All inspections: Bradford District Care NHS Foundation Trust

We carried out this unannounced inspection of the community health service for children, young people and families, provided by this trust as we had concerns about the quality of the service provided.

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

The service did not have enough staff, there were several unfilled vacancies and staff were holding caseloads much larger than recommended by national guidance. Staff sickness and turnover levels were high.
The service was unable to meet mandated contacts for children and young people. Aspects of the service were in business continuity which meant that not all services were being provided. There were waiting lists in place in the looked after children’s team which meant that children waited for individual health assessments longer than they should, and this was not in line with national guidance.
We reviewed 29 records during the inspection. Whilst the majority of records were detailed and consistent, we had concerns that five of the records did not meet the trust's standard in evidencing what action had been taken to address concerns in relation to risks such as domestic violence or mental health concerns. Managers were aware that this was an area of improvement for the service and were undertaking a records audit at the time of the inspection.
The service worked on a risk-based approach whereby children were placed into four tiers dependent on need. We were concerned that in some cases late identification of health conditions and disabilities could occur for those children in lower tiers of need due to lower levels of oversight for these families.

However:

Staff teams worked collaboratively and were encouraged to share ideas and give feedback on service development. Staff supported people to live healthier lives and thought of different ways to engage harder to reach service users.
Staff treated children, young people and their families with compassion and kindness. Staff were passionate about the roles they performed and wanted to provide high quality care. Service users were encouraged to give feedback, which was largely positive. Staff recognised the importance of mental and emotional health as well as physical health and offered appropriate support and information to families.
The service was beginning to consider and introduce some innovative ways of working to meet the needs of the local population.
Leaders at all levels of the service were knowledgeable and passionate and sought to drive improvement. Strategies and development plans reflected the needs and challenges of the service and there were clear action plans in place detailing how improvement would be made. Staff were satisfied with their roles in the service and felt valued and supported.

How we carried out the inspection

During the inspection visit, the inspection team:

• visited six locations

• carried out six home visits and one school visit

• spoke with the general manager and assistant general manager for the service

• spoke with 55 other members of staff including, service managers, school nurses, health visitors, staff nurses and nursery nurses

• spoke with nine service users including one young person

• observed the running of one baby clinic and one immunisation session

• looked at 29 care and treatment records of service users

•looked at a range of policies, procedures and other documents relating to the running of the service.

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 the inspection we spoke with nine service users, including one young person. We also observed interactions between staff, young people and their families during 10 appointments including at an immunisation clinic, school nurse clinic, baby clinics and home visits.

Service users told us that staff were friendly, helpful and approachable and would always give advice and respond to queries. They also told us staff were accommodating at rearranging appointments to support service users. We observed staff providing reassurance and support to those with concerns or worries. The majority of those using the service told us that staff were helpful, approachable and available to give advice and support. Staff took time to explain about the service and ensure service users knew what support was available to them. Service users were regularly requested to give feedback about the service to aid improvement, but staff were clear that they needed to do more to gain feedback from children and young people.

We carried out short notice (24 hours) announced inspections of three of the community mental health services provided by this trust.

We inspected community mental health services for adults of working age because we rated them requires improvement at our last inspection. We inspected specialist community mental health services for children and young people because of the high-risk nature of this service, and because we have not inspected this service since 2014. We inspected crisis and health-based places of safety because of the high-risk nature of this service.

We also inspected the well-led key question for the trust overall because at our last inspection we rated the trust overall as requires improvement.

At this inspection community mental health services for adults of working age, and crisis and health-based places of safety were rated as good overall. In community adults of working age, the rating had improved from requires improvement. In crisis services the rating stayed the same with an increase in rating in the safe key question from requires improvement to good.

Specialist community mental health services for children and young people were given a rating of requires improvement overall, with a rating of good in the caring key question. The rating had gone down since our last inspection.

We did not inspect four services previously rated as requires improvement because we did not have intelligence which told us about risk in these services. We are continuing to monitor the progress of improvements to these services and will re-inspect them as appropriate.

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

We rated services as requires improvement in the safe key question, responsive and effective as good, and caring as good. We rated the trust as good in well-led.
We rated six of the trust’s ten mental health services, and three of the trust’s community health services as good.
The trust had made a number of improvements since the last inspection, the ratings of the trust overall, acute wards and psychiatric intensive care units, and community mental health services for adults of working age had improved, the rating of crisis services had stayed the same.
There were several areas of concern at the last inspection which the trust had made improvements to. This included; governance processes, oversight and management of risk and performance, a reduction in the use of restrictive interventions, improvements to serious incident reporting and oversight and management of supervision, appraisal and mandatory training.
The trust had taken action to improve the safety of services, rapid improvement processes had been used where concerns had been identified. Daily lean management processes meant that leaders were aware of risks and concerns in front line services.
We observed and were told about staff who were kind, caring and compassionate. Staff had received several compliments about their work.
The trust had a focus on the wellbeing of staff, offering incentives as well as practical and emotional support. Staff spoke of a positive culture of openness and transparency from senior leaders and were encouraged to develop both their professional skills and be innovative in the services in which they worked.
The trust was responsive to the diverse needs of the population it served, had awareness of and was working to reduce health inequalities.
The trust engaged with partner organisations to be an active part of the integrated care system. The trust saw staff, governors, patients and carers as partners in care and worked to ensure their voices were heard in the improvement of services.
The trust had an experienced and skilled leadership team and a board of non-executives who were passionate and from a range of backgrounds bringing diverse experience to their roles.
Governance processes were effective and embedded with a clear ward to board structure for reporting.
There were some areas of outstanding practice which included the trust’s work in the clinical incident stress debrief service.
The trust had successfully embedded and managed a large vaccination programme for both adults and children.

However:

The rating of the trust’s specialist community mental health services for children and young people had reduced from good to requires improvement since the last inspection. The trust were aware of the risks and issues in this service and staff told us that they were starting to see improvements and revised governance structures were in place, but these were not embedded at the time of the inspection.
We rated four of the trust’s mental health services and one community health service as requires improvement. In rating the trust, we considered the current ratings of the eleven services we did not inspect this time.
There remained issues in the services we visited in relation to the quality of documentation. Information about patients and their care and risks was not always accessible. In community mental health services for adults and for children and young people, risk assessments and care plans were not stored consistently and often stored in progress notes. Consent to treatment was not always recorded and paperwork relating to community treatment orders was not in line with the Code of Practice.
The management of policies and processes needed improvement. Some policies were not in line with statutory codes of practice and important information on timescales and processes were not always included, this was particularly in respect of human resources policies, and those relating to the Mental Health Act.
The duty of candour regulation was not fully applied in the incidents we reviewed because an early apology was not always given in line with the legislation and was not part of the trust’s processes. The trust did not have a specific duty of candour policy, although the process was outlined within other relevant policies.
The trust had a focus on quality improvement and there were a number of initiatives in place. However, it was not always possible to track how outcomes and actions from some initiatives were monitored, such as actions from the board’s ‘go see’ visits and feedback from staff network groups.
Information collated from the staff survey and workforce race and disability equality standards evidenced that the trust had further work to do in order to tackle inequalities in the workplace.
The trust had an estate at Lynfield Mount hospital and in some community services which was no longer fit for purpose.
The trust had governance processes in place to monitor areas of risk and concern. However, in some risks in front line community services such as staffing, and caseload levels were not always prioritised by the board.
Waiting times in some services were too long. This included waiting times for adult and children’s neurological services and waiting times for dental treatment and therapies.
The trust had begun to make improvements to their patient safety process including improvements in the investigation of serious incidents. However, incident investigations required further improvement on human and causative factors. Incidents were often found to be individual staff error and there were repeat themes in incidents where professional curiosity was lacking and risk thresholds were too high, and it was not possible to track how action had been taken to improve practice when these issues were managed at service level.

How we carried out the inspection

worked with experts by experience who talked to patients and their carers about their experience of using trust services.
visited both specialist community child and adolescent mental health services at Fieldhead in Bradford and Hillbrook in Keighley.
Visited three community mental health teams for working age adults; the City team, North team and the Aire Wharfe team.
visited community crisis services; the first response service, the intensive home treatment teams and the psychiatric liaison service at Airedale General Hospital.
visited trust headquarters to speak with senior leaders.
spoke with a variety of staff in face to face or virtual meetings including; health care assistants, nurses, doctors, allied health professionals, and managers.
Attended and observed several meetings and committees held by the trust.
reviewed several records relating to the care and treatment of patients.
reviewed a variety of documents relating to the management of the trust and the services it delivers.
held four focus groups with; staff network groups, staff side and two open staff drop in calls.
reviewed a variety of information we already held about the trust.
sought feedback from several of the trust’s stakeholders such as Healthwatch, the local authority, NHS England and Improvement and CCG’s.

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 33 patients who had experience of using services who were either patients or carers. Feedback was mainly positive. We also gathered feedback from patients via Healthwatch colleagues.

Young people using child and adolescent mental health services spoke about feeling supported by professional and caring staff who were respectful, and managed confidentiality well. They said that staff listened and understand and were empathic to their needs and that teams were reliable and offered a variety of treatments.

Patients using crisis services described staff who were caring, understood their needs, responsive and who communicated with them well, they said that appointments were arranged quickly.

Patients using community mental health services for adults of working age had positive experiences. They described staff who provided emotional and practical support, said that they had access to doctors and had information about their medication. Some patients told us that the support they were offered had kept them out of hospital.

