Norfolk and Suffolk NHS Foundation Trust

Transcription

1 Norfolk and Suffolk NHS Foundation Trust Community-based mental health services for older people. Quality Report Requires Improvement Hellesdon Hospital Drayton High Road Norwich NR6 5BE Tel: Website: Date of inspection visit: October 2014 Date of publication: February 2015 Locations inspected Name of CQC registered location Location ID Name of service (e.g. ward/ unit/team) Postcode of service (ward/ unit/ team) Hellesdon RMY01 The Julian Hospital Dementia and Complexity in Later Life Team Dementia Intensive Support Team NR2 3TD Hellesdon RMY01 Gateway House Dementia and Complexity in Later Life Team NR18 0WF Hellesdon RMY01 Carlton Court Dementia and Complexity in Later Life Team NR33 8AG 1 Community-based mental health services for older people. Quality Report February 2015

2 Summary of findings Dementia Intensive Support Team Hellesdon RMY01 Chatterton House Dementia and Complexity in Later Life Team Dementia Intensive Support Team PE30 5PD Hellesdon RMY01 Woodlands Unit Dementia Intensive Support Team IP4 5PD Hellesdon RMY01 Main Site Dementia Intensive Support Team IP33 3NR This report describes our judgement of the quality of care provided within this core service by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Norfolk and Suffolk NHS Foundation Trust and these are brought together to inform our overall judgement of Norfolk and Suffolk NHS Foundation Trust. 2 Community-based mental health services for older people. Quality Report February 2015

3 Summary of findings Ratings We are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings will always be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring data and local information from the provider and other organisations. We will award them on a four-point scale: outstanding; good; requires improvement; or inadequate. Overall rating for Community-based mental health services for older people Are Community-based mental health services for older people safe? Are Community-based mental health services for older people effective? Are Community-based mental health services for older people caring? Are Community-based mental health services for older people responsive? Are Community-based mental health services for older people well-led? Requires Improvement Requires Improvement Good Good Inadequate Requires Improvement Mental Health Act responsibilities and Mental Capacity Act / Deprivation of Liberty Safeguards We include our assessment of the provider s compliance with the Mental Health Act and Mental Capacity Act in our overall inspection of the core service. We do not give a rating for Mental Health Act or Mental Capacity Act; however we do use our findings to determine the overall rating for the service. Further information about findings in relation to the Mental Health Act and Mental Capacity Act can be found later in this report. 3 Community-based mental health services for older people. Quality Report February 2015

4 Summary of findings Contents Summary of this inspection Overall summary 5 The five questions we ask about the service and what we found 6 Background to the service 8 Our inspection team 8 Why we carried out this inspection 8 How we carried out this inspection 8 What people who use the provider's services say 9 Good practice 9 Areas for improvement 9 Detailed findings from this inspection Locations inspected 10 Mental Health Act responsibilities 10 Mental Capacity Act and Deprivation of Liberty Safeguards 11 Findings by our five questions 12 Page 4 Community-based mental health services for older people. Quality Report February 2015

5 Summary of findings Overall summary We rated the mental health community services for older people as requires improvement' because: There were no clear procedures in place to manage risks to people and staff safety at all times. The management approaches used to respond to fluctuations in people s mental state were not safe. People s medicines were not routinely monitored to ensure that they were always stored at the safe temperature for them to be effective. People over the age of 65 with dementia had no access to 24 hour crisis team in some areas. This meant they had no access to specialist services and remained at risk. Staff lacked a clear understanding of the vision and values of the organisation. Staff told us that the morale was low as the senior management did not listen to their concerns. Quality was inconsistently monitored at local levels which meant that trends were not fully analysed in order to make improvements to the service. However: People were treated in line with current legislation and national guidance. The physical health needs of people who used the service were assessed and monitored to ensure people s health and wellbeing. Staff were polite, kind and treated people with respect and dignity. Care was delivered in a caring and compassionate way. People told us they were involved in their care. Relatives were involved in care planning and their information was used to develop people s care plans.. 5 Community-based mental health services for older people. Quality Report February 2015

