All inspections: Mersey Care NHS Foundation Trust

We carried out two announced and four unannounced inspections of six of the mental health and community health services provided by this trust, and one unannounced inspection of an adult social care location, as part of our continual checks on the safety and quality of healthcare services. We inspected Ashworth, the high secure hospital because this must be inspected every five years in order to inform the High Secure re-authorisation process, and the last inspection was in 2017 where it was rated good. We inspected acute wards and psychiatric intensive care units (PICU) and community inpatients because we had received information giving us concerns about the safety and quality of these wards. We inspected the forensic and secure wards and wards for people with a learning disability and/or autism because the service had changed significantly since the last inspection and to review outstanding breaches of regulation in the forensic services. We inspected community health services end of life care to review outstanding breaches of regulation. We inspected the adult social care location as it had not previously been inspected under adult social care methodology.

At the last inspection of the trust, we inspected some of the services under the heading of specialist services for people with a learning disability and/or autism. This core service does not exist as part of our current methodology, and those services are now included in the forensic and secure wards inspection.

In 2017, Wavertree Bungalow had been inspected as a hospital location. However, due to changes made by the trust to the registration of this service this was now an adult social care location. In line with our current methodology, the findings from this report will inform the judgements we make about how well-led this trust is, but the ratings will not be aggregated and therefore will not impact on the overall trust ratings. This report will be published separately.

We also inspected the well-led key question for the trust overall because the trust now delivered services formerly run by two different trusts, and to inform the re-authorisation of the High Secure Hospital.

We did not inspect the following core services, which have outstanding breaches of regulation, because we did not have current risk based concerns about these services at the time of inspection. As a result of this, the historical ratings have remained and have been used to determine the overall ratings for each key question and for the trust as a whole:

Community mental health services for working age adults
Community mental health services for people with a learning disability and/or autism
Community health services – adults
Community health services – walk-in centres

We undertook a focused inspection of the walk-in centre core service and mental health crisis core service in 2022, as part of a piece of work looking at urgent and emergency care across the system. These services were not rated at this inspection and no breaches of Regulation were issued.

We did not inspect the following core services, which have changed significantly since the last inspection as they were transferred from another provider to Mersey Care NHS Foundation Trust, because we did not have current risk based concerns about these services at the time of inspection. As a result of this, the historical ratings have remained and have been used to determine the overall ratings for each key question and for the trust as a whole:

Wards for older people with mental health problems
Mental health crisis services and health based places of safety
Community based mental health services for older people
Community mental health services for people with a learning disability or autism 
Community health services for children, young people and families   
Specialist community services for children and young people
Community health – Sexual health services

We did not inspect the following core services that have no outstanding breaches of regulation:

Substance misuse services
Community dental services

We are monitoring the progress of improvements to these services and will re-inspect them as appropriate.

Our rating of the trust stayed the same. We rated them as good because:

We rated caring as outstanding, responsive as good, and safe and effective as requires improvement. We rated the trust as outstanding in well-led.
At this inspection, we rated three of the trust’s mental health services as good, and one as requires improvement. We rated two of the trust’s community health services as good and none as requires improvement. We rated the adult social care location as requires improvement. In rating the trust, we took into account the ratings of other core services not inspected this time.
The trust had the leadership capacity and capability to deliver high quality, sustainable care. Succession planning was in place and leaders had the skills, knowledge and experience to perform their roles and demonstrated integrity in doing so. Leaders were visible and approachable and understood the actions needed to mitigate challenges to quality and sustainability.
The trust had a clear vision and set of values and a robust and a challenging and innovative strategy was in place with quality and sustainability as top priorities. Staff, patients, carers and external partners had the opportunity to contribute to discussions about the strategy and the leadership team regularly monitored and reviewed progress on delivering it.
The trust had planned services to take into account the needs of the local population. The trust engaged closely with the Cheshire and Mersey Integrated Care System and fully aligned its strategy to local plans in the wider health and social care economy. Plans were consistently implemented and had a positive impact on the quality and sustainability of services.
The trust’s culture was centred on the needs and experiences of people who used services. We were told about and observed staff caring for patients in a kind and compassionate manner. Through the acquisitions of other services, the trust had sought to embed areas of good practice in their own ways of working if it was better for patients and staff.
Staff were proud of the organisation as a place to work and spoke highly of the culture. There was a strong organisational commitment and effective action towards ensuring that there was equality and inclusion across the workforce. Staff had access to training, supervision and appraisals and there were opportunities for professional development.
The trust's steps towards a culture change, focusing on a just and restorative learning approach had seen a reduction in formal disciplinaries. The culture encouraged openness and honesty at all levels within the organisation and staff felt able to report concerns. The trust took appropriate learning and action as a result of concerns raised and sought to learn from incidents, deaths, complaints and the wider system.
The trust took a pro-active approach to managing staffing pressures and had a clear workforce plan in place. This included a focus on growing their own staff and the retention of existing staff, which saw trust turnover rates reducing at the time of inspection. The trust managed daily staffing levels dynamically to ensure patient safety.
There was effective accountability across the trust with systems in place to ensure the flow of information from ward to board and back again. Leaders were clear about their areas of responsibility and there was a visible and consistent approach to risk management and board assurance. Appropriate governance arrangements were in place in relation to Mental Health Act administration and compliance.
The trust had clear and effective systems in place to provide assurance and escalate risk when needed. Performance was managed through clear structures and processes. Financial performance of the trust had been consistently strong and there were no examples of financial pressures compromising care. The trust worked with the wider health and social care system to plan for adverse events.
The trust board received holistic information on service quality and sustainability. Leaders challenged and interrogated data and used performance measures to understand the challenges facing the trust at any given time. Systems that were in place to collect data were constantly being reviewed to identify how they could be improved. Submissions were made to external bodies as required and there had been no significant data or security breaches at the trust over the last 12 months.
The trust was a forward thinking and pro-active partner and leader in the wider health and social care system. The trust was actively engaged in collaborative work with external partners, such as involvement with sustainability and transformation plans. Feedback from commissioners was that the trust was an excellent systems partner, supporting other partners and responding to concerns in the wider health economy.
The trust took a leadership role in its health system to identify and proactively address challenges and meet the needs of the population. The trust had a lead role in the system response to the COVID-19 pandemic and continued to support partners with mutual aid.
The trust had a structured and systematic approach to engaging with people who used services, those close to them and their representatives. The trust had access to feedback from patients, carers and staff and were using this to make improvements. Patients, staff and carers were able to meet with members of the trust’s leadership team and governors to give feedback.
Quality improvement and innovation were central to the trust’s vision to strive for perfect care. Staff had training in improvement methodologies and used data to drive improvement. The trust had worked with local and national providers as well as staff teams to identify new technology and innovative practices.
Individual staff and teams received awards for improvements made and shared learning. External organisations had also recognised the trust’s improvement work. The trust was actively participating in clinical research studies and in national improvement and innovation projects

However:

The trust was experiencing staffing pressures across most services as a result of high levels of absence and vacancies. This impacted on patient’s access to therapeutic activities and on staff wellbeing.
Care plans were not always individual to the needs of the patient.
The trust still provided dormitory accommodation which did not ensure the privacy and dignity of patients was protected. Some of the estates needed maintenance and repair. The environment at Wavertree Bungalow did not always meet the needs of people using the service.
Governance systems did not always operate effectively in the core services. Audits did not always identify all areas for improvement and there was a lack of capacity and robust governance around medicines management in some areas.
The trust was not always meeting its internal target in responding to patient complaints and the quality of investigations varied, although work was being done to improve this at the time of inspection. Some trust policy dates were overdue for review and some of the written Duty of Candour letters did not meet the requirements outlined in the trust policy.

