wards had a very low use of restraint and seclusion and the majority of staff and patients told us they felt safe.

• Secure services management, ward staff and patients were working together to reduce blanket restrictions.

• The multi-professional staff team provided a good standard of care. Doctors followed best practice in prescribing and had an excellent system for monitoring physical health in relation to anti-psychotic medication. Occupational therapists ran the shift with registered nurses on rehabilitation wards and this had been a positive innovation. The service had piloted collaborative risk assessments which had improved patient care. Psychological therapies were available and there was a comprehensive range of activities, therapies and life-skills work available at the Malago centre.

• Patients were treated with dignity and respect and supported to be involved in the running and development of the service. The service was working towards developing greater friends and family input.

• Patients could feedback through their community meetings and issues were taken to the service user steering group which was attended by senior managers. The log of the meetings showed that issues were taken seriously and actions developed and followed up. Patients had complained about food quality and a large piece of work had been undertaken to try to improve the quality of the food.

• Senior management and the modern matron were visible to, and accessible to staff. Staff told us they felt listened to and could raise any concerns. Staff had a positive attitude to management. We found that there were measures in place to improve the leadership of new ward managers with coaching. The trust had put in place practice development nurses to provide additional development for nursing staff.

• Governance within secure services was effective. We noted that where we found areas needing improvement, management had identified these and already had a plan in place.

However:

• There were not enough qualified nursing staff on Siston ward and the service was finding it difficult to retain nurses on this ward.

• Although changes had been made to the search policy, there was no system in place to monitor the consistency and effectiveness of the new policy across both units.

We rated Avon and Wiltshire Mental Health Partnership Trust’s substance misuse services as Good because:

• Staff were following ‘Drug misuse and dependence: UK guidelines of clinical management (2007) and National Institute for Health and Care Excellence (NICE)’ guidelines for substitute prescribing and psychological therapy, which also informed trust policies and procedures.

• Staff monitored clients in the community safely and regularly throughout the treatment period. Medical cover was available over a 24 hour period and there were emergency procedures in place.

• Staff completed and updated risk assessments. They had a clear understanding of individual risks and were highly skilled and experienced. Risks were managed well both in community and inpatient settings. Recovery care plans involved the client and were clear and holistic and contained detailed information regarding client’s care and treatment..

• Environments, including clinic rooms, were clean and well maintained and laid out in a way which protected privacy. Information was freely available specific to substance misuse problems. For example other agencies, social services and advocacy.

• Medicines management was effective throughout the services. Where medicines were kept on site they were stored, monitored and audited safely.

• There were sufficient staff numbers to meet the needs of people using the services. The community specialist substance misuse services (SDAS) had reduced their staffing numbers when they redesigned their service models. Managers had worked creatively to ensure client safety through the redesign of the service.

• Community SDAS and inpatient services provided support for all healthcare needs associated with substance misuse. Staff supported people with blood-borne virus testing. Electrocardiograms were taken for people receiving high doses of methadone to monitor the effects on the heart. Some services provided specialist input into general practitioner (GP) surgeries, which was considered by GP’s as a highly effective service.

• Staff were very caring and demonstrated a high level of positive regard and respect to people accessing the services. Staff attitudes towards people were warm, kind, non-judgemental and thoughtful.

• The services were managed by highly committed and inspirational leaders. They demonstrated a clear determination to ensure that needs and safety were not affected by the redesigns and upcoming retendering processes. For example, Avon and Wiltshire Mental Health Partnership Trust provided the South Gloucestershire service. However in the near future other health organisations would have to opportunity to bid to manage this service instead. Staff told us they felt supported, supervised and positive about their place within the teams.

• The trust gave staff opportunities to develop leadership and specialist skills across the different roles within the service. Poor performance issues were managed well.

However:

• Although we saw that risks were discussed, reviewed and updated on Acer Unit, locating where updated risk assessments was difficult in patient records. There was no clear system in place.