6 Summary of findings The five questions we ask about the service and what we found Are services safe? We rated the mental health community services for older people as requires improvement' because: Requires Improvement There were no clear procedures in place to manage risks to people and staff safety at all times. The management approaches used to respond to fluctuations in people s mental state were not safe. Routine checks were not always carried out to ensure that medicines were kept at the safe temperature for optimum effectiveness. There were staff shortages in other areas which resulted in staff having high caseloads. This could affect people s safety and treatment. However: Staff received training in how to safeguard people who used the service from harm and demonstrated that they knew how to do this Are services effective? We rated the mental health community services for older people as good' because: Good People s mental capacity was assessed and where people lacked the mental capacity to make decisions about their care and treatment, decisions were made in their best interests. People were treated in line with current legislation and national guidance. The physical health needs of people who used the service were assessed and monitored to ensure people s health and wellbeing. Staff worked well as a multi-disciplinary team and took a person-centred approach. However, we saw that there was limited input from occupational therapy services. There was a range of treatment approaches available to meet people s needs. Staff were well trained and had access to training and development opportunities. However There were inconsistencies in providing regular supervision and appraisals. Are services caring? We rated the mental health community services for older people as good' because: Good 6 Community-based mental health services for older people. Quality Report February 2015

7 Summary of findings Staff were polite, kind and treated people with respect and dignity. Care was delivered in a caring and compassionate way. People told us they were involved in their care. Relatives were involved in care planning and their information was used to develop people s care plans. Staff demonstrated a high level of emotional support to patients on an individual level and took time to support patients in a sensitive manner. Are services responsive to people's needs? We rated the mental health community services for older people as inadequate' because: Inadequate People over the age of 65 with dementia had no access to 24 hour crisis team in some areas. This meant they had no access to specialist services and remained at risk. Information about services provided was not very clear and could affect effect delivery of care. However: Complaints were taken seriously, investigated, responded to promptly and lessons learnt. We saw that there was a system to respond to urgent referrals using the single point of access. Are services well-led? We rated the mental health community services for older people as requires improvement' because: Requires Improvement Staff lacked a clear understanding of the vision and values of the organisation. Staff told us that the morale was low as the senior management did not listen to their concerns. Quality was inconsistently monitored at local levels which meant that trends were not fully analysed in order to make improvements to the service. Staff felt a disconnect with senior management However: Staff showed passion for their work despite feeling undervalued by senior management. 7 Community-based mental health services for older people. Quality Report February 2015

8 Summary of findings Background to the service The older people community service provides mental health services across Norfolk, Suffolk and Great Yarmouth and Waveney for people experiencing dementia and complexity in later life. The offices and clinics are situated around the counties and provide access to care within clinics and people s own home. The service is provided by two teams, Dementia Intensive Support team (DIST) and Dementia and Complexity in Later Life (DCLL). DIST teams in Norfolk offers assessment, intervention and intensive support to adults with age related needs including established or suspected dementia diagnoses, severe and enduring mental health problems such as anxiety, depression and related behavioural problems. However, the DIST teams in Suffolk cared for people with dementia related issues only. DCLL services offer assessment diagnosis and treatment for adults experiencing memory problems, cognitive impairment, dementia, and other mental health issues associated with later life. The DCLL also offers a memory treatment service that provides assessment and monitoring of patients who were prescribed one of the drugs that have been licensed for the treatment of mild to moderate Alzheimer s dementia. The operational times for all DIST teams included weekends but varied across the trust depending on the population served. The DCLL teams operated from 9am to 5pm Monday to Friday. None of the teams provided 24 hours service. A single point of access for referrals was operated within all teams in Norfolk and Great Yarmouth and Waveney, known as the Access and Assessment Team (ATT) which triage all referrals. These services have not been inspected before. Our inspection team Our inspection team was led by: Chair: Joe Rafferty, Chief Executive Officer, Merseycare NHS Trust Team Leader: Julie Meikle, Head of Hospital Inspection (mental health), CQC Inspection Manager: Lyn Critchley, Inspection Manager, CQC The team included CQC managers, inspection managers, inspectors and support staff and a variety of specialist and experts by experience that had personal experience of using or caring for someone who uses the type of services we were inspecting. Why we carried out this inspection We inspected this trust as part of our on-going comprehensive mental health inspection programme. How we carried out this inspection To get to the heart of people who use services experience of care, we always ask the following five questions of every service and provider: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? 8 Community-based mental health services for older people. Quality Report February 2015 Before visiting, we reviewed a range of information we hold about Norfolk and Suffolk NHS Foundation Trust