How we carried out the inspection:

In the acute and psychiatric intensive care unit (PICU) inspection we inspected 16 out of 17 wards, we did not inspect Hartley Hospital Southport. At Clock View Hospital we inspected four wards, Morris, Newton, Alt and Dee; at Broadoak Hospital we inspected Albert, Brunswick and Harrington wards; at Hollins Park Hospital Warrington we inspected both Sheridan and Austen wards; at Halton Hospital we inspected Weaver and Bridge wards; at The Knowsley Resource Centre we inspected Grasmere and Coniston wards; at St Helens Hope and Recovery Centre we inspected Taylor and Iris wards. We also inspected Windsor House which was a standalone acute ward. Newton ward at Clock View was the only PICU.
In the forensics inspection we inspected ten wards and one individual placement. At Rowan View Hospital we inspected Astley ward, Eden ward, Rivington ward, Marbury ward and Delamere ward as an out of hours visit. At Rathbone Hospital we inspected Allerton ward. At Hollins Park Hospital we inspected Marlowe ward and Tennyson ward. At Whalley we inspected Maplewood 1 and Maplewood 2 and one individual placement at North Lodge.
In the high secure hospitals inspection, we inspected 11 of the 13 wards; Arnold, Blake, Carlyle, Dickens, Johnson, Lawrence, Macaulay, Newman, Owen, Ruskin and Turner ward.
In the inpatient wards for people with a learning disability we inspected the only ward; Byron ward.
In the community end of life care inspection, we inspected two of the three teams.
In the community inpatients inspection, we inspected all four wards at Longmoor House.
We inspected the only adult social care service provided by the trust; Wavertree Bungalow.
We spoke with senior leaders as part of the trust-wide well led inspection.
We spoke with 253 staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, and managers.
We attended and observed several meetings and committees held by the trust.
We reviewed numerous records relating to the care and treatment of patients.
We reviewed a variety of documents relating to the management of the trust and the services it delivers.
We held seven focus groups including staff network groups, staff side and junior Doctors.
We reviewed a variety of information we already held about the trust.
We sought feedback from several of the trust’s stakeholders such as Healthwatch, NHS England and advocacy 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

During our core service inspections, we spoke with 145 patients and 32 carers and family members. Patients, family members and carers spoke positively about the services.

Patients told us staff treated them well and with kindness. Patients told us staff were responsive to their needs and they felt able to talk to staff.

Patients in the community end of life care services told us nurses were caring, compassionate, and often, the care exceeded their expectations. They knew they could contact the service any time of day or night and they would be responded to and felt as though staff took their time to listen to them.

Patients on Byron ward told us staff were nice and respectful and spoke about a range of activities that staff supported them to access.

Patients in the acute and PICU services told us they felt safe and that staff treated them well and were supportive and caring.

Patients in the community inpatient hospital told us that staff listened to their needs and would share humour with them, which helped.

Patients in the forensics service told us they felt safe and that staff treated them well. Patients said they rarely had their escorted leave or activities cancelled, even when the service was short staffed. They told us they felt involved in their care.

Patients in the high secure service told us they mostly had positive relationships with staff and described staff as kind, friendly and caring.

Carers at Wavertree Bungalow told us that staff were amazing and they felt their family member was safe at the service. Carers at Wavertree Bungalow told us they really trusted staff at the service and shared comments including ‘the service was a lifeline’ and ‘it was one of those places we couldn’t do without’. All families and carers we spoke with said they felt involved in their loved one’s care and that staff communicated well with them.  

However;

Some patients on Byron ward told us they found the noise on the ward too loud and that lunch was boring.

Patients in the high secure hospital expressed their frustration of the impact of staffing pressures on access to on and off ward activities and delays in accessing personal care.

We plan our inspections based on everything we know about services, including whether they appear to be getting better or worse.

This inspection report is solely about The Breightmet Centre for Autism in the Bolton area of Greater Manchester. Services were provided as an independent hospital by ASC Healthcare Limited. We inspected the hospital under that management on 14 and 20 June and on 14 July 2019. We had serious concerns about the quality of care and the safety of patients so we removed this location from the company's registration on 16 July. On 19 July Mersey Care NHS Foundation Trust took over responsibility for services at the centre temporarily to provide a safe environment for the patients.

ASC Healthcare Limited successfully appealed against the removal of the location and ASC Healthcare Limited resumed as the registered provider from 4 November 2019.

This report relates to an inspection carried out while The Breightmet Centre was a location of Mersey Care NHS Foundation Trust prior to ASC Healthcare Limited's successful appeal.

We conducted an unannounced focused inspection on 15 October 2019 to check that patients still remaining at the centre were safe and that the service was well led. We looked only at the safe and well led key questions. We did not rate services at the centre.

At the time of the inspection the centre was registered to provide:

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

The centre has 18 beds for men and women with learning disabilities and/or autism. At the time of our inspection, there were seven patients, both men and women, still at the location.

We found that since our previous inspection there had been significant improvements in the quality of care and the care environment, making it safe for the remaining patients. The leadership being provided by Mersey Care was effective and included dealing with some urgent health and safety issues.

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

We rated well-led for the trust overall as outstanding. We rated safe, effective, caring, responsive and well-led as good across mental health and learning disability services. For community health services, we rated caring and responsive as good and safe, effective and well-led as requires improvement. When aggregating overall trust ratings we did not include the ratings of community health services. This is because the trust only acquired these services recently, some as late as April 2018, and CQC has the discretion to give trusts an allowance of up to 24 months before including newly acquired services that are considered to be failing in the ratings aggregation.
We rated ten of the trust’s twelve mental health and learning disability core services as good, one as requires improvement and one as outstanding. In rating the trust’s mental health and learning disability services, we took into account the previous ratings of the seven services not inspected this time.
We rated two of the trust’s community health services as good and three as requires improvement.
The trust had a clear vision and set of values. The trust’s strategy had been developed with involvement from staff and external stakeholders. There was a clear emphasis on quality improvement (striving for perfect care), a culture of learning, and integrated care services delivered at local level. The trust had a strong presence in the local community. Leaders had the right skills and abilities to run services providing high-quality sustainable care. Trust governance and management of risk was effective. The vast majority of staff that we spoke with felt valued.
Staff had the right qualifications, skills, training and experience to keep people safe from abuse and avoidable harm and provide the right care and treatment. Staff followed best practice in medicines management. They kept detailed records of patients’ care and treatment. Staff reported and managed incidents well. Ward staff participated in the trust’s restrictive interventions reduction programme and were proactive in anticipating and deescalating conflict with patients.
Services provided care and treatment for patients’ physical and mental health needs in line with national guidance and best practice. Staff of different grades and disciplines kept their professional skills updated and worked together to benefit patients. Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff cared for patients with compassion and respect. Patients and carers were involved in decisions about care and treatment. Patients’ individual preferences were reflected in how care was delivered. Patients of mental health and learning disability services were also involved in the running of the trust. Staff acted on patients’ feedback.
The trust planned and provided services in a way that met the needs of local people. Services treated concerns and complaints seriously, investigated them and learned lessons from the results. Trust ward environments were adapted for the specific needs of their patients. This included cultural, dietary, disability and mental health needs.

However:

There were not always enough staff in all services.
A number of mental health wards provided dormitory accommodation rather than private rooms.
Staff compliance with mandatory training in a minority of services was low.
In some community health services, the trust could not be assured that controlled drugs had been destroyed safely.
Waiting times for psychological interventions were very long in community mental health teams, and two of the team bases were not accessible to wheelchair users.
Staff working in community health services did not all participate in relevant audits to monitor care quality.
Trust leaders had worked hard to engage staff in the newly-acquired community health services, but there was still some evidence of a minority of staff not feeling supported or comfortable to raise concerns.

This service has not been inspected before. We rated it as good because:

Staff were qualified and had the necessary skills to carry out their roles and provide safe treatment to patients.
Infection control processes followed nationally recognised guidance.
Premises and equipment were clean and well maintained.
Staff reported incidents and accidents, these were investigated and acted upon to reduce the chance of re-occurrence. Learning from incidents was disseminated to all staff in the service through the “Notification of Clinical Improvement” system
Staff were aware about issues relating to safeguarding and there were systems in place to refer children and vulnerable adults.
Staff provided care and treatment based in line with nationally recognised guidance.
There was an effective skill mix at the service to assist with the ever-increasing complexity of patients. Staff worked together as a team and with other healthcare professionals in the best interests of patients.
Staff understood the importance of obtaining and recording consent. They had a good understanding of their responsibilities under the Mental Capacity Act 2005.
Staff cared for patients with compassion. We observed staff treating patients with dignity and respect. Feedback from patients was positive. Patients commented staff were kind, helpful, friendly and caring.
The service considered patients’ individual needs. Reasonable adjustments were made to ensure patients could access dental care.
The service dealt with complaints promptly, positively and efficiently.
Leaders had the skills and ability to support high quality care. Staff told us that management were visible and approachable.
The team worked well together and supported each other.
There were systems and processes in place for identifying risks and planning to reduce them.
Staff engaged with patients, external stakeholders and other healthcare professionals to continually improve the service.