However,

Young people using child and adolescent mental health services told us that communication could be improved as there was not always a point of contact available. Young people and their families were frustrated by long waiting times.

Patients commented that continuity of care and changes of staff could improve in crisis services.

Patients using community mental health services for adults of working age told us that it could be difficult to access support from Somerset House at times.

Bradford District Care NHS Foundation Trust provides five inpatient wards for adults of a working age and one psychiatric intensive care unit. Services are provided from wards located at two sites; the Airedale Centre for Mental Health and Lynfield Mount Hospital.

The trust is registered to provide two regulated activities in relation to this core service:

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

We carried out this unannounced focused inspection because we were made aware of some serious incidents which had taken place on the wards, and this gave us concerns about the safety and quality of the services provided. We also followed up on the provider’s progress with areas of improvements we identified during our last inspection of the service in March 2020.

This inspection was a focused inspection. We reviewed the safe key question and specific key lines of enquiry within the effective, caring and well-led domains.

As part of our inspection we visited four mental health wards for adults of a working age. The wards we visited were:

Ashbrook ward – a 25 bed female acute ward with a one bed child and adolescent mental health service annex, located at Lynfield Mount hospital
Maplebeck ward – a 21 bed male acute ward located at Lynfield Mount hospital
Fern ward – a 15 bed male acute ward located at the Airedale Centre for Mental Health
Oakburn ward – a 21 bed male acute ward with a one bed child and adolescent mental health service annex, located at Lynfield Mount hospital

We did not rate the service at this inspection. The previous rating of good remains. We found:

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients and families and carers in care decisions.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Staff on Fern ward did not always complete regular daily environmental reviews of the ward. On Fern ward the ward manager's office space was located within the clinic room.
Staff compliance with some mandatory training courses on Oakburn ward (management of violence and aggression) and Ashbrook and Maplebeck wards (immediate life support) was below 75%. This was due to an initial pause on training delivery until Covid19 safe lesson plans and environments were identified in line with Government guidance. At the time of our inspection face to face training had resumed with restricted numbers. A prioritisation process to target staff for training was in place.
Care plans were not always personalised. The recording of discharge planning was inconsistent. Patients and carers we spoke with were not all aware of independent mental health advocacy services.

How we carried out the inspection

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

During the inspection we visited four wards, looked at the quality of the environment and observed how staff were caring for patients. We spoke to the ward managers of the four wards we visited, and 16 other staff members including registered nurses, healthcare assistants, doctors, psychologists and occupational therapists. We spoke to eight patients using the service and to nine carers and family members of patients using the service. We reviewed 17 care records including observation and seclusion records and 40 medication charts. We attended four clinical meetings and reviewed a range of policies and procedures relating to the running of the service.

What people who use the service say

We received mostly positive feedback from patients using the service. Patients told us they felt safe in the service. Patients described staff as supportive and caring. Patients generally felt involved in their care and decisions around their care and treatment.

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

The service provided safe care. The trust had taken significant action to improve the safety on the wards. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. Staff provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers supported staff with appraisals and opportunities to update and further develop their skills. Eighty seven per cent of staff within the service had received regular supervision at the time of our inspection. However, on Fern ward this was lower with 59% of staff receiving regular supervision. The ward staff worked well together as a multidisciplinary team and with those outside the ward.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They involved patients, families and carers in care decisions.
The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
The service was well led, and the governance processes ensured that ward procedures ran smoothly.

We did not re-rate the service following this inspection:

Whilst there had been significant improvements in ensuring that patients were safe, systems and processes were still embedding and there remained some areas of concern including staff not always completing environmental checks, ligature risk assessments not always identifying all the ligature risks or being updated, risk management plans were not always personalised or specific to the risks identified in the risk assessment, controlled drugs were not always managed appropriately, and patient leave documentation and the allocation of a risk rating for incidents was not always completed in line with the trust’s policies.

However:

The safety of the service had improved.
Wards were safer, clean, well equipped, well furnished, mostly well-maintained and fit for purpose.
Most staff had completed and kept up to date with their mandatory training, which was comprehensive and met the needs of patients and staff.
Staff assessed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour.
Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
The governance framework and processes had improved and ensured that ward procedures ran more smoothly and ensured that senior leaders within the service had better oversight.
Staff spoke of a change in the culture of the organisation and that there was a collective responsibility. Senior leaders within the organisation were accessible and managers and staff felt supported.
Most patients reported they had a positive experience and that most staff were nice. They told us staff kept them safe and they rarely used physical restraint.

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

The service did not always deliver safe care. Risk assessments of the environment did not include all potential risks, had not been reviewed as required and the trust had not taken action to mitigate all those risks. There were no nurse call alarms on any of the wards for patients to use and no standard procedure for giving patients access to an alarm. The service had blanket restrictions in place that were not based on an individual assessment of risk and need. Staff did not adhere to trust policy in searching patients and monitoring their mail. Staff did not clearly evidence that they had used long term segregation appropriately or that they had followed best practice and trust policy in doing so. The seclusion room contained a safety hazard.
The service was not always well led. Senior managers did not have sufficient oversight of the issues in their service and ensure staff were adhering to trust policy in relation to searching, mail monitoring and long-term segregation. Systems and processes in place to enable good governance of the wards were not always effective. The trust did not have robust systems in place to monitor and safeguard patients in long term segregation. Staff supervision was not effectively monitored and the electronic record system did not enable staff to effectively document seclusion episodes or the monitoring of rapid tranquilisation.

However:

There were sufficient staff to meet the care and treatment needs of patients. Staff and patients reported they felt safe on the ward. The wards were clean and the environment was well maintained.
Staff undertook comprehensive assessments of patients’ physical and mental health needs and used these to develop care plans in collaboration with patients. Staff provided a range of treatment interventions suitable for the patient group and used recognised rating scales to monitor outcomes. Staff across all disciplines worked well together and teams had effective working relationships with external agencies.
Staff treated patients with kindness and respect. Staff understood the individual needs of patients and supported them to manage their condition and treatment. Staff involved patients in their care and treatment and won awards for their innovative practice in patient care. The service provided carers with the opportunity to be involved in their relative’s treatment and to provide feedback on the care they were receiving.
The service was responsive to patients' needs. Staff planned for discharge from admission and discharge only occurred when a patient was ready to move on. A transition team supported patients from pre-admission to post-discharge. Patients had access to facilities to meet their needs and reported the food was of good quality. The trust ensured patients had access to spiritual support and interpreters where required. Patients knew how to complain and staff handled complaints appropriately.
Staff spoke positively about managers within the service and most staff felt respected and supported. Staff reported morale was generally good and that all members of the multi-disciplinary team felt their voice was heard and opinion respected. Staff were not afraid to speak up and felt able to raise concerns if needed.

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

The service used innovative approaches to provide integrated person-centred pathways of care that involved other service providers.
The service was responsive to the needs of the local population and engaged well with hard to reach groups and ethnic minorities to provide individualised care. There was a proactive approach to understanding the needs and preferences of different groups of people.
The service used technology innovatively to ensure people had timely access to treatment, support and care. The Gold Line gave round-the-clock telephone support to patients and carers who needed help, reassurance or advice.
People were truly respected and valued as individuals. They were empowered as a partner in their care practically and emotionally by an exceptional distinctive service.
Carers were seen as active partners in peoples’ care. Staff were fully committed to working in partnership with people and making this a reality for each person.
Staff found innovative ways to enable people to manage their own health and care and delivered holistic patient centred care.
We found that without exception staff were passionate about the care they delivered and were determined to give the best care they could to patients and their relatives. Staff understood and respected the personal, cultural, social and religious needs of patients and their families and took these into account in the way they delivered services. We saw staff delivering holistic patient centred care.
There was a positive culture with good relationships between staff who worked well together. They worked with partner organisations effectively to provide seamless patients care.
The service was well led. Staff spoke highly of the clinical lead and their line managers and said they felt supported. Staff were proud to work for the service and were focused on the needs and experience of patients and families who used the service.
We found the service was continually striving to improve. There was a positive culture of learning, continuous improvement and innovation.
The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service made sure staff were competent for their roles and provided training and development to other staff providing care for patients at their end of life.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff followed best practice when prescribing, giving, recording and storing medicines.

However:

Although the service managed patient safety incidents well, not all staff were familiar with how to locate and complete an incident report.
Staff did not complete the ‘Comfort and Dignity Care Plan’ for all patients who were identified as entering their last days of life.
We had some concerns around staff who updated patients’ records on return to the office. This meant the records were not completed contemporaneously and this may impact on the patients shared care. Staff confirmed there had been no incidents because of this.

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

The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Best practice staffing guidance was not followed following a reduction in the children’s community staffing budget as the service was in transition and part way through a service transformation process. The service had a number of vacancies due to the recent procurement of 0-19 services in Bradford and the transition of skill mix changes. The trust's skill mix information confirmed shortfalls in health visiting, school nursing and looked after children staffing groups.
Caseloads for school nursing and health visiting nursing staff were high. Caseloads for looked after children were high and fell outside of recommended guidance of 100 children per whole time equivalent nurse.
Staff said work related stress had increased and described poor technology connectivity and the increase in safeguarding work as having contributed to this stress.
Performance against children’s health needs assessments was poor.
The service provided annual mandatory training in key skills to all staff which not all staff had completed. The trust did not meet fire safety year one, information governance attendance and Mental Capacity Act level 1 training sessions. Monthly reporting of compliance levels were reported at senior leadership meetings.
The trust target of 80% attendance for Mental Capacity Act level one training was not achieved, figures submitted by the trust confirmed completion of 76% as of 30 November 2018.