9 Summary of findings and asked other organisations to share what they knew. We carried out an announced visit between 21 October and 23 October. Unannounced inspections were also carried out on the late evening of 06 November During the visit we held focus groups with a range of staff who worked within the service, such as nurses, doctors, therapists. We talked with people who use services. We observed how people were being cared for and talked with carers and/or family members and reviewed care or treatment records of people who use services. We met with people who use services and carers, who shared their views and experiences of the core service. What people who use the provider's services say During the inspection, we spoke with eight people who used the service. They were pleased with the care provided. We found that people were positive about their experiences of care and we observed polite, warm and patient interaction with people. People told us that staff were very supportive, included them in their care planning and gave them information that helped them to make choices about their care. People told us that they felt staff treated them with respect and dignity and listened to them. Good practice The DIST team had introduced an innovative helpline to offer support and advice to carers and care homes. Despite the pressures of workload the staff we observed were dedicated, caring and compassionate. The DCLL had integrated its collaborative working with GPs and social workers to increase outcomes for patients. Areas for improvement Action the provider MUST or SHOULD take to improve Action the provider MUST or SHOULD take to improve The trust must ensure that there are robust policies and procedures that keep staff and patients safe in the community. The trust must ensure that people receive the right care at the right time by placing them in suitable placements that meet their needs and have access to 24 hour crisis team. The trust must ensure that all risk assessments and care plans are updated consistently in line with multidisciplinary reviews. The trust must ensure that they provide people with the right information about services. The trust must ensure that there are systems in place to monitor quality and performance of the teams. The trust must improve staff engagement as many staff in mental health community teams felt disconnected from senior managers and the leadership of the Trust. The trust must ensure that health and safety checks are carried out consistently. The trust must ensure that temperatures for medicines stored are regularly monitored in line with medicines management guidelines. The trust must ensure that all staff receive regular supervision and appraisal. The trust must ensure that the teams are adequately staffed including junior medical staff. 9 Community-based mental health services for older people. Quality Report February 2015

10 Norfolk and Suffolk NHS Foundation Trust Community-based mental health services for older people. Detailed findings Locations inspected Name of service (e.g. ward/unit/team) The Julian Hospital Gateway House Carlton Court Chatterton House Woodlands Unit Main Site Name of CQC registered location HQ: Hellesdon HQ: Hellesdon HQ: Hellesdon HQ: Hellesdon HQ: Hellesdon HQ: Hellesdon Mental Health Act responsibilities We do not rate responsibilities under the Mental Health Act We use our findings as a determiner in reaching an overall judgement about the Provider. The teams adhered to the Mental Health Act legislation appropriately where it was applicable. 10 Community-based mental health services for older people. Quality Report February 2015

11 Detailed findings Mental Capacity Act and Deprivation of Liberty Safeguards We found that the community staff had an understanding of the Mental Capacity Act (MCA) and had attended training to ensure that they had the required knowledge. This training was completed as part of the mandatory trust training. 11 Community-based mental health services for older people. Quality Report February 2015