However:

The service did not have a consistent procedure or protocol for the use of hoists to assist patients with mobility difficulties to access dental chairs.
Staff told us that they felt “a bit frazzled” because of staffing issues. Staff worked hard to ensure that high priority clinics were not cancelled.
The policy supporting the use of the “Notification of Clinical Improvement” system had not been updated since 2002.
“Notification of Clinical Improvements” were only sent to one individual. This would pose a problem if this member of staff was ever away for a long period of time.
Individual results of the X-ray audit were not disseminated or discussed with dentists.

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

We rated all key questions as good.
Improvements in the clinical environment and medicine management had been made since our last inspection.
Medicines were now managed safely. Equipment was now cleaned and recorded. Clinic fridge temperatures were also now monitored. Environments had been suitably adapted to meet the needs of patients with dementia. There were enough rooms to accommodate activity and therapy sessions.
Compliance with supervision, appraisals and mandatory training had improved, including basic life support, immediate life support, moving and handling and dysphasia training. Staff were now appropriately trained and supported for their roles.
Risk assessments and care plans had been completed for all patients and reflected patients’ lives and interests. They were personalised, holistic and recovery-oriented. Staff had developed a tool to support patient and carer involvement. Families and carers were involved in care planning and discharge planning.
The food was of good quality and drinks and snacks could be accessed 24 hours a day. Cultural beliefs were accommodated, including special diets.
Staffing levels and skill mix on each ward were appropriate to meet the needs of patients.
The service was now notifying the Care Quality Commission of Deprivation of Liberty Safeguards authorisations for patients. Mental Health Act and Mental Capacity Act policies and procedures were followed by staff.
There were effective systems and processes in place to drive quality improvement and safety. Incidents were reported and acted upon. Complaints were managed well and information fed back to patients.
Managers had the necessary skills and resources to ensure patient care was of good quality.
Staff felt respected by senior managers and morale had improved. Staff treated patients, their families and carers with kindness, privacy, dignity, respect, compassion and support. There were good relationships between patients, staff and carers.

However:

There was dormitory bedroom accommodation on three wards. Beds were separated by curtains. This impacted on patients’ privacy and dignity.

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

We rated all key questions as good.
The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and/or autism and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness. They involved patients and those close to them in decisions about their care and about the service. Staff spoke to and about patients in a way that was consistent with a culture of positive behaviour support.
The ward promoted privacy and dignity for patients. The service was accessible to all who needed it. Arrangements to admit, treat and discharge patients were in line with good practice. Staff helped patients with communication, advocacy and cultural support.
Managers had the right skills and abilities to run a service providing high-quality sustainable care. Managers promoted a positive culture that supported and valued staff. The ward used a systematic approach to continually improving the quality of its services.

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

Staff delivered care in line with best practice and national guidance.
Staff completed and updated assessments of patients, and developed care plans from these. Patients’ physical health care was routinely assessed, monitored and treated when required. Staff minimised the use of blanket restrictions and restrictive interventions and followed best practice and the Mental Health Act when restricting patients to keep them and others safe.
A multidisciplinary team of staff provided care to patients. In addition to medical and nursing staff, care was provided by psychologists and occupational therapists. Other specialists could be accessed when required.
Staff adhered to the requirements of the Mental Health Act. Staff received training about the Mental Health Act and knew how to access advice. Staff were aware of the Mental Capacity Act, and knew how it worked in relation to best interest decision making.
The wards were safe and clean, complied with guidance on the elimination of mixed-sex accommodation, and provided appropriate facilities for patients.
There was pressure on beds, but patients were usually able to have a bed when they needed one. Staff and managers regularly reviewed the availability of beds, and how current patients were progressing through their treatment plan.

However:

On five of the nine wards, most of the patient bedrooms contained more than one bed. This meant that patients had to sleep in the same room as a stranger.
Maintaining safe staffing levels was an ongoing challenge, as there were difficulties in recruiting qualified nurses and in some areas healthcare assistants.
All the trust sites were non-smoking, but patient smoking was allowed/tolerated in outdoor areas and doorways. This was inconsistent with trust policy, and management of smoking was an ongoing concern for staff.
Staff did not record or always explain to patients who were not detained under the MHA that they had the right to leave the ward whenever they wished.
Staff monitored patients on high dose antipsychotic therapy, but this was not consistently recorded and implemented by staff.

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

The service had worked to implement improvement regarding problems noted in the previous inspection. Ligature assessments were completed and up to date. We saw that mixed sex accommodation guidelines were being followed. The units themselves were clean and well furnished, with furniture appropriate to a rehabilitation setting. Staffing figures showed that more staff had been employed, and that safe staffing levels were prioritised. Risk assessments were completed and updated regularly. The service followed the trust guidance regarding no force first, this being evidenced by the minimal use of restraint in the service. Medication management was audited and noted to be of a high standard during the inspection.
Care plans were holistic, personalised, and patient-centred with patient involvement. Physical health monitoring was on-going at the service, starting on admission, and related to individual patient needs. Psychology input was available at the service, with multi-disciplinary input that guided therapy. We attended a psychology group meeting, and saw good interaction and patient involvement. Supervision and appraisals were taking place at the service, and staff told us that input from such sessions was helpful. Staff were trained in the Mental Health Act and the Mental Capacity Act, and we saw that both Acts were being implemented within the service, with access to administrators and consideration in care records of patient rights.
Patients told us they were happy at the service, and felt safe. We were told that staff were kind, helpful, and always available. Carers spoke highly of the service, stating that their relatives’ difficulties had improved since being admitted. Patient experience survey results were very positive, with 100% approval for many of the aspects reviewed. The inspection team saw good interaction between staff and patients, and a willingness by staff to be courteous, respectful, and helpful during this interaction.
The service looked to discharge dates for patients from the first ward review, and worked towards meeting those dates. At the time of the inspection, there were no delayed discharges in the service. Delays to discharge were often not down to clinical problems, but due to external factors beyond the scope of the service. Patients could access bedrooms at any time and there was safe storage for valuable items in each room. There were many different activities available seven days a week, and patients were encouraged to take part. There was lots of information available to patients and carers regarding treatments, rights, smoking cessation, advocacy, and volunteer work for patients.
Leadership training was available to managers in the service, and staff told us they felt that management on each unit were approachable and considerate. The trust visions and values were apparent throughout the service: signs and posters giving information were on each unit, and staff told us they were aware of the values and tried to bring them to the ward environment. An electronic dashboard of information regarding performance was available to managers, outlining service performance, and managers used this information to take the service forward, improving the patient experience. The brain injury rehabilitation unit was due to accept accreditation to a national brain injury charity, after being assessed over a period of time.

However:

Some care plans contained jargon, language that might confuse patients.

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

There were long wait times for patient access to psychological interventions.
Staff compliance rates for role-specific mandatory training were low.
The service was going through a migration of one electronic system to another. New staff could not easily access the previous electronic record system.
Park Lodge and Moss House were not accessible for wheelchair users and the disabled toilet at Moss House was not fit for purpose.

However:

There were no waiting lists for assessment by the community mental health service.
Risk assessments and audits of the environment, including infection control, were done regularly and were up to date.
Patients had robust, person centred care and treatment plans including physical health assessments. They were involved in the decision making about their care and treatment.
Serious incidents were being reported and managers were able to feed into the trust risk register. The service had a variety of ways that risks, concerns, complaints and lessons learnt were being communicated to staff.
The service had robust multidisciplinary and interagency teamworking.
The service provided a variety of information regarding community events, treatments and care services available for patients, carers and families.
Staff were trained in and had a good understanding of the Mental Health Act and the Mental Capacity Act. The service had policies and procedures in place and staff had access to support.
There was good leadership and the service encouraged learning and continuous improvement ideas from staff, patients, families and carers.