• The redesign of the Bristol recovery orientated alcohol and drugs service specialist drug and alcohol service (Stokes Croft) had resulted in pressure and a backlog within the rapid prescribing service. This team was holding high caseloads as they waited to transfer clients to their Colston Fort specialist drug and alcohol service.

We rated one of the core services inspected as ‘inadequate’ and one as ‘requires improvement’. We rated five of the core services ‘good’ overall. We rated the specialist services as ‘good’ overall

We rated the trust as requires improvement overall because;

• We have served two warning notices in the past six months which imposed a legal duty on the trust to make significant improvements. We served one warning notice in December 2015 because we had significant concerns about the Bristol crisis, assessment and recovery services delivered to adults of working age and one during this inspection (May 2016) because of serious concerns about the quality of care in the health based places of safety across the trust. On both occasions we found that the trust did not have effective governance arrangements in place to enable it to assess, monitor and improve the quality of services (including the quality of the experience of service users in receiving those services). The trust had little knowledge of either of the issues until we raised these at the respective inspections and as such, we were not assured that governance arrangements and board oversight were robust enough to identify, address and learn from key risks in a timely manner.

We had serious concerns about the trusts ability to deliver safe, effective and responsive health based place of safety services. Patients were regularly taken to police cells (used as health based places of safety) because of the lack of availability of beds in the trust’s health based places of safety (police cells should only be used in exceptional circumstances). In addition, if the Mason unit at Bristol was full patients would be taken to the emergency departments at the local general hospitals. Emergency department staff raised concerns as this was felt to potentially put patients and staff at risk. Patients waited too long for a Mental Health Act assessment in the health based places of safety. Patients regularly waited over twelve hours for assessment and then waited many more hours for admission to a suitable ward if they needed inpatient care. In addition we had concerns about the safety of the environments of some of places of safety. at The new health based place of safety at Devizes had only been opened the week prior to our inspection despite us telling the trust that the old health based place of safety was not suitable for use during our inspection in 2014. It was not fit for purpose and did not have an appropriate emergency response system.There were on-going environmental issues with legionella at the Mason unit in Bristol as well as multiple known ligature points (environmental features that could support a noose or other method of strangulation).

• All crisis and health based place of safety staff we spoke with told us of the lack of bed availability across the trust which caused significant delays in getting patients into a bed following admission and had a serious impact on the capacity of staff (for example, taking clinician’s a whole shift to find a bed) and on the care of patients.

• The trust board was going through a period of significant change. The chief executive had only been in post three months during our inspection. The trust was recruiting to a number of director posts, including the medical director and finance director and was waiting for a new director of operations to commence in post. In addition, the chair was coming to the end of his term of office. Once the chair left post an interim chair would cover until a perminant appointment could be made. A number of non-executive director posts were also in the process of being appointed to. Alongside this, there had been a whole scale review of senior roles and strengthening of nursing leadership with the director of nursing and quality taking the lead for quality governance. This had caused significant instability, a lack of clear leadership and accountability for some initiatives and delivery of functions and some lack of engagement between senior leaders and staff. Staff reported that senior management based at trust headquarters were not as visible as they would like them to be.

• The triumvirates (locality and speciality management arrangements), whilst generally working well locally, often worked independently of each other and staff felt that they sometimes worked in silos, resulting in a lack of sharing and learning across the trust.

• We found that seclusion practices at Callington Road Hospital were not safe and that Silver Birch ward did not have adequate resources or facilities to care for people requiring seclusion. On some wards when seclusion was required patients were escorted, under restraint, out of the ward and across the hospital grounds to an available seclusion room. We felt that this placed patients in significant danger and did not preserve their dignity. The trust had advised that Silver Birch used secure transport to transfer patients to wards with seclusion facilities. However, the secure transport often took in excess of five hours to respond causing further delays in ensuring patients received the appropriate care at the right time.