12 Are services safe? Requires improvement By safe, we mean that people are protected from abuse* and avoidable harm * People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse Summary of findings We rated the mental health community services for older people as requires improvement' because: There were no clear procedures in place to manage risks to people and staff safety at all times. The management approaches used to respond to fluctuations in people s mental state were not safe. Routine checks were not always carried out to ensure that medicines were kept at the safe temperature for optimum effectiveness. There were staff shortages in other areas which resulted in staff having high caseloads. This could affect people s safety and treatment. However: Staff received training in how to safeguard people who used the service from harm and demonstrated that they knew how to do this Our findings Julian Hospital and Gateway House - Central Norfolk Safe and clean environment We saw that the environment was clean and staff practiced good infection control procedures. The environment was used solely by staff. We saw that security procedures were followed. Safe staffing The teams used the traffic light monitoring system to assess the level of staffing required according the size of caseloads held within the teams. Caseloads were constantly reviewed in the supervision sessions. Both teams consisted of band six and five nurses and band four support workers. Staffing levels and grades were clearly identified with band six nurses responsible for carrying out assessments in people s homes. The band five nurses carried out follow ups and were supported by senior nurses. The band four workers were responsible for observations of care, personal care and support in care homes. The DIST team had medical support from two consultants who provided two sessions a week and one full time speciality doctor. Assessing and managing risk to patients and staff Risk assessments were carried out for all visits to people to ensure that all staff were safe. Where the risk was deemed high, staff saw people in pairs. All staff were aware of the lone working policy and told us that they followed it. Staff had established systems for ensuring staff whereabouts were known and logged and a system was in place for ensuring staff had returned safely following community visits. Patient's risks were assessed prior to care and treatment starting. Risk assessments and management plans matched the identified needs. However the records we saw contained patient information that was misfiled. Information for different patients was mixed in clinical records file so that information was not available when needed. All staff spoken with demonstrated that they knew how to identify and report any abuse to ensure that people who used the service were safeguarded from harm. At Gateway house we saw that portable appliance test was not carried out for the equipment used in the offices. Equipment was not maintained and checked regularly to ensure it continued to be safe to use. The equipment was not clearly labelled indicating when it was next due for service. There was no routine monitoring of the temperature of stored medicines to ensure they were kept within ranges recommended by the manufacturers. This meant their effectiveness was potentially compromised. 12 Community-based mental health services for older people. Quality Report February 2015

13 Are services safe? Requires improvement By safe, we mean that people are protected from abuse* and avoidable harm Reporting incidents and learning from when things go wrong We saw that there was an effective system to record incidents and near misses. We saw that incidents were reported and investigated. Staff told us that they received feedback following incidents through meetings and information was circulated within the team. We saw evidence that learning from incidents took place and that specific changes to practice was made as a result of incidents. This meant that the trust was able to identify, investigate and learn from incidents. Chatterton House - West Norfolk Safe and clean environment The environment was clean and staff practiced good infection control procedures. The environment was occasionally visited by patients and relatives. We saw that security procedures were followed. However the lighting was poor and not working in some rooms. Safe staffing Kings Lynn teams felt stretched, the teams had caseloads above the anticipated numbers. For example DIST had 39 instead of 25. Agency nurses were used to supplement the team numbers. The clinical leads told us that the teams were on risk register for low staffing levels. Low staffing levels had an impact on care and treatment as well as safe discharge in a timely manner. Staffing rotas showed that some nurses were working long hours and consecutive days. This indicated that the service was struggling to staff the service to deliver safe care. Teams monitored staffing levels against required activity. The teams used the traffic light monitoring system to assess the level of staffing required according the number of caseload held within the team. The manager told us that they were mostly amber. There was an escalation plan for local teams to follow for amber and red status. A review of safer staffing in the community had commenced and staff were recording the complexity as well as number of patients in case loads and this would feed into reporting and workforce planning. The teams had a locum consultant psychiatrist and were struggling to recruit a permanent consultant. There was medical cover from a speciality doctor and a junior doctor. Assessing and managing risk to patients and staff Risk assessments were carried out for all visits to people to ensure that all staff were safe. Where the risk was considered high, staff visited in pairs. All staff were aware of the lone working policy and told us that they followed it. Staff had established systems for ensuring staff whereabouts were known and logged and a system was in place for ensuring staff had returned safely following community visits. People s risks were assessed prior to care and treatment starting. There were good examples of completed risk assessments and management plans that matched the identified needs. There were risk assessment and management plans in place that stated how staff should support people safely. There were thorough policies and procedures in place in respect of safeguarding to support staff to respond appropriately to concerns. All staff spoken with proved that they knew how to recognise and report any abuse to ensure that people who used the service were protected from harm. All notes were in paper format and reasonably well maintained. The patient records we examined were written legibly and assessments were comprehensive and complete, with associated action plans and dates. Records were kept safely in lockable cabinets and confidentiality was maintained. Routine checks were not always carried out to ensure that medicines were kept at the safe temperature for optimum effectiveness. Reporting incidents and learning from when things go wrong There was an effective mechanism to capture incidents, near misses and never events. Incidents were reported via an electronic incident reporting form. Staff told us they knew how to report incidents and were encouraged to use the reporting system. Staff were able to explain how learning from incidents and complaints was cascaded to all staff. Learning from incidents was discussed in staff meetings. Carlton Court Great Yarmouth & Waveney Safe and clean environment We saw that the environment was clean and staff practiced good infection control procedures. The environment was 13 Community-based mental health services for older people. Quality Report February 2015

