Derbyshire Healthcare NHS Foundation Trust

We have rated Derbyshire Healthcare NHS Foundation Trust as requires improvement overall because:

• The trust lacked robust leadership. This had resulted in variation in the quality and safety of services provided. The CQC had undertaken a joint inspection of the trust with Deloitte in January 2016. This criticised the quality of leadership. Although some improvements had been made since that joint inspection, the pace of change and ability of the senior leadership to grasp the seriousness of the deficits has not been quick enough. As a group, the executive team lacked the full depth and breadth of skills required to enable the improvements needed in culture, governance and HR throughout the trust.
• Trust assurance and reporting systems had failed to recognise serious safeguarding issues that had occurred on the wards for older people with mental health problems since 2011. Although senior staff were aware of the issues, no decisive action had been taken to effectively safeguard and protect patients from potential abuse.

• Some front-line staff lacked confidence in the leadership team and felt detached from the central management functions. Although the trust leadership team has started work to improve engagement with staff, there is still much to be done in this area.

• The quality of clinical services varied. We have rated the forensic wards and wards for older people with mental health problems as inadequate. This was mainly due to the safety of the environments, concerns about safeguarding and a lack of staff understanding on how to interpret and apply the Mental Health Act and the Mental Capacity Act. In a number of core services, staff were not recording risk assessments, best interest decisions or care plans well.

However:

• We found the staff to be consistently caring and they treated patients with kindness, dignity and respect. The feedback received from both patients and carers regarding the quality of care was positive and demonstrated a staff group who have the patients’ best interests continually in mind.

Following our inspection, CQC has issued the trust with a Section 29a warning notice.

NHS Improvement launched an investigation into Derbyshire Healthcare NHS Foundation Trust in 2015, in respect of governance concerns identified from the judgement of an Employment Tribunal, and concerns raised by other third parties. In February 2016, based on evidence from independent reviews commissioned by the Trust, a focussed inspection by the Care Quality Commission and an independent review of governance arrangements, NHS Improvement formally found the Trust to be in breach of its licence. The Trust has agreed a number of enforcement undertakings with NHS Improvement which it is required to implement, and has developed an action plan to secure delivery of the enforcement actions and return to compliance with its licence.

The CQC and NHS Improvement meet with the trust leadership on a monthly basis; we will be continuing this approach to agree an action plan to assist them in improving the standards of care and treatment. 

The service was well led locally, however staff reported that the executive team were not visible and there was a mixed knowledge of the trust‘s strategy and governance arrangements.

Medical staffing was not at establishment, the paediatricians were having difficulties finding suitably qualified staff to fill their vacancies.

Where there were long waiting lists there were strategies in place to minimise the effect this had on the children and young people.

Not all members of staff had completed mandatory training to comply with the trust target.

Safeguarding procedures were in place with clear lines of reporting. Staff were aware of these procedures and their responsibilities for safeguarding of children and young people. However not all staff had three monthly safeguarding supervision.

The Derbyshire Healthcare NHS Foundation Trust had systems in place for incident recording, investigating and monitoring. Lessons were learnt, when necessary, to prevent similar incidents from happening again.

The feedback from children, young people, their parents and carers was extremely positive at all the locations and programmes we visited. Staff were kind and caring; we observed excellent interactions between staff, children, young people, and their parents or carers. Everyone we spoke with on the telephone, face to face and met in clinics were overwhelmingly positive about staff, they told us staff were kind, caring and listened to their concerns. Staff ensured people experienced compassionate care which promoted their dignity. Staff coordinated care for the whole family and were committed to helping meet people’s emotional, social and welfare needs in addition to their health needs.

Services were located where people could access them, and offered a range of times to accommodate people’s preferences. Overall, children, young people and families received timely community healthcare services. Services met their performance targets with very few exceptions.

The trust worked in partnership with other agencies such as neighbouring trusts, the local authority, education authority and voluntary organisations. We saw evidence that partnership working was routinely included in every aspect of their work. Staff were passionate about their role and they were continually looking how to improve services for children and young people.

The trust provided some unique services to children and young people. These included parent training programmes for Autistic Spectrum Disorders (ASD) and Attention Deficit Hyperactivity Disorder (ADHD).

We rated community mental health services for people with learning disabilities as requires improvement because:

• Across all teams, staff did not complete agreed dates of review on care plans and not all patients had a care plan in place. Not all care plans at Amber Valley team fully contained patients’ views, strengths and goals.