• Older people’s wards across the trust, with the exception of ward four at Bath, did not provide appropriate environments to care for people with dementia. Laurel, Amblescroft North and Dune wards had made minimal adjustments to ensure they were ‘dementia friendly’. Laurel and Amblescroft were bleak and sparse with little in the way of decoration and no dementia friendly signage. Staff had made some changes on Dune, with some tactile artwork, appropriate signage and brightly coloured furniture. In some older peoples wards staff did not always report all incidents that occurred as there was a culture of acceptance about aggression exhibited by elderly patients with mental health problems, including dementia.

In the rehabilitations wards the trust was not meeting guidance on same sex accomadation. For example, Whittucks Road only had bathrooms

in female areas, which meant staff had to supervise if male patients requested a bath.

• In the acute wards and psychiatric intensive care units bed availability caused significant issues. Patients were regularly cared for in an ‘out of area’ bed, sometimes a long way from home. When patients went on leave there was often not a bed in the same ward that they left to come back to.

• The trust faced major challenges with maintaining safe staffing levels. In some services, particularly in crisis services the trust had difficulty providing data outlining the staffing establishments and when it did provide this it provided different information prior to inspection, during inspection and directly from the teams. This made it difficult to understand the staffing arrangements of the teams but all the data reflected that there were significant numbers of vacancies in some teams. The trust had undertaken a review of staffing levels on inpatient wards and for most staffing levels increased. This had resulted in a number of vacancies but the trust was proactively recruiting to fill these. In community and crisis teams, the trust had commissioned a review of working practices and caseloads and as a result staffing numbers had been reduced in some teams, for example the Wiltshire crisis team. Staff were not happy about this and reported that they felt there were not always enough staff to safely meet the needs of the service. There were high vacancy, turnover and sickness rates in a number of services including, forensic, acute inpatient and psychiatric intensive care, older people’s wards and substance misuse services. All areas used bank and agency staff but all areas tried to use the same staff to ensure continuity of care. Ward managers and team leaders were able to adjust staffing levels when bank staff were required. If bank staff were not available, ward managers and team leaders had to seek authority to use agency from service managers.

• In community based mental health services for older people targets for waiting times for memory service assessment were not always being met and in services for people with learning disabilities there was no information kept about waiting times.

However:

• Generally, the trust were aware of areas that required improvement. When we raised issues that the senior team wasn’t as sighted on as they thought they were the response was immediate, really positive and they put in mechanisms to ensure they would be sighted in the future. Throughout the inspection the trust were very receptive to any comments that we made and took immediate action when we raised a concern. For example, the trust undertook an immediate review of seclusion practice at Callington Road Hospital, it put in a senior nurse to support staff and immediately changed transport arrangements so patients could be transported to seclusion facilities in around 10 minutes. It made changes to the health based place of safety environment at Devizes and ensured appropriate emergency equipment and an emergency response system was available.

• We found that the trust had made some significant improvements to the safety and quality of services, staffing levels and governance arrangements across the Bristol community teams. During this inspection we were able to lift the warning notice that we had served during an unannounced, focussed inspection in December 2015. However, we identified that some further improvements were still required in the Bristol north team and asked the trust to provide written assurance by 13 June 2016 of action it would take to ensure the required improvements were made.

• Without exception patients and carers spoke positively about the care they received and patients said they felt safe. Staff were caring, enthusiastic and committed to delivering high quality care and treating patients and carers with dignity and respect. We observed therapeutic, compassionate and relaxed relationships between staff and patients. Across the majority of services patients had good access to emotional support and there was clear evidence that staff considered patient’s diverse and cultural needs.

• There were some impressive services with staff going the extra mile to deliver innovative service in challenging circumstances. For example, substance misuse services where there was a real evidence base to the service delivery with, creative, strong pathways, comprehensive assessments, positive working relationships with commissioners, good partnership working across services. In addition, forensic services had transformed service delivery since our last inspection with a good environment, good risk assessments, some excellent practice around the minimal use of restraint and seclusion. The triumvirate were working well together and had developed a positive culture which staff bought into.