14 Are services safe? Requires improvement By safe, we mean that people are protected from abuse* and avoidable harm occasionally visited by patients and relatives for clinics. Security procedures were followed. The environment was maintained to ensure the safety of staff and people who used the service. Safe staffing Staffing levels for community nurses varied across the different localities. Some of the localities were satisfactorily staffed. Lowestoft community team, particularly DIST, felt heavily stretched and staff had been working over their contracted hours. Lowe staffing levels had an impact on referrals and patient care was not always undertaken in a timely manner. The teams used the traffic light monitoring system to assess the level of staffing required according the number of caseload held within the teams. Caseloads were constantly reviewed in the supervision sessions. However, issues reported in regard to inadequate staffing levels in the DIST team had not been taken into account. This meant that key risks and actions to mitigate any impact upon effective care delivery were not prioritised. There were no junior medical staff in DIST and any assessments had to be done through the GP. There was a lack of medical input from the team to ensure that those patients with high and complex needs, such as patients waiting for the availability of a bed, received the required medical care to meet their needs. Staffing rotas showed that some nurses and support workers were working a number of excessive consecutive shifts. This indicated that the service was struggling to maintain adequate staffing. Staff told us that the service is not adequately staffed. The clinical lead for DIST told us that the team had a large geographical area to cover and staff spent a great deal of time travelling. There were two vacancies for band six nurses. Assessing and managing risk to patients and staff The AAT team triaged all the referrals and this helped to identify patients who were at immediate risk. Staff were able to prioritise and refer these patients appropriately to the relevant teams. Patients needs were assessed prior to care and treatment being commenced and we saw examples of completed needs assessments and care planning. The handovers and meetings within the teams were effectively used to identify patients in the community with escalating needs. There were no clear policies and procedures in place to identify and manage risks to people and staff safety in urgent cases where people required continuous support or were waiting for a bed. Staff undertook night sitting in patient's home without appropriate arrangements in place to ensure that both staff and patients were safe. Staff told us that they did not feel safe working out of hours in the community especially as it was the less experienced and skilled staff that were working on out of hours duty. Staff were not aware of how to access immediate support in case of emergency. The trust had a lone working policy and staff were aware of it, however this was not followed when working out of hours. All staff had a good understanding of how to identify and report any abuse to ensure that people who used the service were safeguarded from harm. All staff spoken with knew the designated lead for safeguarding who was available to provide support and guidance. Information was readily available to inform people who used the service and staff on how to report abuse. Records within the team were managed appropriately using a paper filing system. Records were well organised and different team members could access people s records when needed. Medicines stored by the service were not routinely monitored to ensure that there were always stored at the safe temperature for them to be effective. Reporting incidents and learning from when things go wrong There was an effective mechanism to capture incidents, near misses and never events. Incidents were reported via an electronic incident reporting form. Staff told us they knew how to report incidents and were encouraged to use the reporting system. Incidents reviewed during our visit demonstrated that thorough investigations and root cause analysis took place, with clear action plans for staff that were shared within the team. Woodlands Unit - East Suffolk Safe and clean environment The environment was very clean, in a modern building and well decorated; there was an immediate and positive impression of a caring environment. The security 14 Community-based mental health services for older people. Quality Report February 2015