However:

We spoke with 15 mothers, four fathers, one child and one young person. about their experiences. They said they were involved in their care and decision-making and were happy with the care and treatment received.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
The service-controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
The service had suitable premises and equipment and looked after them well.
Staff completed detailed records of patients’ care and treatment and updated risk assessments for each patient. Records were clear, up to-date and easily available to all staff providing care.
The service managed patient safety incidents well. When things went wrong, staff apologised and gave patients honest information and suitable support.
The service provided care and treatment based on national guidance and evidence of its effectiveness. The trust had made good progress in the implementation of the Healthy Child Programme and had evidenced based initiatives in place.
The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care.
The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

Due to the concerns we found during this inspection, we used our powers to take immediate enforcement action. We issued Bradford District Care NHS Foundation Trust with a section 29A warning notice. This advised the trust that our findings indicated a need for significant improvement in the quality of healthcare. We will revisit these services to check that appropriate action has been taken and that quality of care has improved.

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

The provider was not delivering safe care. People were not safe and at high risk of avoidable harm. Staff had not undertaken risk assessments of the care environment and mitigated those risks. Where patients demonstrated higher levels of risk staff did not follow processes and procedures to mitigate these via appropriate monitoring and recording. The service used restrictive interventions and the quality, purpose and proportionality of these was not reviewed and appropriately recorded. Audits were not effective. We had concerns about the management, storage and administration of medications. Staff did not ensure all clinical equipment was present and fit for purpose. Compliance with mandatory training was low. Staff did not always ensure that incidents were correctly categorised to ensure opportunities for investigation and learning could take place.
The care provided was not always dignified. Patients were caused distress when their beds were allocated to other patients whilst they were on leave.
The provider was not delivering effective care. Not all patients had care plans which were personalised, and none of the patient care plans we reviewed contained a detailed, goal orientated discharge plan. The service did not work from a multi-disciplinary approach. Staff were not appropriately supervised according to the trust’s own policy.
The service was not always responsive to the needs of individual patients. The admission process was not led by ward teams. Bed occupancy rates and readmission rates were high. Staff did not find effective ways to communicate and care plan for patients with communication difficulties and did not have care plans in place to ensure they could communicate their wishes. The trust did not have a robust and clear procedure in place to support the dignified conveyance of patients between wards.
The service was not well led. The trust systems and processes did not ensure the effective identification of risks. When risks were highlighted to the service via external bodies and following incidents, the trust did not act in a timely manner to make the required improvements. Processes and practices were not always taking place according to trust policies. Ward level audits were either not effective at identifying these issues or action did not take place to address the issues identified at all, or in a timely way.

However:

The wards were clean and well furnished. The reporting of safeguarding was of good quality, staff knew how to spot signs of abuse and how to report incidents. The trust had recently changed the staffing model and staff and patients told us there were enough staff to meet the needs of patients.
Staff supported patients’ physical health needs and provided therapies and activities to meet the needs of patients as per best practice guidance.
Staff were caring, compassionate and professional in their interactions with patients.
Staff supported patients cultural and spiritual needs. Staff understood the complaints process and complaints were managed according to the trust’s own policy. Staff supported patients to access their local community and maintain relationships which were important to them.
Staff told us that leaders were supportive and approachable.

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

People in the area were receiving an effective 24/7 crisis response. Those in immediate risk could be seen and responded to immediately. Peoples’ risks were consistently managed and any changing risks were considered and addressed through effective handover meetings.
People had access to a full pathway of care from the first call or referral, including identification of risks, completion of a comprehensive assessment and interventions delivered all in a timely manner.
Staff were skilled and able to deliver best practice interventions to people accessing the service. Staff were using innovative approaches of working with patients using technology. The needs of the families were consistently considered and the teams were looking at ways in which family members could be further supported.
Patients were supported to access resources in the community and to look at ways in which they could keep themselves well. The service worked well with other teams within the trust and with external partners such as the police, local authority and the ambulance service to ensure that new ways of helping people were always being explored.
All teams had effective leadership who understood the needs of staff and patients. Staff felt supported and staffing levels were managed. Systems and processes were generally well established and operated effectively to assess and manage risk and improve the quality of the service.

However:

Staff were not up to date with ten of the role specific training courses, which included safeguarding children, basic life support and immediate life support.
Staff did not feel informed about several serious incidents which had occurred in the previous 12 months. Investigations from serious incidents were not effectively communicated to staff and staff were unclear as to the actions and learning from these incidents. Incidents were not always categorised by staff appropriately which meant they were not investigated as they should have been in line with the trust’s policy.
The trust was not collecting data to monitor the effectiveness of the service. The local managers understood the running of the service on a day to day basis, but this did not form any key performance indicator monitoring.
There were some issues with the patient record system which meant that information was not always stored in the correct place. The trust was aware of the issues and were working on ways to improve this for staff and patients.

The service provided safe and effective care, there were sufficient numbers of staff who were adequately supported through supervision and appraisal and staff were very knowledgeable about their areas of work.
Managers provided extensive support to staff and were approachable, visible and always helpful. Staff and managers clearly had a lot of respect for each other and worked well together.
Staff used best practice in treatment and care offered.
Staff treated patients with compassion and kindness. They showed a good understanding of patients’ needs and they made efforts to involve families and carers wherever they could.
The service work closely with the community to ensure they were able to reach individuals that might need the service. They offered a wide range of appropriate interventions and activities which met the needs of patients.
The service had implemented an effective incident reporting system and they ensured that they shared information gathered using this process. They used lessons learnt from incidents and complaints and patient and carer feedback to make changes to services where appropriate.

However:

We had some concerns about the way information was recorded and stored on the new electronic patients recording system and it was not clear if patients were routinely offered a copy of their care plan.
Whilst the sites that we visited were clean and well maintained, some clinics and storage areas were cluttered and untidy.
Waiting time for a memory assessment in some areas were high.

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

The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well, 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 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, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Staff did not review the blanket restriction mandated by the trust in relation to bathrooms and shower rooms.
The trust did not have an effective system to record and monitor supervision. The service did not have local arrangements to support that staff received regular supervision in line with trust policy.

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

Staff did not always follow their processes for maintaining and checking emergency equipment and drugs. Also, staff did not always follow best practice when dispensing and recording medication to reduce the risk of error and patient harm.
Staff had implemented blanket restrictions on both wards including the use of plastic cups, locked bedroom doors and outdoor spaces on the Dementia Assessment Unit and daily room searches on Bracken Ward with no audit or review.
Not all staff understood the Mental Capacity Act. Staff did not record capacity and best interest decisions in some patients’ records. Staff did not make deprivation of liberty safeguards applications when needed. Staff did not monitor the progress of applications to supervisory bodies.
Staff reported issues with the entering and accessing of information on the new electronic patient record system.
Trust governance processes were not always effective in ensuring staff applied policy and practice consistently across the services. There was lack of evidence of mental capacity compliance audits and there was no overarching policy for the management of ‘guest’ patients on Bracken Ward.

However:

Patients assessments were comprehensive, evidence based and contained detailed physical health assessments. Care plans and risk assessments were holistic and reflected individual patient need.
Ward environments were accessible to all patients including patients who had difficulties with mobility or a disability. There was a range of facilities available to patients and a range of inclusive activities.
Both wards were clean, well equipped, well furnished, well maintained and fit for purpose.
Staff involved patients and their carers and families in all aspects of their care. Patients and carers told us they were treated with kindness, dignity and respect and staff demonstrated a knowledge and awareness of the individual needs of patients.
Managers made sure staff teams incorporated a range of skills needed to provide high quality care. Staff were supported with regular appraisals, supervision, team meetings and opportunities to develop and innovate.
Concerns and complaints were taken seriously. Staff had a good understanding of the duty of candour. Complaints would be investigated, lessons learnt and shared.
Managers had processes and procedures in place to monitor and meet key performance indicators in relation to training, supervision, appraisals and bed management.

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

We rated the trust as requires improvement overall in safe, effective and well led. We rated caring and responsive as good. Our rating for the trust took into account the current ratings of the services not inspected this time.
We rated well-led for the trust overall as requires improvement.
Of the 14 core services, one is rated as inadequate and five as requires improvement, taking into account the current ratings of the services not inspected at this time. Of the eight core services inspected during this most recent inspection, one was rated as inadequate and three were rated as requires improvement.
Overall ratings went down for the acute inpatient mental health services for adults of working age and the psychiatric intensive care unit to inadequate, and for the community health services for children and young people to requires improvement. The forensic low secure services were rated as requires improvement. The rating stayed requires improvement for the wards for older people with a mental health problem.
Due to the concerns we found during our inspection of the trust’s acute inpatient mental health wards for adults of working age and psychiatric intensive care unit, we used our powers to take immediate enforcement action. We issued the trust with a Section 29A warning notice. This advised the trust that our findings indicated a need for significant improvement in the quality of healthcare. We will revisit these services to check that appropriate action has been taken and that quality of care has improved. However, by the time of the well-led review the trust had already taken significant action to address the issues identified in the warning notice.
The trust was not providing consistently safe care, particularly on the inpatient mental health wards. Issues identified included ligature and environmental risks not being identified and managed, the maintenance of premises and equipment, medicines management, blanket restrictions that were not individually risk assessed, no alarms for patients to call staff in an emergency.
The trust did not have effective systems in place to investigate incidents within appropriate timescales to identify learning from incidents and make improvements.
The trust was not consistently providing effective care. The trust had failed to address concerns identified in the 2017 inspection in relation to staff supervision and audit of the Mental Capacity Act. Staff understanding and adherence to the Act was inconsistent.
The arrangements for governance and performance management did not always operate effectively. Whilst there had been a recent review of governance arrangements the plans to change these were in the early stages and were not embedded at the time of the inspection.
The trust did not always deal with risk issues and poor performance appropriately. Senior leaders were not aware of all the concerns found during the inspection. Areas for improvement identified at the last inspection in 2017 had not been addressed at the time of this inspection.