We have not previously inspected this service. We rated it as requires improvement because:

Although the priorities for the service were aligned to the North West Palliative Care Network, the service did not have an overall strategy or workable plans to turn it into action.
Although the trust had undertaken service reviews across several community services, this had not been undertaken for the Liverpool palliative care team at the time of our inspection. A service review had been undertaken for the South Sefton palliative care team, an action plan had not yet been implemented to make improvements where needed.
There was not always evidence that controlled drugs had been destroyed after a patient had passed away, in line with legislation as well as trust policies and procedures. Records indicated that there was no evidence of this on two out of eight occasions. Additionally, a recent care of the dying audit that had been completed in June 2018 indicated that there was only evidence that controlled drugs had been destroyed on 62% of occasions.
The service had suitable equipment but had not always looked after it well. Records indicated that only 67% of syringe drivers in the South Sefton area had been serviced in line with manufacturers’ guidance. This meant that there was an increased risk that equipment would malfunction while being used.
The service had not planned to review all expected patient deaths before the time of our inspection. This meant that there was an increased risk that areas for improvement had been missed. However, the management team informed us that a new process had recently been implemented so that all expected deaths could be reviewed.
Not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Patient records indicated that consent to treatment had not always been documented in line with trust policy.
Although staff informed us that the palliative care team were responsive when support was needed, the service had not monitored compliance with the service’s policy to triage urgent patients within four hours as well as triaging all other patients within 24 hours and undertaking a clinical review within 72 hours. This meant that it was unclear if these targets had been achieved consistently.
Although there was evidence that staff had provided emotional support to patients and relatives to minimise their distress, records indicated that not all relatives had been offered bereavement support after a patient had passed away. We found that there was no documented evidence of this being undertaken on nine out of 11 occasions. In addition, a care of the dying audit that had been undertaken in June 2018 had identified that only 45% of relatives had been offered bereavement support.

However:

The service provided care and treatment based on national guidance. This included the Supporting Care Improving Outcomes guidance (National Institute for Clinical Excellence, 2004), End of Life Strategy (Department of Health, 2015) as well as the Care of Dying Adults in the Last days of life (National Institute for Clinical Excellence, 2017).
Staff of different kinds worked together as a team to benefit patients. Members of the palliative care team worked well alongside staff, both internally and externally.
Staff cared for patients with compassion. Both members from the district nursing and palliative care teams were committed to providing high quality and compassionate care.
Patients and relatives who we spoke with told us that the care and treatment delivered had been of a high standard. Comments included ’we are extremely happy with the care that we are getting’ and ‘we are more than happy, we can’t fault it and that staff are very helpful’.
Most managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The palliative care team were very proud of the work that they had done. They were focused on providing the best possible care and meeting the needs of the people that used the service.

We have not previously inspected this service. We rated it as good because:

Services were found to be good for safe, effective, caring, responsive and well led.
The service had effective strategies for identifying, managing and reducing risk, learning and improving when things went wrong.
There were sufficient numbers of competent and experienced staff to reduce the risk of harm to patients.
The service used best practice guidance to inform the delivery of care and ensured treatment was based on evidence based practice.
Staff within the service demonstrated good levels of commitment to patient care and they adopted holistic patient and family centred care. Patients and families believed the care provided was good.
The service planned and delivered care based on the identified needs of the community it served, but also built the service around the individual needs of patients. Staff were proactive in their approach to establishing the individual needs of patients.
There was an exceptional family focused approach to care delivery and staff had extensive knowledge about their patients.
The service was well led by effective and enthusiastic managers, who were aware of risks to the service and were capable of tackling difficult issues head on with a view to service improvement.

This is the first time we rated this service and we rated it as requires improvement. We rated it as requires improvement because:

The service did not always have the right number of staff although staff had the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse to provide the right care and treatment.
There was a lack of clinical supervision in some services and competency based training was not always carried out.
Some equipment necessary for carrying out treatments was not always available.
Controlled medications were not always destroyed and disposed of in line with Trust policy and procedures.
A number of Trust policies and procedures were out of date.
Some staff told us that there was a lack of visibility of senior and middle management.
Some staff told us that they were reluctant to speak up to the ‘freedom to speak up champions’ due to previous experiences.

However:

The Trust planned and provided services in a way that met the needs of local people and worked well with external organisations.
The service primarily used electronic patient records. Patient records were easily accessible by staff working in all community teams. Staff could access records using electronic devices in patient home and on computers based in clinic areas.
Records were clear, legible and information collated was in chronological order.
Staff from different specialities worked together collaboratively to benefit patients and their families.
The service controlled infection risk well and infection rates were low.
The service managed incidents well. Staff recognised incidents and reported them appropriately. There was a positive culture around the reporting of incidents and lessons learnt were shared with the whole team.
The service provided care and treatment based on national guidance and evidence based care.
The service had a clear vision and strategy in place. The service knew what it wanted to achieve and workable plans to turn it into action.

We rated high secure services at Ashworth Hospital as good because :

Wards were clean and well furnished. Mirrors and closed circuit television cameras were used to ensure that patients and staff were safe and monitored on every ward. Staffing was being managed by ward managers and matrons, using a safe staffing system, and we were informed that 53 new staff had been recruited to the trust and would soon be ready to join the teams. National policies relating to night time confinement and long term segregation were being followed. Medication management followed guidance, and the introduction of an electronic prescription system had improved monitoring. Incidents were reported and appropriate actions were taken to deal with these incidents.

Care plans were comprehensive and holistic across the service. Staff involved patients in the development of their care plans and gave copies of care plans to patients when the patient agreed to accept them. Staff were able to access further specialist training from external bodies, up to and including masters level qualifications. The care records indicated that staff paid as much attention to patients’ physical healthcare as they did to patients’ mental health. The provider had recruited psychologists to the service.This improved the patients’ access to effective psychological therapies. All patients were detained under the Mental Health Act.Staff across the service adhered to the guidance in the Mental Health Act Code of Practice. However, the trust Mental Health Act policy referred to an out of date Code of Practice; the trust was using the current Code of Practice. The Mental Capacity Act was applied across the service, and we saw evidence of capacity assessments in care records.

Interaction between patients and staff was seen to be of a high standard, empathic and professional. Patients told us that staff treated them with kindness and respect. We observed a patient forum and saw excellent interaction between staff and patient representatives, with matters discussed openly and with due consideration for all. We spoke with carers of patients and were told that, generally, they were positive about the service. Some carers raised points that we looked further into, and were assured that the service was acting in the best interest of patients. Patient viewpoints were listened to and helped to define the service.

The service was adhering to national recommendations regarding times for referral and assessment of patients. Wards were updated and refurbished on a rolling basis, as older wards were redecorated and improved. Forster ward had recently closed and re-opened as Newman ward, the new ward being appreciatively more modern than the old ward. The service had plans in place for patients from different cultures and countries, considering food, treatment and religious aspects.

The trust visions and values were embedded in the service. All staff knew of the values of the trust, and the direction the trust wanted to move. We saw evidence of senior staff involvement in the service, including at chief executive level. Staff were involved in clinical audit; the service itself had been involved in a number of audits in the 12 months prior to the inspection. Ward managers felt they had the authority to do their job. Staff told us that morale on the ward was quite high, but it would improve more when new staff joined the teams.

We rated substance misuse services as good because:

All the services we visited were tidy and well maintained. The furniture was in good repair and the clinic areas were clean and well organised. Staff understood infection control procedures.

Staffing levels and skill mix were planned and reviewed to keep patients safe and meet their needs. There were effective procedures for escalating concerns about staffing levels. There were effective handovers to ensure staff were aware of the risks to patients.

There were clearly embedded systems, processes and standard operating procedures to keep patients safe. The staff knew how to look for signs of abuse and how to make a safeguarding alert if necessary. This meant that patients were protected from avoidable harm.

Managers encouraged openness and transparency about safety. Staff knew what to report and how to report it. They understood their responsibilities relating to the duty of candour.
In most cases, patients’ needs assessments included consideration of clinical needs, physical and mental health and wellbeing, and nutrition and hydration needs.
Staff planned care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Links to best practice guidance were available on the trust’s website.
Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.
Staff respected patients’ diverse needs. Patients were supported, treated with dignity and respect, and involved as partners in their care. There was a visible person centred culture.
Patients were involved and encouraged to be partners in their care and in making
decisions, with any support they need. Staff spent time talking to patients so that they understood their care, treatment and condition.
Staff took into account the needs of different groups so that they met patients’ needs.
Patients understood how to complain or raise a concern. Staff took complaints and concerns seriously. They listened and responded to in a timely way.
The service was transparent and open with stakeholders about performance. Information was used to support effective decision-making and drive improvement. Staff reported and reviewed information on patients’ experiences alongside other performance data.
Staff felt respected, valued and supported. They were committed to their roles and enjoyed working with the patient group. They described a strong and supportive team.
Managers supported staff to work in innovative ways. They encouraged staff to discuss issues and ideas for service development.