• It is our view that the provider had made significant progress in developing services and bringing about improvements since our last comprehensive inspection in 2014. The new chief executive and director of nursing and quality had brought a real focus on quality and a proactive style of leadership. The ‘can do’ attitude of the senior leaders was having a positive effect on changing culure and there was a real commitment to actively engage with staff, patients, the public and partner organisation. Given time, we believe, that with a continued focus on quality and the establishment of a stable trust board to lead and drive through changes the provider will realise its vision. However, some significant work is still required to improve quality and consistency of services and effectiveness of working practices across the trust.

• We will be working with the trust to agree an action plan to assist them in making the improvements the standards of care and treatment.

We rated acute wards for adults of working age and psychiatric intensive care units good overall because:

• Statutory and mandatory training was good. Staff were receiving regular supervision and appraisal rates were good. Staff morale and team spirit was high on most wards and staff meetings were occurring regularly.

• Medication management was good. The storage and disposal of medicines was well managed and recording errors were addressed.

• Overall, safeguarding procedures were being adhered to and incidents that should be reported were reported and there were lessons learnt from incidents.

• Overall care plans were good, up to date and recovery orientated. Risk assessments were completed and aligned with plans of care. We found that physical health care monitoring was good and occurred routinely and regularly.

• Handovers were structured, comprehensive and informative. Information that was shared amongst staff was risk based and comprehensive.

• Overall, adherence to the Mental Health Act and Mental Capacity Act was good.

• Patients were treated with kindness and respect with regular community meetings held on wards. In addition, wards held drop in sessions for family members. Patients told us that they felt safe and patient complaints were investigated. Patients had access to advocacy services who visited the wards regularly. There was a range of psychological, educational and recreational activities to meet patient’s needs.

• Two electroconvulsive therapy (ECT) suites within the trust were well managed and organised with good governance arrangements in place

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

• Staff demonstrated an awareness of risk. The majority of care records contained an appropriate and up to date risk assessment. Staff had safe lone working arrangements. Staff had an understanding about how to report incidents. Staff felt confident in raising concerns and knew how to escalate them if necessary.

• The teams included a full range of specialist allied health professionals to provide effective assessment and treatment. The staff in the teams worked well with other local services and with the other older adult services provided by the trust in their locality.

• Patients and carers that we spoke with reported that the staff were kind and caring. They said they felt included in their care and we saw that this was clearly documented in almost all of the care records we reviewed.

• Staff reported that management within the locality were approachable. They said that morale was generally good and that things had improved in recent years.

However:

• Some teams (North Somerset later life therapies and Swindon memory service) were not meeting the trust’s targets for assessment.

• In the North Somerset teams, although there were alarms available for staff to use, there was no record to show these had been routinely checked.
• While local management was approachable and involved, staff reported that the senior management team based at trust headquarters were not as visible.

We rated mental health crisis services and health-based places of safety as inadequate because:

• Within the health-based places of safety, the wait for a Mental Health Act assessment was too long. We found evidence that people regularly waited over twelve hours for assessment. People also waited for many hours while found suitable placements for people following an assessment. There were significant challenges in relation to the capacity of places of safety that the trust. We have served a warning notice that requires the trust to take significant action. This will need a multi-agency response. There were many reasons for lack of access to the places of safety, delays in beginning and completing assessments and finding suitable placements for people following an assessment.

• Police regularly took people subject to section 136 to a police station because there was no available space at the places of safety. Police stations can be a place of safety, but should not be seen as an appropriate location for people experiencing a mental health crisis. The Mental Health Act Code of Practice 2015 (paragraph 16.38) states that a police station should be used as a place of safety only on an exceptional basis.