However:

We rated community health services as outstanding overall for caring. We rated community end of life care services as outstanding overall. Three of the six mental health core services we inspected were rated as good. There were improvements in the overall ratings for the trust’s wards for people with a learning disability or autism and mental health crisis services and health-based places of safety. The community mental health services for older people with a mental health problem were also rated as good.
Two of the trust’s services were rated as outstanding for caring, and 11 were rated as good. (This took into account the current ratings of the six services not inspected this time.)
Staff interactions with patients we observed were kind, respectful and compassionate. Feedback from patients and those close to them was continually positive in almost all the services we inspected about the care provided. Feedback from patient and carer surveys was positive.
Staff found innovative ways to enable people to manage their own health and care, particularly in those services rated as outstanding.
Most of the trust’s core services were providing care in a way that was responsive to patients’ individual needs. The community end of life care services were rated as outstanding in the responsive key question.
The directors of the trust had completed all the checks needed to work at that level. They all had disclosure and barring service certificates and met the fit and proper person requirements.
The trust had implemented a new vision and strategy and had plans to improve services. Staff knew and understood the provider’s vision and values.
The trust actively engaged in collaborative work with regional and place-based external partners to agree joint health and care priorities to support the delivery of high-quality, sustainable care and treatment, and to meet the needs of the local population.

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

The service was not entirely safe for patients because staff had not taken into account all of the risks to patients and assessed and recorded them appropriately, such as; ligature points, blanket restrictions, incidents, the use of restrictive interventions and safeguarding concerns. Staff did not always recognise and discuss when an incident may meet the trust threshold for duty of candour.
The service did not always provide effective care and treatment because staff did not receive specialist training in meeting the needs of patients with complex needs and did not always provide care in line with national best practice guidance. Staff undertook some audits to measure the quality of care but did not always make improvements following these audits or take action in a timely way. The trust did not audit the wards compliance with the Mental Health Act and Mental Capacity Act Codes of Practice.
There was a disconnect between the risks, issues and challenges presented at ward level and how these were fed into leaders above ward manager level. The monitoring systems in place did not always provide detailed assurance about quality and safety of care. The senior leaders had not recognised the concerns we highlighted during the inspection.

However:

Patients felt safe and well supported and described staff who were caring and compassionate, and carers told us that they did not have concerns about the safety of the ward. Patients had thorough risk assessments, which staff updated regularly. There were sufficient nursing staff available to meet the needs of patients. Staff monitored and assessed patient’s physical health needs.
Patients had comprehensive assessments of their needs and staff regularly updated them. Staff had completed capacity assessments and best interests discussions when patients lacked capacity to make specific decisions.
The service had a good admission and discharge processes, which meant that the service could meet the needs of the local population and that there was an embedded system of discharge in line with the transforming care agenda. Patients were aware of their rights and understood the reasons for the treatment. Staff encouraged patients to visit their local community and to maintain relationships with people who were important to them.
The trust had a clear vision underpinned by values, which the senior leadership team championed and which were known by the staff working on the ward. Staff felt supported and senior leaders were open, engaging and encouraging feedback and contact with staff. The service celebrated staff success and encouraged staff to achieve high quality care.

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

The service was not entirely safe for patients. Not all staff were trained in life support techniques which meant that not everyone could respond to patients in a medical emergency. Not all staff were trained in breakaway techniques to maintain their own safety. The physical environments of both health based places of safety required improvement to maintain the safety, privacy and dignity of service users.
The service was not always well-led. Managers had not maintained proper records to show that all staff received regular supervision. Managers had not ensured that all staff received the required training for their role and appraisal rates varied between teams in the service. Audits had not identified areas of concern in relation to the physical environment or in records related to the use of the Mental Health Act. The service did not audit the use of the Mental Capacity Act.

However:

The service was providing care which was effective. Patients received a care plan which was designed specifically to meet their needs. Staff used recognised rating scales to monitor patient’s outcomes. The service was multi-disciplinary as teams brought together skilled staff from a range of professional disciplines. The service worked in close partnership with a number of other agencies to deliver effective care.
The staff working in the service were caring. Staff offered practical, professional support for patients and demonstrated an approach which was kind and compassionate. Patients and carers were positive about the service and the staff. Staff were adaptive to the needs of patients and had a number of routes for people who used the service and their relatives to provide feedback.
The service was responsive to the needs of people using the service. People could access the service at any time and there was a clear pathway for patients based on their individual needs. Staff worked proactively to engage people who had difficulty engaging with services. There were examples of the service using patient complaints to improve the service.

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

The service building was clean and tidy and all necessary testing in relation to health and safety such as fire, electrical wiring and gas safety had been completed.
There were contingency plans in place in the event of the service building or electronic systems being unavailable.
The people who used the service that spoke with us told us staff were kind, caring and were aware of their needs and that they were involved in decisions about their care and treatment.
The people who used the service were able to given feedback via surveys and user groups.
Two patients worked as volunteers at the service.
Staff made efforts to engage with patients who had not attended appointments or were reluctant to engage with mental health services.
The trust had policies and procedures in place to protect people from discrimination, unfair treatment, harassment and bullying.
Staff assessed and monitored patients’ physical health and encouraged them to attend appointments with other services such as GP appointments.
Staff encouraged patients to live healthier lifestyles by taking exercise, eating healthily and smoking cessation and there were posters and leaflets in the waiting area giving advice on a wide range of health conditions such as cancer and diabetes. The service provided breast screening in conjunction with another external organisation.
Staff were knowledgeable about safeguarding, knew how to report incidents and received information about learned lessons from incidents, complaints and patient feedback to improve practice within the service.
The trust reported there were no serious incidents in the 12 months prior to our inspection.
Staff knew what their responsibilities were under the duty of candour in relation to being open, honest and transparent with people when things go wrong.
Staff received training in equality and diversity and the trust had policies to protect people from discrimination, unfair treatment, bullying and harassment
There were sufficient numbers of staff to meet the needs of the patients, there was no freeze on staff recruitment, and sickness absence figures were at 2.12% which was better than the trust’s target of keeping levels down to 4%.
The multidisciplinary team comprised a wide range of professionals and there were effective meetings and handover arrangements within the team.
Staff were experienced and qualified to do their job.
Staff had access to specialist training for their role and managers identified their training and development needs.
The service’s medicines management arrangements were effective and were in line with the National Institute for Care and Health Excellence, Royal College of Psychiatrists, Faculty of Intellectual Disabilities and Stopping the Over-Medication of People with Learning Disability and Autism guidance.
The service had an effective lone working process to ensure staff were safe when they were working in the community.
Pathways used by the service included mental health, behaviour, maternity, ophthalmology, respiratory and dementia.
Patient care records were holistic, person-centred and recovery orientated.
The service used positive behaviour support plans for patients, which were tailored to meet patients’ individual needs and centred around reducing their behaviours that challenged.
Staff received mandatory training in the Mental Capacity Act and had a good knowledge of the Act.
The service made effective and appropriate use of best interests decisions and capacity assessments and supported patients to make their own decisions.
Staff were appraised and agreed with the trust’s visions and values.
The numbers, experience and role mix of staff meant the service could meet patients’ needs.
Staff morale and job satisfaction were positive, there was a good level of support from peers and managers, staff felt proud to work for the trust.
The trust recognised staff’s success and staff within the team had won awards from the trust and a member of staff had won a national learning disability award.
Staff could add items to the service and trust risk registers and knew where to access the trust’s whistleblowing policy.
The service worked with the local police to raise awareness of issues associated with learning disabilities, a health care support worker supported the service and trust with the delivery of learning disabilities awareness training for first year student nurses and a speech and language therapist led a quarterly communications champions' network forum and ran consultancy clinics during which staff could discuss patient cases.
The service worked with external care providers and services to promote the use of information technology to older people to enable them access to various forms of online support. It also delivered learning disability awareness sessions to acute hospitals.
The service had run training sessions to local support providers around active support and behavioural monitoring and had positive and proactive champions and communication champions networks that shared best practice around the use of positive behaviour support and communication methods for people with a learning disability.
The service participated in one of the Commissioning for Quality and Innovation’s national audits in relation to ensuring patients were able to access national physical health checks.

However

Staff compliance rates for required training in level three safeguarding children and adults, managing violence and aggression – breakaway and basic life support were below 75%.
The garden area that was situated at the top of a grassy bank with a steep incline with insufficient protection to prevent people falling.
Mental Health Act training was not a mandatory training requirement for staff at the service.
The service were unable to provide accurate data in relation to the number of cancelled appointments, numbers of patients subject to community treatment orders and numbers of complaints.
The service had insufficient monitoring arrangements in place to ensure mandatory training was within the trust’s 80% compliance target, clinical supervision was taking place, all care plans and risk assessments were reviewed at least every six months in line with the service’s policy and all initial risk assessments were included in care records. The trust did not monitor compliance with staff supervision.