However:

At the Windsor Clinic, the fire risk assessment was out of date and actions had not been completed.
Not all patients had a comprehensive risk management plan that staff reviewed regularly.
Care records were not always comprehensive and holistic. They did not always take account of patients’ views. Some were not recovery focused and were not reviewed regularly.
Systems for audit and review in relation to care records were not always effective.
Some care records did not contain individual plans for unexpected exit from treatment.

We rated learning disability and autism secure services as outstanding because:

Staff were highly skilled at anticipating and de-escalating behaviour that might have led to violence or self-harm.The trust had trained its staff to use effective de-escalation techniques. Staff developed, applied and reviewed good positive behavioural plans; especially for patients who were individually nursed. As a result, staff used physical restraint and other restrictive interventions on many fewer occasions than in the past.
Person-centred therapeutic interventions were being delivered to patients to support them to achieve improved independence and wellbeing. There was a wide variety of activities available to patients both on and off site. Information in a variety of formats had been developed to ensure that it was easy for patients to communicate and to express their needs. All patients had access to a wide range of social, recreational, therapy based interventions, and a recovery college called ‘our shared college’. Individualised care had been adapted to meet patients’ specific communication needs. All patients had received input from speech and language therapists where necessary to ensure their communication needs were met.
Staff ensured patients and relatives were engaged with assessments, care plans and discharge arrangements. Patients were involved in developing their own care plans and staff provided them with copies which were in an ’easy read’ format to meet their needs.
The service was proactive in promoting equality and diversity and meeting the specific needs of vulnerable groups of patients. The service had introduced a health awareness and improvement initiative called ‘Dr Feel Well’. This project aimed to improve patients’ physical health by the use of patient education, guidance and encouragement.
Interactions between staff and patients demonstrated personalised, collaborative, recovery oriented care planning and involvement. All patients had a moving on plan, which the individual and other stakeholders had developed collaboratively. Some patients had been involved in filming a number of short videos about the wards with the trust’s patient led media crew.These videos were available online to help new patients know what to expect from admission and the transforming care agenda.
Comprehensive risk assessments for patients were completed and reviewed. Patients’ individual care and treatment was planned and best practice guidance was implemented, ensuring outcomes were monitored and reviewed.
Staff had an understanding of the Mental Capacity Act 2005 and the Mental Health Act 1983. They assessed mental capacity and enabled patients to make decisions where possible. Staff routinely referred patients for advocacy support if they lacked the capacity to do so themselves.
Staff received mandatory training, specialised training, supervision and appraisals. Staff had knowledge and skills to deliver effective care and treatment. Staff received support, appraisals, mandatory, specialist training, and supervision from their managers and peers. There was an ongoing recruitment programme to fill vacancies and managers ensured that bank and agency staff were familiar with the service and patients. The division monitored and adjusted staffing levels daily in response to risk on the wards and monitored and reviewed their divisional risk register.
Patients were protected and safeguarded from avoidable harm and incidents were appropriately reported to the local authority. Staff had received training in safeguarding and mandatory training compliance levels for staff were good.
Patients and their carers were positive about the care and treatment they received and staff behaviours were responsive, respectful and caring. Staff involved patients and their carers in the care and treatment they received.
The autism risk group provided a proactive, creative and dynamic approach based on best practice guidance and psychosocial approach to risk, engaging all patients that attended in self-discovery. There was an established championing recovery meeting co-produced with patients and facilitated monthly. Patients attended as designated recovery champions for their wards to share ideas and plan new recovery focused activities from their perspective. Staff empowered patients to have a voice. Patients reported their opinions and views were listened to and considered by staff in all aspects of their care.
The management and governance arrangements within the division were effective.
Managers were able to provide information into the governance meetings and staff received regular feedback from these meetings. They were kept up to date about the trust and wards’ performance.

We rated the trust as good overall because:

The trust’s restrictive practice reduction programme was effective. There was a clear commitment to safeguarding. Almost all of the individual patient risk assessments we reviewed were thorough and up to date. The trust was compliant with duty of candour requirements and had taken potential risks into account when planning services. Trust buildings and clinical equipment were mostly clean and well-maintained. Security arrangements and environmental risk assessments were effective. Most teams had put measures in place to reduce the impact of low staffing, and staffing was discussed regularly at all levels of the trust. Overall compliance with mandatory training was good. Medicines management on most of the wards was good. Staff reported and learned from incidents.
Within high secure services, there was a clear aspiration to reduce the use of seclusion and long-term segregation. The trust had recruited an additional 19 psychology staff since our last inspection, which had improved access to psychological therapies in the local division. The quality and range of psychological and occupational therapies in learning disability and autism secure wards was excellent. Therapeutic intervention and treatment provided in most of the core services was in line with best practice guidance. Staff evaluated the effectiveness of their interventions using standardised outcome measures and clinical audit. Care planning and record keeping was mostly effective throughout the trust. The majority of staff were experienced and skilled, and compliant with trust requirements for supervision and appraisal. Multidisciplinary meetings and handovers were patient-focused and effective. The majority of staff understood and applied the Mental Health Act and Mental Capacity Act.
Almost all of the patients and carers we spoke with were positive about staff and the service. Patients said that staff were supportive, helpful and kind. All of the interactions we observed in five of the six core services we inspected were caring and respectful. Staff involved patients and carers in the care they received. Patients were oriented to the wards on their arrival. There were many opportunities for patients and carers to give feedback and help develop services.
The trust’s services were planned and delivered to meet the diverse needs of the population. There were good escalation procedures in place for delayed discharges. Staff took active steps to understand and engage people from disadvantaged groups and those with protected characteristics under the Equality Act 2010. Food provided to patients had improved since our last inspection. Patients on all but two of the wards we inspected had access to at least 25 hours of activity each week. Services met people’s individual needs, including disability, spiritual and dietary needs. The trust listened to and learned from complaints.
The trust had a clear vision, values and strategy. Safety and quality were paramount. The trust was financially stable and secure. Non-executive directors and the council of governors were effective in holding the trust to account. The trust had an up to date risk register and there were clear risk identification and review processes in place for risks at corporate and divisional level. There were effective surveillance systems in place and each division had a clear governance structure. Leadership at all levels was visible and effective. The trust was committed to its goal of developing a fair and just culture. Staff were aware of the whistleblowing policy and felt able to raise concerns. Overall, staff morale was good despite service pressures. Staff and patients were engaged in all aspects of strategy delivery.

However:

There was an infection control risk in patients’ laundry rooms on four of the medium secure wards. On the STAR unit, staffing was not sufficient to manage the level of need. There was low compliance with training in basic and immediate life support on three wards for older people with mental health problems and one ward for people with learning disabilities and autism. Medicines were not always managed safely in wards for older people with mental health problems and on the STAR unit.
Five trust policies referred to the out of date 2008 Mental Health Act Code of Practice, which meant staff were not following current guidance. The trust had not notified CQC of authorised Deprivation of Liberty Safeguards applications. This is a requirement of their registration. At Wavertree Bungalow, care plans for patients who were not independently mobile did not include a detailed moving and handling risk assessment. Also at Wavertree Bungalow, there was insufficient information in care records to enable staff to safely support two patients with epilepsy.
We observed negative interactions on wards for people with learning disabilities or autism. On Wavertree Bungalow, we saw staff ignoring patients, talking about patients in front of other patients, and failing to provide verbal reassurance during moving and handling.
There was a lack of meaningful activity on wards for people with learning disabilities or autism. On STAR unit we found that staff did not always use patients’ communication aids and could not control the level of noise in the environment to make it suitable for patients with sensory needs.
Some ward staff told us that low staffing levels were affecting their morale and making it difficult for them to perform their roles safely. The proportion of staff who would recommend the trust as a place to work was worse than the national average for mental health trusts. Governance at local level was not always effective.

We rated wards for people with learning disabilities and autism as requires improvement because:

We were concerned about staffing levels at the STAR unit and the impact of this on patients and staff.

Staff had not had sufficient training in a range of areas essential to this core service, including autism awareness, learning disability awareness, epilepsy and communication skills.