• Staff did not always carry out assessment of capacity to consent in a consistent way in all teams. Some records where patients had been identified as lacking capacity had no associated documentation in place.

• There have been long average waiting lists of 27 weeks for psychology and 41 weeks for speech and language therapists across the community learning disability teams.

However:

• All of the teams completed patients’ comprehensive assessments and risk assessments that were reviewed and updated by the multidisciplinary team. The teams used a variety of clinical outcome measures.

• Staff had completed mandatory training and had the skills and knowledge to meet patients’ needs. Staff assessed and supported patients with their physical health care needs.

• Staff reported incidents and the managers discussed lessons learnt from incidents to improve practice. Each team had a safeguarding lead and staff had good awareness of safeguarding procedures.

• The teams worked well as a multidisciplinary team and with other external organisations to ensure that patients were given the right support. The teams responded a timely manner to patients referred in a crisis
• Staff in all the teams spoke and behaved in a way that was respectful, kind and polite. Staff involved patients in their care and treatment planning. Staff supported patients with access to advocacy. Patients were given information in easy read format.
• The teams had objectives that reflected the trust’s values and objectives. Staff felt morale was good within the teams and their team managers supported them.

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

• Skilled staff worked within a multidisciplinary approach to ensure they were responsive to urgent referrals or patient crisis. They consistently reviewed and monitored patient risk, and worked collaboratively with carers to promote independent living and avoid hospital admission.

• There were adequate numbers of staff available to prioritise and monitor waiting lists, providing information to patients, carers and referrers ensuring they knew what to do if patient’s condition deteriorated.

• The teams had developed good external links to GPs, social services and other local agencies, to ensure patient’s holistic needs were thoroughly care planned.

• Patients told us staff were caring, compassionate and responsive to their needs, providing emotional and practical support. They told us staff involved them and their carers within their care and looked after their best interests.

• Staff received regular supervision and support from their team managers, and attended to their training needs. Staff told us morale was good and they worked well as a team.

However:

• We found that although staff were trained in the Mental Health Act & Mental Capacity Act, their knowledge of key areas that related to their patient group, such as community treatment orders, was limited. This was reflected in the lack of documentation in the care records. We also found that patients were not consistently given a copy of their care plan

• The service missed opportunities to learn from incidents, complaints and audits. Staff recognised incidents but did not always record them.

• Patients told us they did not receive written information on how to make a complaint, such as Patient Advocacy and Liaison (PALS) leaflets, although they told us they would speak with their care co-ordinator.

• Waiting lists for psychological interventions were long, which prevented patients receiving appropriate treatment when they needed it.

We rated CAMHS as outstanding because;

• The teams delivered a good range of evidence based care and treatment and there was high use of routine outcome measures.
• Urgent referrals and deterioration in mental health were responded to quickly and the development of the rapid intervention, support and empowerment team meant that staff were accessible seven days a week, 08.00 to 23.00.
• Routine referrals were seen within an average time of six weeks and urgent referrals were seen within 24 hours. The target for routine referrals was 18 weeks.
• Risk assessments were completed and updated regularly and care plans were up to date and patient focused.
• Feedback from young people and families was very positive and the team were described as going the extra mile.
• The inspection team observed staff showing warmth and being respectful to young people and their families.
• There was a high level of participation by young people and parents throughout all levels of the service.

.

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

• The health-based place of safety located in the Hartington Unit had multiple ligature points and other risks, including blind spots. It lacked emergency equipment and ligature cutters.
• The door to the health-based place of safety at the Hartington Unit had an uncovered clear glass panel that people in the reception area could see through.
• All the crisis resolution and home treatment (CHRT) teams had low training rates for medicines management and the Derby City and County South team had low rates for basic life support training.
• Patients’ medication records for the Derby City and County South team showed gaps for medicine reconciliation and the recording of patients’ allergies.
• Care plans in the Derby City and County South team lacked detail and were not always up-to-date.
• Although staff had recognised and reported safeguarding issues internally, the Derby City and County South team had not made any referrals to the local authority.
• The lone working arrangements for staff in the High Peak team were not robust or safe.
• Staff in the Derby City and County South team did not receive regular one-to-one supervision and appraisals.
• The Derby City and County South CRHT experienced difficulties transferring patients to community mental health teams because of long waiting lists.
• Staff in the Derby City and County South team did not feel assured that their service would remain safe during the transition to integrated community services.
• The trust did not routinely measure performance on key activities such as four-hour response times to referrals.
• Governance systems and processes to help ensure effective practice were inconsistent across the teams.
• The health-based places of safety did not contain clocks. The health-based place of safety at the Hartington Unit did not have anything for patients to lie down on