• The trust did not have effective systems in place to monitor the health-based places of safety across the trust and to assess the impact of gaps in service provision. We were concerned that the trust was not able to identify incidents that occurred in the health-based places of safety in Wiltshire as these were recorded as part of the ward incident data. The trust could not provide data for incidents that had occurred within these places of safety. There had been no reviews undertaken into the use of restrictive interventions across any of the places of safety. We found significant problems with the availability and robustness of the data collected to monitor the operation of places of safety in Wiltshire and Swindon. This meant that the trust could not monitor quality and safety effectively. We found issues with the safety and suitability of some of the environments of the places of safety, including ligature points and lack of appropriate furnishing.

• All the teams we met with told us that bed availability caused significant issues and that the delays had a serious impact on staff capacity (taking a clinician a whole shift to locate a bed) and on care for some patients. Staff told us about increased length of time waiting in places of safety, deterioration in mental health in the community and patients being transferred multiple times between hospitals or to locations great distances from their homes.

• The trust intensive teams operated a gate-keeping function for inpatient beds, and all staff spoken with told us that lack of bed availability caused significant issues. We heard from staff that finding a bed took a substantial amount of time. All teams had bed management caseloads, detailing people who needed repatriation to a local bed, which could take up a significant amount of staff time.

• Arrangements for night-time crisis calls varied between the localities. With the exception of Bristol, where there was a dedicated crisis line, calls to most of the intensive teams were taken by a call centre from 5pm until 8am weekdays and at weekends. The call centre was a messaging service and took basic information from the caller but was not staffed by trained mental health clinicians. Teams could not clarify how long it took them to return a call. The South Gloucestershire team operated an on-call system at night, with crisis calls being put through to a ward in the first instance.

However:

• It was to the credit of the local team at the Mason unit that despite significant challenges in relation to managing the health-based place of safety, and a lack of clear planning and direction from the commissioners and trust, morale was good and the team were positive and proud of their work. The team felt valued and well supported by their team manager. The team had developed and maintained excellent working relationships with the police. The ward staff that supported the Wiltshire and Swindon places of safety also demonstrated good understanding of the processes and meeting people`s needs. The police were positive partners in working with the trust to meet more effectively the needs of people presenting in mental health crisis.
• The trust intensive teams that formed a core part of the crisis service provision across the whole trust had clear clinical pathways to support effective assessment, management and treatment of clinical needs. The intensive teams and Bristol access and triage team worked effectively and collaboratively with other services to ensure continuity and safety of care across teams, including involvement of external agencies. The teams worked hard to meet the varied demands on the service despite challenges they faced at times with limited resources; for example, lack of in-patient beds.
• We observed that staff in all of the intensive teams were caring, compassionate and kind. People we spoke with were positive about the care and support they received. Staff demonstrated that they knew the needs of the people on their caseloads, and discussions in handovers were patient focussed and respectful.

• The intensive teams had systems and capacity to respond to referrals in a timely manner. The teams were confident that they all worked within the assessment targets agreed by the trust, and data collected by the trust reflected this. We found that there were variations between the localities we visited, in relation to receiving and responding to crisis calls and ‘out of hours’ contacts. However, from trust data only one person had complained about response times out of hours if they had called any of the teams. People we spoke with told us they could access the teams by telephone easily and got a timely response.

• The intensive teams had meeting structures in place that supported effective local management oversight and development across the whole service; for example, the trust-wide crisis good practice network and locality multi-agency meetings with police, acute hospital and local authority colleagues, mental health liaison and in-patient services. However, crisis concordat meeting minutes from the past 12 months showed that concerns were consistently raised about the capacity of places of safety and the use of police cells and emergency department, with little evidence of a senior management plan to monitor and respond to these concerns.

• We saw good examples of local leadership from the team managers, modern matrons and service managers of the intensive teams. Staff told us that they felt well supported by their team managers and were able to raise concerns and contribute to service development. The service managers and modern matron showed a good understanding of the current challenges for this service and staff.