At Wavertree Bungalow, not all patients with epilepsy had an epilepsy care plan. Patients who required moving and handling assistance did not have written assessments or plans for this.

We undertook short observations at both services and noted negative interactions with patients at times and that staff did not always follow support plans.

At the STAR unit and Wavertree Bungalow activities were not always taking place as planned.

We noted observation records were not fully completed, with gaps where staff had not recorded observations.

However:

Wards were clean and well furnished.

Infection prevention practice was good.

Positive behavioural support plans and risk assessments were well completed and comprehensive.

Patients and carers gave positive feedback about staff at the services.

At the STAR unit, a well equipped sensory room was available on the ward and well used.

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

The service was not providing safe care and treatment in relation to medicines management. Allergies were not being recorded on medicine cards, which meant there was a risk of a patient being prescribed medicines they were allergic to. On Irwell ward, there was no guidance to staff of how to administer medicines to a patient covertly and medicine administration cards had several administration boxes left blank. We noted delays in treatment starting for up to three days.
Training was a concern. Training levels for basic life support, immediate life support, Mental Health Act and Mental Capacity Act were low across the wards. Dysphagia training (to assist patients with swallowing difficulties) was not available to staff; this had been identified as being required in an action plan following the death of a patient.
Staff were not receiving supervision and appraisal in line with trust policy. Staff reported morale as low, particularly following the closure of one of the wards caring for patients with dementia.
Patient access to a variety of staff from different disciplines varied across the wards, especially in relation to psychology, occupational therapy, speech and language therapy and gerontology(a doctor specialising in old age and ageing).
Accessible information was not available to patients to assist with orientation to the ward at admission.
The service provision in some of the wards did not reflect national guidance in relation to the environment and activities available.
There was no evidence that staff followed legal advice to review a patient’s capacity pending the outcome of a Deprivation of Liberty Safeguards Application. Only one of the five wards notified CQC of authorised Deprivation of Liberty Safeguard applications.

However:

Feedback from patients and carers was positive in relation to the care provided and we observed respectful, responsive and encouraging interactions from staff.
Incidents and complaints were managed well and learning was shared with staff via team meetings.
Staff had a good understanding of safeguarding and how to respond if safeguarding concerns were raised.
Physical health was managed well, with assessments taking place on admission. Frailty reviews took place for all patients, which were multidisciplinary in nature and clear actions set and reviewed. The service provided ongoing physical health care.

We rated forensic inpatient/secure wards (medium and low secure) as good because:

All wards had a ligature risk assessment in place. Security procedures that were in place for accessing the wards met the needs of each individual service and the level of security required.
Clinic rooms were functional; medical devices were checked regularly and serviced and calibrated annually. Physical health was monitored routinely, and patients had access to a GP twice weekly if this was required.
Risk assessments and care plans were in place for all patients. These were up to date and reflected the patients’ needs. The majority of patients told us that they had been offered a copy of their care plans.
Incidents were reported through the trust’s electronic incident reporting system. Staff received feedback on incidents and complaints through staff meetings and quality practice alerts.
Staff used National Institute for Health and Care Excellence guidance to guide their practice, and used recognised rating scales to monitor patient outcomes.
Staff received supervision and annual work performance appraisals. Staff felt skilled and competent to perform their role and had lots of opportunity for additional training should they wish to develop their skills further.
We observed positive and supportive interactions between patients and staff, which showed that staff treated patients with dignity and respect. Patients told us that staff were respectful and caring.
The independent mental health advocate was available on thewards, and supported patients in ward rounds and with their concerns. Community meetings took place monthly.
A referrals meeting took place weekly across the medium and low secure wards to review all referral, discharges and movements between the services.
Both diversionary and occupational activities took place on the ward seven days a week. The majority of patients told us that the food was good, and they had access to hot and cold drinks throughout the day and could have snacks. Both units had a multi faith room and could access spiritual leaders to support their patients’ cultural and spiritual needs. There was disabled access on both sites.
Staff were aware of the vision and values of the organisation. Staff felt that there was a high presence of the matrons within the low and medium secure services.
There were good governance systems in place for monitoring compliance with staffing sickness, mandatory training and appraisals. The ward managers felt that they had enough authority to perform their role and had access to key performance indicators, which helped to monitor the performance of their teams.
Staff morale was good and there was evidence of good team working. Staff were able to provide feedback on their services through team meetings. They were also invited to send any feedback to the trust chief executive.
All the wards were part of the quality network for forensic mental health peer review initiative.

However:

At the Scott Clinic, the sluice on four of the wards was located within the patient laundry room. This did not apply good infection control principles for clean and dirty areas.
Patients that were secluded at the Scott Clinic could potentially see the computer screens in the staff office which could cause a breach of confidentiality.
The ward staffing levels meant there were not always enough staff on duty to meet the needs of the patients; patients and staff told us that leave often had to be rescheduled.
The drug detection dog attended all the wards on a frequent basis. We felt that this practice was overly restrictive on low secure wards.

We rated this core service as good because:

•The service had developed clear, evidence based clinical pathways to support effective assessment, treatment and management of clinical needs. The teams worked effectively and collaboratively with other services to ensure continuity and safety of care across teams, including involvement of external agencies. We found that there were inconsistencies between the localities we visited, in relation to caseload management and service delivery. This meant that people may have a different experience of care or outcome of treatment, depending on where they receive their care. However, the community learning disabilities teams worked hard to meet the varied demands on the service despite challenges they faced at times with limited resources.

•People who used the service were treated with kindness, respect and dignity. Individuals were positive about the way staff treated them and were involved in the planning of their care. Clinician`s kindness, expertise and skills within the teams were highly regarded by all carers and patients we spoke with. The staff we met ensure the people who use the service at the centre of what they did.

•The service operated an open referral system and had capacity to respond in a timely manner. The teams were confident that they all worked within the assessment targets agreed by the trust, however the systems in place to monitor compliance with waiting and response times did not appear to accurately reflect this. The teams worked flexibly to meet individual`s needs and worked closely with a number of different agencies to meet their needs, promote community involvement and social inclusion.

•The trust had a system to identify and monitor quality and safety of the services they provided. However, there were concerns with accuracy of recording and quality of data to monitor compliance with waiting and response times. There were not effective systems in place to monitor referrals, waiting lists, unmet need and the potential impact of gaps in service provision. There was a clear system in place to report incidents. However, we were concerned about the lack of comprehensive investigation into a serious incident affecting a member of staff last year.

• The community learning disabilities service was undergoing a comprehensive review of service delivery, local team performance monitoring and management structures, as part of the service re-design.Some teams, for example, both of the Asperger`s teams, and the administrative teams, did not have a line manager. Meeting structures were not in place which would support effective oversight monitoring across the whole service, for example, there were no management meetings or administration meetings in place. Most staff were concerned that there could be reduced learning disability representation within the senior management team with the restructuring.

•We saw good examples of local leadership from the team managers we met. 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 manager and modern matron showed a good understanding of the current challenges for this service and staff.

We rated the health based places of safety as good overall because:

There was evidence of good inter-agency working including shared forums for reviewing issues, strategic meetings, addressing continued service improvements and positive relationships within the operational services.

Joint protocols were in place across Merseyside police, Mersey Care NHS Trust, the acute hospital trusts, local authorities and ambulance services involved in the detention, assessment and conveyance of people detained under section 136 of the Mental Health Act.

Joint procedures included a 10 step pathway for all involved in the process of section 136 to follow. The police used a traffic light rating system to support joint decision about remaining at the assessment or leaving.

There was a designated health-based place of safety in the city for children under the age of 16 years.

There had been no detentions of anyone subject to section 136 to police cells within Merseyside in the previous 12 months.

There was a culture of continued development. This included the street car initiative and the development of a heath-based place of safety within adult mental health inpatient services. There was also the implementation of employing health care assistants within accident and emergency services to provide one to one support for people detained under section 136.

However

The section 136 room at Aintree University Hospital did not provide a safe and a suitable environment for the assessment of patients detained under section 136 of the Mental Health Act (MHA) 1983 and there was a privacy and dignity issue at the Royal Liverpool University Hospital as the toilet door had been removed for safety reasons.

There were some considerable waits for section 136 assessments to be concluded. The reason was not clearly recorded in all the instances.

All of the forms that we reviewed required multi-agency input to record each stage of the 10 step care pathway retained within the A&E departments were incomplete.