15 Are services safe? Requires improvement By safe, we mean that people are protected from abuse* and avoidable harm procedures were followed and staff practiced infection control procedures. Regular health and safety checks were completed of the place and identified risks were put right to ensure the safety of people using the service and staff. Safe staffing The teams used the traffic light monitoring system to assess the level of staffing required according the number of caseload held within the teams. Caseloads were constantly reviewed in the supervision sessions. The team consisted of two band five nurses, three band six nurses with one vacancy which was being recruited for. There were one and half OTs, two band four assistant practitioners and three band three support workers. The team got one day a week psychologist input with no medical input and the team was regarded as a nurse led service. Medical input was accessed through DCLL. Staff told us that they worked long hours and at times without breaks but were able to claim back their time owed. Every patient was reviewed daily and the team was able to respond to the referrals within specified targets including urgent referrals. The caseload for each nurse was eleven and at times could go as high as 14. There was no waiting list in the team. Staff told us that they felt the caseload was manageable but pressure came from the integrated delivery service which had a waiting list of six to eight weeks. Assessing and managing risk to patients and staff There were procedures in place to identify and manage risks to people. We observed that staff discussed risks related to patients in staff hand-over and multi-disciplinary meetings. Patient safety was taken into account in the way care and treatment was planned and links to community other teams were discussed. Risk assessments were carried out for all visits to people to ensure that all staff were safe. People s needs were clearly assessed prior to care and treatment starting. There were good examples of completed needs assessment and detailed care plans that matched the identified needs. There were risk assessment and management plans in place that expressed how staff should support people safely. All staff were aware of the lone working policy and told us that they followed it. All staff we spoke with had a good understanding of how to identify and report any abuse to ensure that people who used the service were safeguarded from harm. All staff spoken with knew the designated lead for safeguarding who was available to provide support and guidance. We saw that information was readily available to inform people who used the service and staff on how to report abuse. Records were held in electronic system called EPEX and also in paper formats. Patient records were generally well maintained and well completed with clear dates, times and designation of the person documenting. Records were kept safely in lockable cabinets and confidentiality was maintained. No medicines were kept on site during our visit. Reporting incidents and learning from when things go wrong There was a trust wide electronic incident reporting process which all staff we spoke with were aware of. Staff had good knowledge and understanding of incidents that should be reported and they told us they were reporting incidents. We saw that incidents were reported and investigated. Staff told us that they received feedback following incidents through meetings and information was distributed within the team. Main Site - West Suffolk Safe and clean environment We saw that the environment was clean but was discoloured and not well maintained. Staff practiced good infection control procedures. We saw that security procedures were followed. Health and safety checks were carried out to ensure the safety of staff. Safe Staffing The teams used the traffic light monitoring system to assess the level of staffing required according the number of caseload held within the teams. Caseloads were constantly reviewed in the supervision sessions. The team was led by a band seven nurse and consisted of four band five nurses, one band six nurse with one vacancy for band six and two for band five. The clinical lead told us that there were delays with recruitment taking up to three months to appoint staff internally. There were three OTs, one social worker and four band three support workers. Medical input was accessed through DCLL. 15 Community-based mental health services for older people. Quality Report February 2015