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

• We found very caring, compassionate and motivated staff, and, saw good, professional and respectful interactions between staff and patients during our inspection visit. Patients were extremely complimentary about staff and commented positively about how kind the staff were towards them. We found that staff promoted relationships with patients based on respect and showed empathy consistently. We saw evidence of initiatives implemented to involve patients in their care and treatment. Comprehensive assessments were completed in a timely manner. Most care records showed personalised care which was recovery oriented.

• Following on from the concerns we raised at our December 2015 inspection visit, the Trust had reviewed the skill mix in the Bristol teams and increased the number of registered staff. Staffing levels were safe and recruitment was in progress to fill vacancies. Caseloads were managed and informed by a comprehensive case management tool and re-assessed regularly and were discussed in supervision. Waiting times from referral to assessment and through to start of treatment were now kept to an absolute minimum. The Trust set targets were being met, with very few exceptions.

• Governance structures had been reviewed and systems put in place, since our inspection visit in December 2015, which meant that managers were now aware of how effectively their teams were performing. Where performance was below the standard expected, managers were alerted in a timely way so that they could plan and take act to correct any poor performance.

However:

• Across all 11 teams, there was no system in place for monitoring uncollected medication from the community team bases, and at the Swindon team base, there was no effective system for monitoring repeat prescriptions.
• Brookland Hall and the Greenway Centre still required full implementation of the premises improvement plans, developed following our concerns raised in December 2015. There were also ongoing concerns about the size and complexities of the recovery navigator caseloads in North Bristol.

On 8 and 9 December 2015 we inspected the crisis, assessment and recovery services that the trust delivered to adults of working age in response to a number of concerns.

The local commissioning group and local safeguarding adults team told us they were also concerned about the poor performance of services and that patients may be at risk.

Assessments were not always carried out in a timely way, there were over 500 patients waiting for assessment at the time of our inspection. A small number of these patients had been waiting several months. Some patients did not have risk assessments or risk assessments were not linked to patients' care plans. We found that patients' care needs were not always met in a timely way, that some patients did not have care plans whilst others had plans of poor quality. In some cases care plans were out of date.

There were not enough qualified nursing staff to provide care for complex patients, the current model underestimated number of qualified staff needed. Qualified staff needed to devote large amounts of time to supporting recovery navigators (support workers not qualified in mental health nursing) in addition to carrying a caseload which was larger than that planned in the new model.

Recovery Navigators were supporting complex people. Recovery navigators often had no experience of working within the NHS and didn’t understand how to work with such complex patients. There was a 30% turnover of recovery navigators which meant some people had not had a consistent worker. The majority of recovery navigators were new in post.

There were inadequate governance systems in place. Not all the assessment and recovery teams had a system in place to ensure all referrals were tracked and there was no effective system in place to identify, track and follow up safeguarding concerns. The trust were aware of the difficulties within the service. No effective measures had been put in place to address the issues. The lack of a service manager for the assessment and recovery teams meant there was nobody with overall responsibility for the systems and processes within these teams. Senior managers were aware of the problems but there was no effective strategy in place to tackle them.

Systems in place to audit electronic care records had not identified the poor quality of these records.

We returned to the trust on 17 February 2016 to check that the actions specified in the section 29a warning notice had been completed. We only checked the trust had completed the specific actions required by 1 February 2016.

We found that there was now an effective system in place to monitor referrals. The provider had established a tracking tool and escalation process to monitor the waiting lists and times for referral to assessment and referral to treatment. Individual teams now had information about all patients on the waiting list, how long they had been waiting, and reasons for any wait over four weeks. Staff updated the tracking system daily.

The trust had provided extra staff resources to address the waiting lists and manage the service. The trust had reached agreement with the Clinical Commissioning Group (CCG) to undertake a skill mix review to ensure there were enough qualified staff to assess and care manage patients.

The service had revised its governance structure within Bristol to focus on gaining detailed assurance that all teams were delivering safe and effective care in a timely manner. The trust had introduced new governance groups across Bristol.

The service had established a safeguarding tracking system and was in the process of rolling out additional training to all staff over the next two months.