Overall, we rated community based mental health services for adults of working age as good because:

The CMHT’s at Arundel, Kirkby and Moss House had safe and clean environments. Clinical rooms were sufficiently equipped and the equipment was generally well maintained. Staff adhered to infection control requirements and good practices in medicines management. Staffing levels ensured people using the service received safe care. All the CMHTs visited, managed vacancies and sickness to ensure there was minimal impact for people using the service. Staff assessed and managed the risks of people. These were reviewed regularly. Staff discussed crisis plans with people and included them in their care packages. Staff were knowledgeable in safeguarding requirements. Staff reported on incidents and lessons learnt, were shared across the teams at location level and trust wide.

Peoples’ needs were assessed to enable staff to plan their care with a holistic and recovery focused approach. The CMHT’s had access to a full range of disciplines. Staff were well supported, appropriately trained and able to develop their roles. The CMHT’s held effective and regular multi-disciplinary meetings. There were good links with social services, inpatients settings and crisis provisions to ensure good care. Staff adhered to the Mental health Act 1983 (MHA) and the MHA Code of Practice and demonstrated good practice in applying the Mental Capacity Act (MCA) 2005.

Staff were kind and respectful to people using the services. Staff actively involved people in developing and reviewing their care and maintained people’s confidentiality. Staff also made sure that their families and carers were involved when this was appropriate.

Staff saw referrals within the trust targets. There was a clear process to discuss steps to be taken for people who found difficulty in engaging with the service. Inpatient discharges into the community and discharges from community services were planned and consultant led, with care co-ordinator involvement. Information was available to people and accessible in varying formats and languages as needed. People using the service knew how to complain and learning from complaints was discussed within staff teams.

Staff knew the trust’s vision and values and felt these were embedded into service delivery. Morale within teams was generally good and staff felt supported by management. Staff had opportunities to develop and were encouraged to do so. Managers had sufficient autonomy and support for their roles. Staff had attended trust wide events learning from incidents.

However,

The trust’s Lone Working Policy lacked detail on how regularly checks should be made to account for workers on community visits and who should conduct these checks.
People using the service had limited psychological interventions and with long waiting lists for psychotherapy.

Teams had not been subject to audits to ensure the MHA was being applied correctly in relation to community treatment orders (CTOs).

Some managers reported that systems for reporting training, supervisions and appraisals were not robust.

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We rated wards for people with learning disabilities and autism as good because:

When every patient was admitted, a comprehensive assessment of needs was carried out. This included a detailed risk assessment and risk management plan that were updated regularly after every incident.

Staff were trained in safeguarding and demonstrated a good understanding of how to identify and report abuse. Staff knew how to recognise and report incidents through the reporting system. Learning from incidents was shared with staff.

There was evidence of regular and thorough physical health checks and monitoring in records. Staff were trained in different areas of physical health such as catheter care, postural positioning and peg feeding.

The medicines charts sampled showed that the National Institute for Health and Care Excellence guidance was followed when prescribing medication.

Staff received regular supervision, appraisals and participated in clinical audits. There were regular and effective clinical review meetings that involved the relevant members of the multi-disciplinary team.

Patients were treated with respect and dignity and staff were polite, kind and willing to help. Patients and families were complimentary about the support they received from the staff and felt that they got the help they needed.

Patients were actively involved in their clinical reviews and care planning and were encouraged to involve relatives and friends if they wished. Patients and their families told us that they were able to access advocacy services when needed.

Patients were not moved between wards during an admission, unless this was justified on clinical grounds and was in the patient’s best interest. All discharges and transfers were discussed in the multi-disciplinary team meeting and were managed in a planned or co-ordinated way.

Each patient had an individual structured programme of activities which related to their individual needs. A variety of communication tools were used by staff to help individuals communicate their needs. Families and carers told us that they were able to raise any concerns and complaints freely.

Staff told us that they knew how to use the whistleblowing process and felt free to raise any concerns. Staff were offered the opportunity to give feedback on services and input into service development through the annual staff surveys. The trust used performance indicators to gauge the performance of the team. Where performance did not meet the expected standard action plans were put in place.

Both units had well-equipped clinic rooms that had all emergency equipment such as automated external defibrillators and oxygen and these were checked regularly.

However:

Only 50% of staff at Wavertree had received training in Mental Capacity Act. Staff at Wavertree did not demonstrate a good understanding of the Mental Capacity Act and were not clear about how to apply the law in practice.

At Wavertree, patients were not assessed for their capacity to consent to admission or any specific decisions to their care and treatment. Patients that were not able to take food orally and who were fed via percutaneous endoscopic gastrostomy had no assessments of whether they had capacity to consent to medication given through this intervention. This had also not been checked with other teams in the community. There were no records of any ‘best interests’ meeting held to decide if this was in the person’s best interest.

A bed was not always available if a patient required more intensive care if their behaviour had worsened.

Three patients told us that they were not happy with the food choice at lunch time.

The Wavertree Bungalow did consider how best to segregate men and women It did have approved plans and finances to ensure it would meet best practice in relation to gender segregation by the end of the year.

We rated the community based services for older people as ‘Good' overall because:

People had their needs assessed, care planned and delivered in line with best practice.
Multi-disciplinary teams managed the referral process, assessments, on-going treatment and care. This included care navigators who support people with dementia.
Common assessments and pathways for post diagnostic support for people with dementia had been agreed across mental health, acute and specialist NHS trusts.
People who used services had timely access to care and treatment.
There were systems in place to triage referrals based on the individual needs of people who used the service. Services were planned and delivered to meet people’s needs in a person centred way, taking their cultural needs into account.
Each team was well led by committed managers.
Each team had team objectives which helped guide staff and teams.
Two out of three of the memory clinics were accredited as excellent, with the Royal College of Psychiatrists’ memory services network accreditation project.

We saw outstanding user involvement initiatives with significant service user involvement and community engagement, including by people with dementia. This was particular apparent in Central Liverpool. This included:

the work of the service user reference forum.
service users and staff working as partners to be involved in developing apps to assist their memory, reminiscence and daily functioning and working with businesses to make them 'dementia friendly'
partnership work with Everton Football Club.

People were exceptionally positive about the care they received.

However, there were vacancies within teams which meant that some staff had to manage caseloads greater than they usually would. Care navigators were managing large numbers of people. We did not see significant impact on patients from these; managers were looking to address these by recruiting staff and working with commissioners.

Some risk assessments for people using the service were over 12 months old. Lone working practices did not always fully ensure staff safety. Staff were not always proactive in following up on updates on safeguarding processes. There were minor issues with equipment in the clinic room at Central Liverpool older people’s CMHT

We gave an overall rating for wards for older people with mental health problems of requires improvement because:

We had serious concerns about the safety of patients on Irwell ward. It did not comply with the guidance on same sex accommodation. It did not have any action plans in place to mitigate against the risk of suicide that the environment may present. It was in breach of its own plan to help prevent the risk of suicide. The ward environment presented risks for older people with dementia. Staff did not have clear lines of vision to ensure good levels of observation of all areas.
Boothroyd and Oak wards also presented challenges to good levels of observation of all areas.
The alarm system for patients on Boothroyd was insufficient.
On Irwell ward staff were not adequately skilled to safely meet the needs of patients.
On Irwell ward identified risks were not appropriately addressed in care plans.
On Irwell ward staff providing care and treatment were not adequately supervised or supported in their role.
Across all wards there was poor understanding of the Mental Capacity Act 2005.
Patients receiving care and treatment were not afforded privacy whilst accommodated on Irwell ward.
On Irwell ward patients were not provided with food and drinks in a manner that promoted their independence and dignity.

This inspection highlighted a number of problems and issues on Irwell ward. This was a dementia assessment unit in Clock View hospital. The ward had only been open for four months. The issues identified on this ward, were at variance with the other older people’s inpatient services we inspected at Mersey Care.

Patients and their relatives were mostly positive about the care and treatment provided on the wards. Staff were mostly caring and compassionate. We observed some very kind and responsive interactions between staff and their patients.

The trust had a robust falls management process that was well embedded on all the wards. During our inspection we saw outstanding falls management, on Acorn ward and Heys Court led by committed multidisciplinary teams.