However:

• All CRHT teams had safe staffing levels for their respective caseloads at the time of our inspection.
• The CRHT teams had good risk assessment and management systems and processes.
• Staff undertook comprehensive assessments of patients’ needs taking into account social, psychological and physical needs.
• Patients and relatives gave positive feedback about the CRHT service and described the staff as kind and helpful.
• The CRHT teams had local systems in place to help provide continuity of care, wherever possible.
• The CRHT teams fully involved patients (and relatives, where appropriate) in care planning.
• Staff ensured that assessments of patients detained in the health-based places of safety started as soon as possible after their admission.
• All CRHT teams had good access arrangements covering 24 hours a day, seven days a week, and had no exclusion criteria as long as the presenting issue was mental ill health.
• The CRHT teams prevented hospital admissions by providing intensive short-term support to patients in their own home.
• Patients received timely support, tailored to their needs, in their own home. Staff negotiated the type and frequency of contact with patients.
• All CRHT teams had a clinical leadership model to team and service management, which helped ensure that clinical and managerial needs informed practice and service development.
• The new local leadership team for the Derby City and County South team had made significant improvements to the service following a prolonged period of crisis.
• Staff in the Chesterfield and High Peak teams described good team working, and staff in the Derby City and County South team reported improvements in team morale, and trust and confidence in the team’s new managers.
• The trust participated in a multi-agency group concerned with the operation of section 136 of the Mental Health Act.

We rated community based mental health services for adults of working age as requires improvement because:

• Not all locations where patients were seen and treated had access to emergency equipment.
• Waiting lists for psychological interventions were long, which prevented patients receiving treatment when they needed it.
• Levels of training and appraisal for staff were below the target levels set by the trust.
• Not all areas of buildings were clean and well maintained which impacted negatively on patient comfort, privacy and confidentiality.
• Staff did not routinely participate in clinical audit activities; this meant that the care provided was not being reviewed against agreed standards.
• Staff did not routinely give patients on community treatment orders their S132 rights in line with the Mental Health Act Code of Practice and did not routinely provide patients with information on advocacy services or how to complain. Care plans did not consistently demonstrate patient involvement or a focus on recovery.
• Staff felt that there was a lack of leadership from board level in the organisation and little ongoing guidance was provided on service transformation and the implementation of the Neighbourhood model. Staff did not consistently report that senior managers were visible or accessible.

However:

• Patients and carers were happy with the way that staff worked, describing them as respectful, caring, and responsive.
• There was a range of information leaflets available to patients and carers.
• We saw local examples of good and innovative work practices including equine therapy and initiatives to reduce the stigma of mental health.
• Staff supported patients with physical health, accommodation, employment, recreation and financial needs.

We rated forensic inpatient/secure ward as inadequate because:

• Patient safety was compromised by the lack of staff training in key aspects of care such as basic life support and intermediate life support.
• Monitoring of patients’ physical health following restrictive interventions and/or rapid tranquillisation was inconsistent.
• Environmental risks identified had not been addressed despite action plans indicating mitigating actions to be taken.
• We found that care plans were not holistic, personalised or recovery-focused. Patients input into their care plans were not evident. Provision of physical health assessments for patients on admission to the service was inconsistent.
• Patients were not provided with the opportunity to create advance decisions detailing their preferences for care and treatment.
• The seclusion rooms did not comply with the guidance set out in the Mental Health Act (1983) or the Code of practice (2015).

However:

• Nursing staff had undertaken nursing risk assessments called functional assessment of the care environment (FACE) of patients upon admission. Nurses had updated these risk assessments regularly to reflect any changes in risk. FACE risk assessments are not as detailed as HCR20v3 risk assessments.
• Staff knew to report and record all risk incidents, and all near misses, and did this consistently. They were open and transparent and explained to patients when things went wrong.
• Patients had wellness recovery action plans (WRAP) which were personalised and staff had created these in collaboration with the patient.
• The service was participating in the Quality Network for Forensic Mental Health Services. They were also engaged in Commissioning for Quality and Innovation (CQUIN) towards the provision of a recovery college and reducing the use of restrictive interventions.
• Bed occupancy was low; the average length of stay for patients was short and readmissions within 90 days were low.
• Staff were responsive to patients’ needs and they were supportive. Patients told us staff were kind and caring.