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

The service could not evidence they had carried out fire risk assessments or health and safety assessments at two of the locations we inspected where they saw patients.
Half of the patients’ records we looked at did not contain up-to-date risk assessments and some did not have a crisis plan documented for patients. Staff did not monitor physical health needs for all the patients in their care.
The service did not carry out medication audits so could not ensure medicines were always managed appropriately. Some medication records had not been reviewed in line with trust policy.
Some patients did not have up-to-date assessments of their needs and some did not have a personalised care plan. The service did not monitor outcomes for patients and none of the records we looked at had discharge plans in place for patients.
Managers could not provide assurance that all staff had access to regular supervision in line with trust policy.
Not all staff knew about the application of the Mental Capacity Act or about the trust’s responsibilities regarding duty of candour. Not all staff were up-to-date with their required training and managers did not provide training for staff in the Mental Health Act.
The service did not monitor waiting times for patients in the community mental health service and did not always respond effectively when audits highlighted gaps in care records.

However:

The overall appearance of the patient areas in both the locations we inspected were clean, well maintained and had furnishings which were in good order.
Staff were good at responding when patients became mentally unwell. Generally patients had good access to a psychiatrist when needed. Staff met regularly and frequently to discuss patients and share information with the wider care team. They knew how to identify potential signs of abuse and neglect and how to report these.
Patients had access to a skilled multidisciplinary staff team with access to healthier lifestyle advice, employment support and activities aimed at promoting recovery.
Feedback from patients and observations of interactions showed that staff demonstrated a caring and compassionate approach. Staff treated them with respect, listened to their concerns, and showed genuine empathy. Staff had good links with carer’s support and signposted patients’ families and carers.
Staff provided assertive outreach visits for patients and referred them to a rapid response service when they needed support out-of-hours.
The service had an accessible complaints procedure and patients found staff approachable and willing to resolve concerns.
Senior leaders understood the services they managed and communicated the trust vision and values to staff. Staff felt valued by their immediate managers and could raise concerns when needed.
Staff met to discuss learning from incidents and where needed, they made changes to systems and procedures.

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

We rated long-stay or rehabilitation wards for working age adults as requires improvement because:

The service did not always have enough staff. The trust reported that 80 shifts were not filled in the 12 month period between 01 July 2016 and 30 June 2017. Between 01 January 2017 and 31 July 2017 56 shifts fell below the safe minimum staffing levels and three shifts did not have a registered nurse on duty. Staff told us that registered nurses could not always have dedicated time with patients.
Half of the patients’ care plans reviewed did not contain information about interventions and support required to meet patients’ needs. None of the records reviewed contained care plans with evidence of patient involvement or completed outcome measures. Staff had not ensured that they informed two patients of their rights under the Mental Health Act regularly. Training rates for Mental Health Act were low at 41%. Training in the Mental Capacity Act had not been consistent and although this was at 94% at the time of inspection, it had been 65% prior to our inspection.
The clinic room was cluttered and this could impact on how quickly emergency equipment could be accessed when needed. A bottle of alcohol was stored with controlled drugs in the clinic room.
The service did not have an allocated member of staff to complete patient observations each shift. When patients were on leave and missed physical health monitoring, staff did not always record whether they offered these checks again when patients’ returned.
The therapy kitchen was not fully accessible for disabled people because no areas of the kitchen had lowered worktops. Staff did not always respect patients’ privacy; two patients told us they did not knock on their bedroom doors before opening and entering.

However:

The ward was open access and had the appropriate restrictions expected for a rehabilitation ward. Patients had open access to a therapy kitchen and could make their own meals and drinks at anytime. The service had facilities, activities and encouraged access to work to promote mental health rehabilitation and recovery. The service was clean, had good furnishings and was well maintained.
Feedback from patients and observations showed that staff knew patients and their needs well. Staff were polite, respectful and supportive. They involved patients and their families, carers, advocates and care co-ordinators in multi-disciplinary meetings well.
Staff managed and mitigated risks well. Patients risk assessments contained detailed information on risks and staff understood regular risk assessments of the care environment. Staff used de-escalation techniques and the service reported only three incidents of physical restraint in a 12-month period.
The service reported no delayed discharges, serious incidents or safeguarding referrals and complaints in a 12-month period.
Senior leaders were visible in the service and understood the services. Staff had opportunities for leadership development and they felt supported and valued.
The trust provided opportunities for staff to participate in seminars on research, conferences and specialised learning events.

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

Required training compliance rates were low with a compliance rate of 39.5% for clinical risk training and 53.5% for medication management.
Training compliance rates for the Mental Health Act and Mental Capacity Act were low and staff understanding of the Acts was inconsistent.
Staff received management and clinical supervision infrequently.
Safeguarding processes had not identified where patients could have been placed at risk through a potential breach in professional boundaries.
Incident recording lacked detail of the type and duration of restraints used and process did not demonstrate if safeguarding referrals had been considered following incidents of patient on patient assault.
Blanket restrictions were in place on Bracken ward including daily room searches and searching patients following section 17 leave.
Patients had limited access to psychology whilst in hospital with patients being referred to the community psychologist for support.

However:

The service had effective medication systems in place and completed regular medication audits including regular checks by the pharmacist.
Clinic rooms provided appropriate facilities and equipment to meet patient needs and were clean and well maintained.
Patients’ assessments were comprehensive, evidence based and contained a detailed physical health assessment for all patients. Care plans and risk assessments were holistic and reflected individual patient need.
Staff were seen to interact with patients in a way which demonstrated kindness, dignity and respect. Staff demonstrated a genuine knowledge and awareness of the individual needs of patients.
Ward environments reflected the needs of the patients, they were accessible to patients with a disability or difficulties with mobility. Handrails were available in communal areas and in bathrooms. There was a range of facilities available to patients including activity space, outdoor space, computers, electronic tablet devices and empathy dolls and pets.
Managers had a good oversight of the needs of the wards and had an effective governance framework in place to highlight the wards performance. Action plans were in place to address the areas that the framework identified as an issue.

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

The service provided a welcoming and clean community dental service that was well regarded by the patients we spoke with.
A range of clinics were offered including: clinics for emergency dental care, clinics for those patients who were unable to leave the house, dental care for patients who, because of their particular needs, could not be seen by a general dental practitioner, and mobile care for hard to reach groups, such as the homeless.
Staff appeared motivated and had systems and processes in place to support them, including access to equipment they needed, and enough time, to enable them to see and treat patients safely.
The service was well-led by a team of senior leaders who ensured there were adequate governance, risk and quality management systems in place to ensure safe care of patients and that the service continually strived to meet the needs of its local population.

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

The service provided safe care and treatment to patients. Staff were competent in reporting and learning from incidents and safeguarding concerns. Staff were also supported to develop competencies and their professional practice.
Multidisciplinary teams delivered evidence based care and treatment across the service. Services were planned and delivered to meet the needs of patients, including tailored services for patients with specific needs.
Staff delivered outstanding care to patients. This was supported by comments and feedback received from patients, observations of caring interactions, and examples of where staff were able to go ‘over and above’ to deliver person centred care.
There was a positive, patient centred culture within the service where staff felt supported by leaders to deliver good quality patient care.

However:

Governance processes did not always provide assurance about performance or practice within the service. Examples of this included management and clinical supervision not being consistently practiced or documented. Other examples of this included incomplete data being provided around role specific training for staff.

Our rating of the trust went down. We rated it as requires improvement because:

We rated six of the 14 core services provided by the trust as requires improvement overall. This takes account of the ratings of core services that we did not inspect this time.
We rated safe, eff ective and well-led as requires improvement for the trust overall. Our rating for the trust took into account the current ratings of services not inspected this time.
We rated well-led at the trust level as requires improvement. The trust’s senior leadership team did not have eff ective oversight of staff training, staff supervision and of restrictive interventions in inpatient services. The trust had not ensured that all staff had checks with the disclosure and barring service in line with trust policy. The trust had not ensured that documentation was maintained in line with the fit and proper persons requirements. There was an inconsistent approach to audits in relation to the use of the Mental Health Act and Mental Capacity Act. The trust had not updated all active policies to reflect the changes to the Mental Health Act Code of Practice in 2015. The trust had not ensured that all serious incidents were reviewed in line with the requirements of the duty of candour and that serious incidents were investigated appropriately and eff ectively.
Services were not consistently managing risks safely. Risk assessments were not always completed or reviewed regularly. Staff were not consistently trained in line with the trust’s requirements. Services had high sickness, vacancy and turnover rates and some relied on agency and bank staff to maintain safe staff ing levels. Staff were not consistently recognising and reporting safeguarding concerns to external agencies. Staff had a mixed understanding of the duty of candour.
Services were not consistently providing eff ective care. Care records in some services contained information that was incomplete or had not been reviewed for some time. Not all care plans were holistic and centred on the individual needs of the patient. Not all staff were regularly receiving supervision in line with the trust policy. Staff had a mixed understanding of the Mental Health Act and Mental Capacity Act.

However:

The staff showed a caring attitude to those who used the trust services. Feedback from people using services and their relatives and carers was highly positive. Staff in all services were kind, compassionate, respectful and supportive. People who used services were appropriately involved in making decisions about their care.
The trust had ensured that services were responsive to meet the needs of people. Services were planned so that local people could access services when they needed them. There was a systematic approach to managing access to services which was based on individual needs. The trust had ensured there was a clear pathway so that people were transferred appropriately between services.