16 Are services safe? Requires improvement By safe, we mean that people are protected from abuse* and avoidable harm Staff told us that there were pressures due to staff shortages and this was impacting on the effective delivery of care. Every patient was reviewed daily and the team was able to respond to the referrals within specified targets including urgent referrals. The team was well organised and had a clear operational policy on how to meet their targets. There was no waiting list in the team. Staff told us that the felt that the caseload was manageable but pressure would come from the integrated delivery service which was a new initiative. Assessing and managing risk to patients and staff Risk assessments were carried out for all visits to people to ensure that all staff were safe. Where the risk was deemed high, staff saw people in pairs. There were risk assessment and management plans in place that expressed how staff should support people safely. All staff were aware of the lone working policy and told us that they followed it. All staff spoken had a good understanding of how to identify and report any abuse to ensure that people who used the service were safeguarded from harm. All staff spoken with knew the designated lead for safeguarding who was available to provide support and guidance. We saw that information was readily available to inform people who used the service and staff on how to report abuse. Records within the team were managed appropriately using electronic and paper file systems. We saw that the records were well organised and different team members could access people s records when needed. Reporting incidents and learning from when things go wrong Incidents were reported and investigated. Staff told us that they received feedback following incidents through meetings and information was circulated within the team. Learning from incidents took place. Specific changes to practice were made as a result of incidents. 16 Community-based mental health services for older people. Quality Report February 2015

17 Are services effective? Good By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Summary of findings We rated the mental health community services for older people as good' because: People s mental capacity was assessed and where people lacked the mental capacity to make decisions about their care and treatment, decisions were made in their best interests. People were treated in line with current legislation and national guidance. The physical health needs of people who used the service were assessed and monitored to ensure people s health and wellbeing. Staff worked well as a multi-disciplinary team and took a person-centred approach. However, we saw that there was limited input from occupational therapy services. There was a range of treatment approaches available to meet people s needs. Staff were well trained and had access to training and development opportunities. However There were inconsistencies in providing regular supervision and appraisals. Our findings Julian Hospital and Gateway House - Central Norfolk Assessment of needs and planning of care Records sampled showed that comprehensive assessments had been completed on initial contact which covered all aspects of care as part of a holistic assessment. However there were inconsistencies in updating care plans to reflect discussions held within the multidisciplinary meetings. There was evidence of physical health monitoring in records and staff confirmed these checks were undertaken. We saw that physical health was discussed and further assessment of these needs had been offered. This meant that patients physical health and wellbeing as part of a holistic approach was monitored. Best practice in treatment and care National Institute for Health and Care Excellence (NICE) guidelines were followed in respect of medication prescribed and in delivering psychological therapies, particularly around memory - services. The teams had established a therapeutic base for interventions. Staff showed us evidence of clinics held, which included cognitive behavioural therapy (CBT). The teams consisted of staff trained in CBT. The nature of the issues people presented with often led to referral on for psychological therapies following assessment. People were assessed by a specialist to determine a diagnosis of dementia. The teams worked closely with GP surgeries and held monthly meetings with their allocated nurse. Links were also maintained with Norwich and Norfolk hospital for any referrals. Information on patients subject to the Care Programme Approach (CPA) and section 117 after care was readily accessible to both health and social work staff via secure computer access. This meant that the assessing and coordinating of care for people with complex needs was shared with external professionals. Skilled staff to deliver care Staff we spoke with understood their aims and objectives in regard to performance and learning. This was reviewed at their annual appraisal. These objectives were being revisited and reviewed on a monthly basis throughout the year in supervision. Staff told us and records we looked at showed that regular caseload or line management supervision had been taking place regularly. We saw that staff received the training they needed and where updates were required, this was monitored through a system that highlighted specific needs. Staff told us that they received further training in different areas of their specialities that benefited and addressed the needs of people who used the service. The team had nurses specialising in areas such as nurse prescriber, CBT and cognitive stimulation group. At Gateway House there was a lead nurse for onset dementia. Support workers were seconded to have training in mental health foundation degree to become assistant practitioners. This meant staff were appropriately qualified and skilled in their job role. The team consisted of nurses, consultants, speciality doctors, psychologists, occupational therapists (OT), social workers and support workers. 17 Community-based mental health services for older people. Quality Report February 2015