• Staff morale was good and they were very positive about the leadership by the new unit manager. They spoke very positively about their team; they were proud of their team and were supportive of one and other.

We rated long stay/rehabilitation wards for working age adults as good because:

• Staff completed risk assessments on admission and updated them regularly. Potential risks to patients were discussed ward handovers. Staff had received safeguarding training and understood when to make a referral. Medicines management was of a high standard and used a system that considered patient safety while also promoting independence

• Patients said that they staff were open and honest with them. Staff treated them with dignity and respect and there were high levels of staff engaging with patients. Carers felt fully involved and appreciated being able to attend carers groups.

• Patients had access to lounges, outside space and were encouraged to shop for their own food and prepare this. Staff offered support and guidance around healthy eating if required. The wards and the rehabilitation occupational therapy team provided access to a wide range of community based activities, which promoted recovery and independence.

• Staff showed a high level of commitment to the patients. They felt well supported by managers and were engaged in making improvements to the services by giving feedback. This support allowed them to feel confident in being open and transparent with patients when incidents.

However:

• Staff were not always clear about the use of the Mental Capacity Act and Deprivation of Liberty Safeguards, or when to use this legislation.

• Patients at Cherry Tree Close felt the five-week rotation of multidisciplinary team meetings meant they had to wait to discuss their treatment. They felt they would like to have appointments that are more regular.

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

• The trust did not consistently ensure the safety of those using services. This was due to a combination of high levels of bank/agency staff, low levels of staff training and by not carrying out the action plans from environmental risk assessments.

• Staff did not always monitor and record care interventions in line with trust policies or national guidelines. The lack of integrated care notes made information less accessible and increased the risk of miscommunication between clinical staff.

• Staff understanding of the Mental Capacity Act varied, many staff relied on the doctors to assess. Staff did not always indicate reasons for capacity assessments or fully complete the forms. Staff did not always implement care and treatment in line with the Mental Health Act and Mental Health Act Code of practice.

• Most inpatient beds were on dormitory style wards. Three wards segregated beds by curtains. This compromised patients’ privacy and dignity. The trust had no plans to phase out this style of ward.

• Governance systems in place were weak. Not all staff had the opportunity to discuss lessons learnt with each other; staff business meetings were irregular and time limited due to wards being short staffed. Ward managers were often unable to complete ward duties when on call, as they needed to manage the health-based place of safety and respond to incidents within the units. The trust did not always learn from lessons and systems to share information with staff were ineffective.

However,

• The Trust were part of the national ‘Triangle of Care’ scheme. The ‘Triangle of Care’ scheme encourages a therapeutic relationship between patient, staff member and carer that promotes safety, supports recovery and sustains wellbeing.

• Both units offered a wide range of therapeutic and recreational interventions across seven days and throughout the evenings.

In July 2015, Monitor opened an investigation into the Trust, due to governance concerns identified from the judgement of an Employment Tribunal. Monitor also has concerns following related complaints raised by other parties including individuals who have approached Monitor in line with its whistleblowing policy. The Trust is currently undertaking two pieces of work to respond to the issues raised by the judgement and by the Monitor investigation:

• An independent investigation into the findings of the judgement, both as they relate to the performance and conduct of individuals and to wider issues of standards of corporate governance.
• An independent investigation into individual complaints raised by current or ex-members of staff about the behaviour of current or ex-members of staff.

The Trust appointed an external agency to carry out a focused review of specific elements of its governance arrangements. Monitor, the Care Quality Commission (CQC) and Deloitte looked into the leadership and governance arrangements and into the performance of the HR and related functions at the Trust. Each body will report separately. This report describes the findings of the CQC focused inspection.

This focused inspection looked specifically at the following:-

• Vision, values & strategy
• Are recruitment and performance management processes objective and transparent?
• Are there clear roles and accountabilities in relation to board governance (including quality governance)?
• Does the board actively and effectively engage patients, staff, governors and other key stakeholders on quality, operational and financial performance?

We would like to thank the trust and its staff for their help and co-operation throughout the review.