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

The Care Qualty Commission conducted this announced focused inspection to review two requirement notices given at our last comprehensive inspection in June 2014. These related to breaches of Regualtion 9 Person-centred care and Regulation 15 Premises and equipment. The breach of Regulation 9 was found in the adult acute services and this related to people’s needs not being met in a timely manner due to inconsistent medical care. The breach of Regulation 15 was in relation to the health based places of safety not meeting the Royal College of Psychiatrists guidance to assure against the risks of unsafe or unsuitable premises.

The methodology we use to inspect in June 2014 has changed and the core services were different. For example, psychiatric intensive care units (PICU) and health based places of safety (HBPoS) were inspected under the same core service. Health based places of safety are now inspected in the same core service as mental health crisis services. As the requirement notices did not relate to mental health crisis services, we did not visit any of them during this inspection.

Following the inspection in June 2014, the trust submitted action plans to us telling us how they would make improvements. This also covered areas where we had made recommendations.

We inspected the trust on 11, 12 and 13 January 2016. We visited five adult acute ward areas and two HBPoS. We spoke with staff of different grades, spoke with patients using the service and looked at care records.

We visited the following ward areas;

Fern and Heather wards at The Airedale Centre for Mental Health
Maplebeck, Ashbrook and Clover wards at Lynfield Mount Hospital
We also visited two HBPoS which are based across both sites.

We found the trust had met the requirement notices. The HBPoS environments had been refurbished and now meet the Royal College of Psychiatrists guidance. The trust had made improvements relating to the availability of medical staff to review patients on the acute wards. We reviewed the actions plans submitted by the trust to meet recommendation made by us in June 2014 and found these had also been completed.

This meant we were able to re-rate the trust at this inspection as we found they had taken sufficient action to ensure all areas of concern had been addressed.

We announced our visit to Bradford District Care Foundation Trust to conduct a focused inspection within the health based places of safety (HBPoS). This was to review one requirement notice from the last inspection in June 2014. When we last visited, we found that people who used the service and others may be placed at risk because each of the HBPoS suite environments had ligature points and did not meet fundamental standards within good practice of the RCP to assure against risks of unsafe or unsuitable premises.

At this inspection, we were assured that this requirement notice had been met.

We found that the trust had implemented systems to ensure that on each of the acute wards, consultants had dedicated weekly time slots for when they were available to attend the wards. In addition to this, the acute wards each had dedicated junior doctors and advanced nurse practitioners who were available around these times to assist with all aspects of patient care.

The trust had reduced its use of out of area beds over the last 12 months to zero. This meant patients received the care they needed nearer to their home.

The wards worked towards discharge from the point of admission. The wards had dashboards in place, which allowed them to monitor patient’s progress on a daily basis.

Staff told us comprehensive discharge planning was carried out which included home visits. Care records we reviewed confirmed this.

Ward managers told us patients were discharged from the ward during the daytime only.

The acute admission wards are based on two hospital sites at Airedale Centre for Mental Health and Lynfield Mount Hospital. Airedale is a purpose built facility and provides two acute inpatient mental health wards for adults aged between 18 – 65. Referrals come from the Intensive Home Treatment Team or following a Mental Health Act assessment.

We found that there were clear procedures for reporting incidents and these were investigated and reviewed to prevent them from happening again. Learning from these incidents was shared with all staff.

There were also clear systems in place for reporting safeguarding concerns and staff understood what they had to do.

We found that at times systems for management of medicines led to delays in administration of medicines and staff did not always follow the trust procedures for reporting occasional gaps and omissions on medication charts.

There were procedures for identifying and managing risks to people’s health and safety. Managers had clear strategies for responding to changes in people’s mental state.

However, we found that there were health and safety issues in the ‘activities of daily living’ kitchen. For example, the temperatures of the fridges, where people’s food was being kept, were not monitored, and the food itself was not properly stored and labelled after it had been opened.

Staffing levels were good and were flexible, for example should the patients require greater observation. Temporary staff were given an induction programme.

Risk and needs assessments were carried out when people were admitted and we found them to be comprehensive and followed by detailed care plans.

We saw that there were systems in place for people to give feedback to the service and this was acted on. We found that the team had systems in place to monitor the quality of the service and took necessary measures to improve their performance.

There were appropriate policies and procedures for people detained under the Mental Health Act. However, consent to treatment and rights under the Mental Health Act were not adhered to at all times.

We observed that staff were polite, kind and treated people with respect and dignity. People who used the service told us that they were pleased with the care they received. We found that people were involved in their care; however, there was a limited range of activities for people, and a lack of input from psychology services.

We found that medical staff were not always readily available to support the nursing team and people who used the service. We also saw that people’s reviews were constantly cancelled and that consultants did not turn up for scheduled reviews.

However, the service took people’s complaints seriously; investigating them, responding to them promptly and learning the lessons from them.

There were strong links with other internal and external agencies to help people move smoothly between services – from referral, admission and discharge.

We found there was a clear vision and strategy for the service and staff understood it well. Staff told us that they felt supported by their managers and were pleased to work for the trust

We found that the trust was providing a good service to the population that it served. Within all the core services inspected we saw evidence of good practice. This was being delivered by caring and professional staff who were working collaboratively.

We saw that the trust was not always providing a safe service for people across some of the services it provided. This included the children and adolescent mental health service, the long stay/forensic/secure mental health service and the health based place of safety. We identified robust systems in place for managing risks within the trust. Clear protocols were established for the identification and investigation of safeguarding concerns. Staff were aware of their role in proactively identifying and reporting risks. However within the children’s and young people’s community service, staff we spoke with were concerned about the low number of new referrals accepted by the local authority, which they felt placed them at risk. The trust told us they will undertake a review of these concerns and talk with the local authority. We also found that in the children and adolescent mental health service and the long stay/forensic/secure services that risks were not always fully assessed or reviewed by staff. We have issued a compliance action in relation to the health based place of safety due to issues with ligature risks and received assurances that these risks would be addressed. We did not find wider organisational or systemic concerns about safety.

Overall, trust staff adhered to the requirements of the Mental Capacity Act 2005 to assess capacity to consent and work within best interest considerations where people lacked capacity; but in community health and learning disabilities services this could not always be evidenced. We visited most of the wards at each location where detained patients were being treated. In the majority of the care records we reviewed, which related to the detention, care and treatment of detained patients, the principles of the Mental Health Act (MHA) and the MHA Code of practice had been followed and adhered to.

We saw that the trust was providing evidence based treatments in line with best practice guidance. We saw that people were being supported to make choices and gave informed consent where possible. Evidence was seen of effective outcome measures being used throughout the trust in most of the services. The exceptions were within learning disability services where outcomes were unclear and assessments of capacity were not detailed and community health services where we found similar issues regarding capacity assessments and supervision of staff was not always occurring. The trust employed appropriately qualified and trained staff throughout their services. There were good systems to ensure adherence with the Mental Health Act 1983 when people were compulsorily detained.

We saw that overall the trust was providing a caring service for people across all core locations. Throughout the inspection we saw examples of staff treating people with kindness, dignity and compassion. The feedback received from people who used services and their visitors was generally positive about their experiences of the care and treatment provided by the trust.

We saw that the trust was not always responsive to people’s needs across some of the services it provided but this appeared to be a transient problem due to the development of administrative hubs. Throughout the inspection we noted that the trust had organised services so that they met the needs of the local population based on the resources it had. We saw outstanding care for people receiving end of life care. Patients were highly complementary of the service and confirmed they had received a coordinated and seamless service with 24 hour access to ‘The Gold Line’ service. We found that mostly people’s individual needs and wishes were met when the trust assessed, planned and delivered care and treatment to people. However recent changes to services including integrated care, single point of access and a move to administrative hubs meant that people had experienced (and still had to experience) longer than necessary delays in getting the care and treatment they required, particularly on the acute mental health wards and in community health services. Service users reported difficulty accessing crisis mental health services at night. The crisis team offered only telephone contact at night. Those who needed immediate assessment were directed to the emergency department at Bradford Royal Infirmary and Airedale General Hospital; where they might have to wait a long time to be assessed by the liaison psychiatry team because these services were not commissioned on a 24 hour basis.

We saw that overall the trust was well led with proactive and responsive trust wide leadership. There was a clear governance arrangements in place that supported the safe delivery of the service and to monitor and improve trust performance. Lines of communication from the board and senior managers to frontline services were mostly effective. Staff felt engaged with the trust and were well supported by local managers. We saw some recent good examples where board members spent time within services to understand the challenges faced and were actively engaging with front line staff including clinical buddying, walk abouts by the non executive directors and the culture conversations initiated recently by the chief executive officer. Staff felt well supported by their immediate line managers. However the organisations vision and values were not fully embedded across all community health teams. The recent scale and pace of change within the organisation was continuing to cause difficulties for the front line community mental health team staff. There had not been the appropriate level of engagement from leaders to ensure that this change was managed well. The scale and pace of change had also caused difficulties for service users in terms of accessing services and communicating with people within teams. We saw that there had been some recent improvements and a commitment to make these changes work including increasing trust board oversight and ownership of these issues.

Bradford District Care Trust offers a range of crisis and home treatment services including: the intensive home treatment team (IHTT), A&E liaison service and single point of access team.

Crisis and home treatment services were safe. Staff understood and implemented safeguarding procedures well. The team routinely discussed caseloads and any associated risks, and these were also discussed more formally during handovers. IHTT had a traffic light system in operation, whereby staff could determine people’s risks and needs quickly and at a glance. New information about risks was communicated effectively. In addition, the use of the RIO electronic records system made sure that key information was shared in real time with other teams involved in a person’s care.