There was a good understanding of staff responsibilities in adhering to the Mental Health Act and its Code of Practice. The trust had provided training for staff on the Mental Capacity Act 2005 (MCA) but we found that staff knowledge and application of the law was poor in most areas.

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

Although the physical environment varied across wards, the trust had actions plans in place to ensure that any risks associated with the environment were addressed. The wards were clean and well maintained and there was good evidence that infection control was monitored. There were dedicated wards for men and women, and the mixed wards complied with gender segregation guidelines. Medication was managed safely in most areas. However, on the Broadoak Unit we found that staff had limited understanding of what constituted rapid tranquilisation and how the patient should be monitored afterwards, and there were errors in the controlled drugs register.

All patients were assessed on admission to the wards, which included an assessment of their mental and physical health and a risk assessment.

Staff treated patients with dignity and respect and were responsive to their needs. Patients were given information about the service and their care and how they could make comments or complaints.

Most of the care records we looked at were person centred and recovery orientated, but there were gaps on some of the wards. Patients had their basic physical healthcare needs met, but the trust was working to improve this further.

Staff reported and investigated incidents, action was taken and learning was shared with staff through supervision, meetings and bulletins. Most patients were admitted to a hospital within the trust when they needed a bed.

We found that services were well led and that staff were familiar with the vision and values of the organisation. They were aware of the trust’s initiatives that aimed to reduce the use of restraint within the trust, no force first and the zero tolerance to suicide strategy.

Managers of the service met regularly to review practices and areas of concern. They provided staff with regular supervision and appraisal and ensured that staff had under gone training, including being up to date with mandatory training.

We gave an overall rating for long stay/rehabilitation mental health wards for working age adults of requires improvement because:

The ligature assessment on Rathbone Rehabilitation was out of date; actions from previous years did not appear to have been completed. Previous assessments did not take into accounts the risks in the garden such as the gym.
Brain Injury Rehabilitation Ward did not have access to ligature cutters for all staff. These were locked in the clinic room in a cupboard that only certain staff could access.
There was an average of 2 shifts per week left on Rathbone where staff numbers were below what was clinically required. There was also a high level of sickness.

1:1 supervision rates of staff were not in line with trust policy.
Mandatory training records showed that staff at Rathbone Rehabilitation Ward, were not up to date with required training, which was set at 95%.
Staff were not appraised in line with trust policy, 3 staff had not been appraised for 2 years.
Knowledge and access information for IMHA and IMCA services was out of date.

However:

Wards were clean, tidy and well maintained. There was good medical cover from doctors and a nurse practitioner to take the lead on physical health assessment. Staff carried out audit of patients care plans and of infection control risks. Safeguarding training was up to date and there was generally good knowledge around safeguarding procedures. NICE guidelines were followed for prescribing and offering therapies such as Cognitive Behavioural Therapy. Staff were observed to have a caring attitude towards the patients and the interactions were positive.

Patients reported feeling safe on the ward and they were supported after being discharged through follow up groups. There was a comprehensive range of disabled equipment and wards were adapted to have very good disabled access. Wards had activity timetables that were generic but also produced individualised activity plans that were of a multi-disciplinary approach. There were procedures in place to listen to and escalate complaints, the services showed they listened to and adapted according to patient feedback. Morale of staff was reported as good and staff felt free to raise concerns. Rathbone Rehabilitation Ward was AIMS accredited whilst Brain Injury Rehabilitation was accredited with Headway meaning that they were providing a service that was of a high quality and measured against national standards.

Overall we rated the service as good this was because:

There was a good culture of safety; staff had implemented the no force first initiative to good effect. There was good reporting of serious untoward incidents and staff learned lessons from these. There was a trust wide incident reporting process, with a clear expectation of 72 hour review and lessons learned exercises. Staff had a clear understanding of safeguarding and knew when to report abuse.

Staffing levels had been difficult for the trust but they were working to resolve this and had an active recruitment plan in place.

There was a trust mandatory induction programme and staff in the secure division had additional specially tailored training. The majority of staff felt that they received a good level of professional development and that training was actively encouraged. Staff were up to date with mandatory training, although in some places supervision was sometimes cancelled and staff had not had their annual appraisal.

Care plans were up to date and completed with patients’ involvement, where patients had refused to participate, this was noted in the file. This was with the exception of the Scott Clinic, which did not always demonstrate patient involvement.

There were effective multi-disciplinary meetings in place and clear care pathways for individuals.

Patients reported positively on staff engagement. Overall patients felt that staff were kind and respectful and they spoke highly of the Positive Intervention Programme. This was valued for the work they did on engagement and advocacy.

The trust’s visions and values were clearly articulated and staff were positive about the trusts vision. They were also positive about their managers and felt supported and valued. Communication was good and staff felt they could raise issues of concern and that they would be listened to.

However:

We found concerning issues following which the trust undertook an immediate review into the use of seclusions rooms and closed two rooms one at the Scott Clinic and one at Ashworth Hospital.

We were concerned that activities were often cancelled and that there were long waits for psychological intervention.

We found that the provider was performing at a level which led to an overall rating of good.

The trust was well led and had some exceptional leaders, managing in very challenging circumstances. The board was highly aspirational and committed to delivering services which were of high quality and where every person matters. It was clear that most staff across the organisation understood, and were committed to, the vision and values of the organisation. These were well communicated and the work to win both hearts and minds was apparent. For instance, staff at all levels of the organisation were able to clearly articulate the drive for zero tolerance to suicide and understood the no force first initiative.

The trust had new ways of working, such as peer support models and recovery colleges. We saw good evidence of involvement across both corporate and frontline services such as the service user assembly and the commitment by the trust to involve experts by experience in all recruitment drives.

Key stakeholders, including the clinical commissioning gropus and local authorities, were positive about the trust and relationships were transparent, open and honest, with a good degree of challenge. This was also true of the relationships at board level. We concluded that the board worked well together and were professional and respectful in their interactions. They were able to offer high challenge, without rancour or defensiveness. They were passionate about people and committed to understanding, first and foremost, the lived ‘experience’ of people who use services.

The trust had good systems in place which helped them understand what was happening on the frontline. These systems helped them respond quickly and efficiently to areas of concern. For example; a weekly surveillance meeting, led by the chief executive, identified ‘hotspots’. This may be where incidents had occurred, or where a complaint had been made, or where data was showing the potential for risk. Action plans were developed immediately and directors tasked to go back into the service and deliver on assigned tasks.

Alerts were sent out across services called ‘quality practice alerts’. These enabled other services to learn from serious incidents and complaints. It was expected that actions arising from this learning was disseminated across services.

The trust had good monitoring systems for assessing safety and quality through its Governance of Quality Framework. This had resulted in identifying very clearly those services, which require improvement and had detailed actions in place to address any areas of risk or concern.

The process for monitoring of risk was robust and the board were clearly sighted on both the corporate and operational risks facing the organisation. These were presented in board meetings via a risk register.

The structure of meetings and committees, which provide the board with assurance, were well embedded. Most had non-executive director oversight. This ensured that the trust have leaders who are more objective and were well placed, to provide the appropriate challenge.

We found the trust had the right policies in place to support staff in their work and that staff received relevant training and support. An exception to this was the Rathbone unit, where staff had not completed mandatory training, had not been adequately supervised or received an appraisal. There were gaps in staff understanding and application of the Mental Capacity Act and Deprivation of Liberty Safeguards in some teams. A requirement notice has been issued for the inpatient learning disability service, due to failure to ensure that documentation on capacity and consent to treatment and best interest decisions is completed.

We found that across the trust morale of psychologists’ was low and there was a lack of psychological support for people. We were pleased to see the trust had recently appointed a Head of Psychology. However, there were considerable access problems across the services in relation to psychological therapy and the trust have been issued with a requirement notice in this respect.

We found significant concerns in relation to one of the older peoples’ inpatient services and requirement notices have been put in place. These specifically relate to ensuring the dignity of patients is preserved. We were also concerned that Irwell ward was not a safe environment in relation to lay out of the ward and the use of glass doors and large glass reflective windows. Staff did not always meet the communication needs of individuals and during meal times food was not presented in an acceptable manner, for instance wrapped sandwiches were left on a table for patients to help themselves.

In forensic services there were concerns raised relating to some seclusion rooms which were not fit for purpose and did not comply with the Mental Health Act Code of Practice. The Trust responded immediately to our concerns and closed two seclusion rooms.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

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