People’s care and treatment was planned effectively and was recovery-focused. Assessments were comprehensive and took account of people’s skills, as well as their areas of need. Care and treatment was also person-centred and people were involved in the development of their care plans. Teams were multidisciplinary and worked well together, and staff received training and supervision for ongoing professional development.

Staff treated people with dignity and respect. Care was delivered with kindness and compassion, and staff made sure that people were involved in all stages of their care, treatment and support. Staff also listened to people’s views and provided information clearly so that people could make informed decisions. The language used by staff was encouraging and demonstrated empathy.

Services were responsive to people’s needs and had been developed in consultation with local people. People who used the service knew who to contact for support during the day and at night. Staff responded quickly to changes in need and, when needed, provided more visits. IHTT teams worked closely with community mental health teams and were involved with people before being admitted to hospital, during their stay in hospital and when planning and facilitating discharge back to the community. However, there was a risk that people might not receive the right care at the right time because A&E liaison was not a 24-hour service and IHTT could not provide face-to-face assessments out-of-hours as they only had one member of staff on duty throughout the district after 9pm seven days a week.

Crisis and home treatment services were well-led. Staff felt well supported by their managers and were consulted about the future direction of the trust. Staff and people who used the service were encouraged to get involved with service development. We also saw evidence of learning from incidents and responding to feedback. Staff understood the need for on going improvement of the service and this was achieved by regular audits and monitoring of quality.

There were effective systems in place for reporting patient safety incidents and the service compiled and reviewed safety information from a range of sources. Staff were however unclear about the lone working policy. Risks were not always recorded in the electronic care notes system in an effective way.

There was a system in place for assessing people’s needs, however, the service did not have an effective audit programme in place. The service environments were suitable for young people and families. Written information was not always available in appropriate formats.

The different professionals in community services worked well together and made sure that people’s needs were met. These staff had access to effective training, managerial and clinical supervision and appraisal.

All of the people that we spoke with were positive about the staff and the care they received. Feedback from young people and their families was however not used effectively.

The team had a range of therapies, collaborations, outreach programmes and specialty roles. There was also a good system in place for managing referrals and waiting lists safely and effectively.

The transition of young people to adult mental health services and concerns and complaints were effectively managed.

Staff felt supported within the team and from service and executive level staff.

Clinical dashboards and safety information was managed effectively at governance level, however systems for ensuring that policies and procedures were up to date were not effective.

Community health services for children, young people and families included a range of services. During our inspection we reviewed the health visiting service, the school nursing service (including aspects of sexual health and immunisation), the looked after children service, the family nurse partnership service and the ‘families first’ health team. We talked with 58 health visitors and support staff such as nursery nurses, 23 school nurses including 2 nurses from the special school nursing service, 9 family nurse partnership nurses and the lead for the looked after children’s team. We also spoke with the ‘families first’ lead along with 1 mental health worker and one school nurse from the same team. We talked with one of two heads of care from the service, the deputy director responsible for the services and one of the safeguarding children leads.

We visited 11 locations throughout the city of Bradford and Airedale where service teams were based and delivered services. Locations we visited included, Shipley health centre, Westcliffe medical centre, Woodroyd health centre, Flockton house, Daisy Chain children’s centre, Canalside health centre, Meridian house, Westbourne Green, Undercliffe health centre, Holmewood health centre and Highfield health centre.

We spoke with 15 parents who were either accessing services during our inspection along with 2 parents by telephone. We accompanied one health visitor and one family nurse partnership nurse on home visits. We received 19 CQC comment cards which had been completed by parents prior to or during the inspection.

Services were safe. The staff we spoke with knew how to manage and report incidents, and we saw that there had been learning and development from incident investigations. Risks were actively monitored and acted on, and we found that there were good safeguarding processes in place. However, the health visitors we spoke to were concerned about number of new referrals the local authority accepted, which they felt placed them at risk. The trust said it will review these concerns and talk with the local authority. We found that there were enough staff, with the right qualifications, to meet families' needs. In addition, we saw that the clinics and health centres we visited were clean.

Services were effective. We found good evidence that the service reviewed and implemented national good practice guidelines. The trust had also successfully implemented evidenced-based programmes, such as the family nurse partnership programme. We also saw that patient outcomes and performance information was monitored regularly, and that staff received regular training, supervision and an annual appraisal. There was good evidence of multidisciplinary and multi-agency working across the services.

Services were caring. Children, young people and parents told us that they received compassionate care with good emotional support.

In general, services were responsive but they needed to be improved in one area. We found that the service planned and delivered services to meet the needs of local families. In addition, parents, children and young people were able to quickly access care at home or close to home. However, we were concerned that a lot of health visitors said the new administration hubs delayed referrals to other teams and specialities, such as speech and language therapy. Some health visitors said they now had to do their own administrative work, which meant they could not visit as many families. Health visitors and some parents also told us that families found it more difficult to speak with their local health visiting team. This meant the service may not be able to respond to a child’s or families’ needs quickly enough, or provide appropriate support at a time when the family need it.

Services were well-led. There were good arrangements in place for local governance and risk management, which fed into the wider trust governance systems. Staff understood leadership structures, particularly at a local level, and felt well supported by their line managers. However, we found that there was not a specific vision and strategy for the children’s community health services, and that the trust did not have a formally nominated non-executive director for these services. This meant there was not a non-executive board member to champion the rights of children, and there may not always be appropriate challenge to the executive team on matters relating to children.

Bradford District Care Trust provides a range of adult community-based mental health services, including the assertive outreach team, community mental health teams and the early intervention service.

Adult community-based services were safe. Staff received appropriate training and they understood safeguarding procedures. Risk was managed effectively and communicated promptly on a daily basis. Although the number of community caseloads had increased overall, good line management and effective caseload management systems meant that they were well managed.

People’s care and treatment was planned and delivered effectively. Care was recovery-focused and people were supported to achieve positive outcomes. Assessments of people’s needs were thorough, and person-centred care plans were developed in partnership with people who used the service. Staff were supported well by their team managers and there was a good mix of professional backgrounds and skills in the teams. Multidisciplinary working was embedded across community services and information about people was shared appropriately. Staff received regular training and supervision.

Staff delivered care and support with kindness and compassion, and treated people with dignity and respect. People felt listened to and involved in decisions about their care, and their cultural needs were included in their care plans. People were also able to influence how the service was managed and developed.

Adult community-based services were responsive. The trust’s follow-up of people after discharge had improved since last year, and people were being provided with the right care at the right time. In addition, we did not find any issues with appointments or waiting times. Services were planned and delivered in a way that took account of the different needs of local communities. The relevant community teams were involved before people were admitted to hospital, during their stay in hospital, and in planning and supporting their discharge back into the community. We also saw evidence of trust-wide learning from complaints and incidents, for example through updates from team managers and trust-wide emails. This information was also included and discussed at monthly team meetings.

We found that teams were well-led by their team managers and that staff were aware of the trust’s vision and strategy. We found evidence of responsible governance, and that the trust had an oversight of key risk areas, as identified on their risk register.

Bradford District Care Trust provides inpatient and community services for older people with a functional mental illness, such as depression, and organic conditions, such as dementia.

Services for older people were safe. Staff understood and implemented safeguarding procedures well. In addition, community caseloads were well managed and there were good systems in place to manage risk on a day-to-day basis.

People’s care and treatment was planned effectively, which helped to achieve good outcomes. Older people’s needs were also comprehensively assessed. Staff provided person-centred care and treatment that was in line with people’s individual care plans. We also found that the way in which the multidisciplinary team worked together was excellent, and that information was shared appropriately. Staff were supported well by managers and colleagues, and received appropriate training, supervision and professional development. This enabled them to deliver safe and effective care.

Staff provided kind and compassionate care. Older people and their carers were treated with respect, and their dignity and privacy were maintained. Although carers were involved in the planning and delivery of care, this was not always recorded. Staff were, however, committed to providing good quality care and treated people as individuals.

Services were responsive to older people’s and carers’ needs. The teams understood people’s needs and wishes, and could respond to these. Services were planned and delivered in a way that met the different needs of the local communities. For example, we saw a range of services provided that addressed the different cultural needs of people using the service. In addition, the service provided an extended seven-day service in the community. This meant that they could respond more effectively to people’s needs. There also were good arrangements in place to support effective working with other agencies.

Services for older people were joined-up and well-led. Managers were visible and accessible to people who use the service, carers and staff. The trust encouraged development of the service development and also involved people who use the service and their carers. The trust’s governance structure also supported the delivery of the service.

Bradford District Care Trust provides care for people who have a learning disability. They have two registered locations, which are: Highfield Treatment and Assessment Unit at Lynfield Mount Hospital and Waddiloves Health Centre, which provides a range of community health services. There are also other, smaller community teams based around the local area.

Staff across the services were caring and compassionate. We saw that they worked positively with people and supported them well.

There were strong policies in place to make sure that people who used the service were safe.

We found that staff worked well together to meet people’s needs and that they were able to respond to individual needs and preferences.

Staff said that they were supported by managers and senior managers, which helped them to feel valued.

Clover Ward is a psychiatric intensive care unit (PICU) for people detained under the Mental Health Act 1983. It is a mixed gender unit that provides a safe and secure environment for people who cannot be safely assessed or treated in an open acute inpatient facility. The health-based places of safety are units where people arrested under section 136 by the police are taken for an assessment of their mental health.

We found that there were clear procedures for reporting incidents, and that they were investigated and reviewed to prevent them happening again. Learning from incidents was shared with all staff and there were systems in place to cascade it to staff. There were also clear systems in place for reporting safeguarding concerns and staff understood their responsibilities in this area.

However, we found that the two health-based place of safety were not fit for purpose. The environments were not safe because they posed a risk to people and compromised people’s privacy and dignity. In addition, we saw that people were not always observed closely enough in the PICU when they were using the shared communal areas.

There were also health and safety issues in the activities of daily living kitchen where, for example, temperatures for fridges with people’s food were not monitored.

We found that there were enough staff and they were flexible enough to meet any patient’s needs, such as increased observations.

Assessments for risk and patient’s needs were carried out on admission, and we found them to be comprehensive. These were also followed up by detailed care plans.

The multidisciplinary team in the PICU comprised of psychiatrists and nurses only. This meant that other health professionals, such as psychologists and occupational therapists, were not integrated into the team providing people's care.

We saw that staff received training required to perform their job roles and were supported through regular supervision and annual appraisals.

The staff we observed were polite, compassionate and treated people with respect and dignity. People who used the service also told us that they felt safe and were happy with the care they received. We found that people were involved in their care, but that there were limited activities for them.

People received the right care at the right time from the nursing and medical team, and had regular reviews. They were also able to receive care for their physical health needs from other specialist health professionals when needed.

Complaints were taken seriously, investigated, responded to promptly, and lessons were learnt.

There were strong links with other internal and external agencies to help people move between services from referral, to admission and discharge.

We found that there was good local leadership in place and that staff were proud to work for the trust. Staff said that they felt supported by their managers and were pleased to work on Clover Ward.

Bradford District Care Trust provides inpatient services for men aged 18 years and over with mental health conditions, who require management under conditions of low security. Services are provided at Moorlands View forensics unit, which is based on the Lynfield Mount Hospital.

We observed staff and people interacting well on all the wards. Staff engaged with people in a caring, compassionate and respectful manner, answering questions and providing support when asked. People appeared to be comfortable approaching staff when they needed support.

The wards used the ‘my shared care pathway’, which is a recovery and outcomes-based approach to care. The care plans we saw were well documented and described how people’s needs were being met at each stage of their care. There were also set dates for care planning approach (CPA) meetings. Feedback we received from people across the wards confirmed they felt involved in decisions about their care.

The wards had good links in the community to make sure that people were prepared when they were discharged back into the community. Across the wards, people were positive about the community links and they described the arrangements that had been made before their discharge.

All of the wards had access to occupational therapy, psychology and other specialist input when it was needed. In addition, staff worked with people to promote independent living skills and social inclusion.

The wards proactively sought feedback from people who used the service and we found evidence that they acted on this feedback and implemented changes as a result.

The trust had a clear vision for the low secure and rehabilitation services, which involved increasing the community provision and working in the least restrictive for people. For example, using de-escalation (managing aggressive behaviour) to underpin people’s recovery. It was clear that these strategies were in place and staff understood and knew how to implement them. On the wards we visited, staff told us that the use of restraint was low in response to incidents.

The wards and outreach team had strong governance arrangements in place to monitor the quality of the service delivered. Managers had regular meetings to consider issues of quality, safety and standards, which included monitoring areas of risk such as incidents. These were monitored regularly by senior staff in the service.

Overall, the wards had effective systems in place to assess and monitor risks to individuals. However, we found that risk assessments were not always reviewed or undertaken before a person, who was detained under the Mental Health Act (MHA) 1983, started leave. This is a requirement of the MHA Code Of Practice.

Staff across the wards said that there were enough staff on duty to meet people’s needs, but they acknowledged that it was challenging when there were short notice staff absences. On Baildon Ward, we found that staffing issues had impacted on activities taking place and leave away from the ward being accommodated. The ward was trying to manage gaps in staffing by using bank staff and they had appointed a temporary member of staff to cover one member of staff who was on long-term sick leave.

Most staff we spoke with said they had access to the mandatory and specialty training they needed. However, some staff felt they would benefit from specific training to give them better skills and knowledge to help them carry out their roles.

Thornton Ward was not following any guidelines on the use of CCTV in the visitors' room. There was no sign to inform people that CCTV was in use during visits, and relatives and people were not verbally informed of the use of CCTV.

End of life services were safe. There were arrangements in place to minimise risks to patients, including health risks and risks of harm to the patient. In general, staffing levels were safe and there was on-going monitoring to make sure that the number of staff on duty was flexible and met patients’ needs.

Arrangements were in place to manage and monitor infection control, medicines, and the safeguarding of people from abuse. There were also dedicated teams to support staff and make sure that policies and procedures were implemented.

Staff knew the process for reporting incidents, near misses and accidents and were encouraged to do so. In addition, learning from incidents was shared between teams and across the organisation.

Services were effective, evidence-based and focused on the needs of patients. We saw some examples of very good collaborative work and innovative practice.

We also found evidence that patients approaching the end of life were identified in the right way. Care, including effective pain relief, was delivered according to their personal care plans, which were regularly reviewed. Patients in the last days of life were identified quickly and appropriate action was taken.

The majority of staff were up-to-date with mandatory training and there were systems in place to make sure that staff received regular appraisals. However, the clinical supervision of staff varied across the service and some staff did not have regular protected time to reflect on clinical practice.

End of life services were caring. Patients and relatives told us that staff supported them well and we observed that staff were compassionate and caring. Staff were also aware of the emotional aspects of caring for people with end of life illnesses, and made sure that specialist support was provided for people where needed.

The service understood the needs of the people it cared for, and developed services to meet those needs. There were systems in place to make sure that patients were able to access the right care at the right time, and that services were flexible enough to fit in with patients’, and their families’, lifestyles. This included, for example, their individual preferences, spiritual, ethnic and cultural needs. We saw excellent examples of staff making sure that the needs of patients with a learning disability accessing end of life care were understood and taken into account.

Systems were in place to encourage patients and their carers and/or families to provide feedback. There were also complaints procedures available and we saw that complaints were handled effectively.

End of life services had a clear vision and strategy to improve and develop high-quality end of life care. Managers and staff understood the roles and responsibilities of governance and quality performance. While most staff were aware of the trust’s vision and strategy, not all staff knew about these.

Local managers provided good leadership and support, and most staff felt engaged with senior management. There was a positive culture in the service and staff felt that the leadership models encouraged them to be supportive of each other and compassionate towards people who used the service. In addition, staff were encouraged to raise problems and concerns about patient care without fear of being discriminated against.

People were encouraged to give their views on the service. We saw that these were heard and acted on, and that information on patients’ experience was reported and reviewed, alongside other performance data. Where issues were identified, action plans were put in place to make improvements to patient care.

Bradford District Care Trust provides a range of community health services for adults with long-term conditions. These include district nurses, community matrons and community clinics, such as podiatry, speech and language therapy, leg ulcer clinics and continence clinics.

Overall, patients received safe care across all services and teams. Patients and relatives told us that they were treated in a caring and friendly way and were kept informed. In general, we found that there were enough staff for the service to be safe. While there were vacancies in some community teams, the number of staff on duty was monitored to make sure that the service was flexible and met patients’ needs. Recruitment for staff vacancies was on-going. The senior managers and district nurses we spoke with confirmed that they met regularly to discuss the number of staff and what support was required across the different teams.

Arrangements were in place to manage and monitor infection control, medicines and the safeguarding of people from abuse. There were also dedicated teams to make sure that policies and procedures were implemented. For example, the safeguarding lead told us that the safeguarding team undertook record keeping audits to check that policies and procedures and were complied with. In addition, there were measures in place to minimise risks to patients, for example pressure ulcers. These measures included using the NHS safety thermometer tool to monitor and analyse patient data on harm-free care.

Staff knew how to report incidents, near misses and accidents, and were encouraged to do so. However, we found that learning from incidents, and the sharing of learning within teams and across the organisation, was inconsistent.

Services were effective, evidence-based and focused on patients’ needs. There were also examples of staff working well together.

We saw some excellent practice from the district nurse team and in the clinics we visited, where staff provided compassionate and individualised care that promoted independence. Staff were aware of the emotional aspects of caring for people living with long-term health problems, and made sure that specialist support was provided where needed. The patients we spoke with were positive about the services and said that the care they had received was good and met their needs. Patients also told us that staff involved them in decisions about their care and treatment.

The majority of staff were up-to-date with mandatory training and there were systems in place to make sure that they received appraisals. However, we found that the clinical and reflective supervision of staff varied across the community nursing teams.

Patients, their carers and/or families were encouraged to provide feedback about their care and treatment, and we saw examples where feedback had been used to develop the service. There were also complaints procedures available and complaints were handled effectively. Staff across the services told us that they offered patients choices about where they wanted to be treated, and there were, for example, community clinics for wound management.

Managers and staff understood the roles and responsibilities of governance and quality performance. While most staff were aware of the trust’s vision and strategy, this was not embedded across the service. In addition, some staff were unaware of the issues about quality that were affecting their service.

There was a positive culture, where staff were encouraged to raise problems and concerns without fear of being discriminated against. However, some staff told us they did not always get feedback about the problem or concern they had raised.

Community team managers provided good leadership and support, and most staff felt engaged with their line managers. However, some staff told us that they felt disconnected from the trust’s board, although they did acknowledge that this had improved recently.

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.

These older reports are from our old approaches to inspection, including those from before CQC was created.

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.

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.

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