18 Are services effective? Good By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Multi-disciplinary and inter-agency team work In all teams we visited staff described positive relationships with other services and the multi-disciplinary approach to care and treatment was optimal. We saw evidence of working with others including internal and external partnership working, such as multi-disciplinary working with GPs, hospitals, other community mental health teams, independent sector and local authority. Staff spoke of good relationships with other teams and transfer between teams involved working in partnership and where possible undertaking joint visits. Other teams we met with during our visit described effective collaborative working with DIST and DCLL staff. The DCCL team held monthly Integrated Care Meetings at GP practices attended by GPs, palliative nurses, district nurses, social workers and any other professionals involved. Transfer of care between teams and shared care within teams was effectively managed. This enabled smooth transition between teams for the patient as part of their ongoing recovery. Staff were clear about the lines of accountability and who to escalate any concerns to. Staff told us and we saw that they attended their review meetings. We found that there was not enough input from OT services, the OT only worked part time. Adherence to the MHA and the MHA Code of Practice Staff received training and updates in regard to the Mental Health Act. We saw records for people subject to section 117 after care these were reviewed and updated appropriately. Staff told us that social workers and approved mental health professionals (AMHP) in the teams provided guidance on the Mental Health Act to support compliance. Good practice in applying the MCA Capacity to consent to care and treatment was addressed as part of the assessment routine and this was documented. The relevant legislation and the assessment of mental capacity had been used appropriately to ensure that people s rights were respected and exercised control over their lives. We saw that people had access to an independent mental health advocate (IMHA). All staff had received training in the Mental Capacity Act (MCA). Chatterton House - West Norfolk Assessment of needs and planning of care Records sampled showed that comprehensive assessments had been completed on initial contact which covered all aspects of care as part of a holistic assessment. Care plans and risk assessments were updated to reflect discussions held within the multidisciplinary meetings. There was evidence of physical health monitoring in records. Staff told us that physical health checks were undertaken. We saw that physical health was discussed and further assessment of these needs had been offered. This meant that patients physical health and wellbeing as part of a holistic approach was monitored. Best practice in treatment and care Staff were aware of the most recent, relevant NICE guidance. Information about up to date clinical research and policy was shared amongst the team. Staff showed us evidence of clinics held, which included CBT. The teams consisted of staff trained in CBT. The nature of the issues people presented with often led to referral on for psychological therapies following assessment. People were assessed by a specialist to determine a diagnosis of dementia. The Health of the Nation Outcome Scales (HoNOS) were the mostly widely used routine clinical outcome measures as is recommended by National Service Framework for Mental Health. The scales aid the assessment process and can determine through its evaluation the progress of therapeutic intervention. Addenbrooke s Cognitive Examination (ACE-R) was also used to assess the cognitive domains. These were completed by practitioners who had received training in how to undertake this. Skilled staff to deliver care Staff understood their aims and objectives in regard to performance and learning. This was reviewed in supervision. However, these objectives were not being revisited and reviewed on a regular basis throughout the year due to infrequent meaningful supervision. Records showed that some staff had not had supervision for over six months. Staff told us that they received annual appraisals. Appraisals were now monitored through the electronic system where staff would receive an when their appraisal was due. 18 Community-based mental health services for older people. Quality Report February 2015

19 Are services effective? Good By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. All new and agency staff were provided with an induction period in which they shadowed experienced staff to ensure that they knew how to support patients safely. An agency member of staff confirmed that they had undertaken a period of induction on starting with the trust. We saw that staff received the training they needed and where updates were required, this was monitored through a system that highlighted it. Staff told us that there were delays in getting some of the training as the places were limited or it would be very far away from Kings Lynn. Staff told us that they received further training in different areas of their specialities that benefited and addressed the needs of people who used the service. The team had nurses specialising in areas such as nurse prescriber, CBT and cognitive stimulation group. We noted a good skill mix of staff in all teams to support evidence based care. The team consisted of nurses, consultants, speciality doctors, junior doctors, psychologists, occupational therapists, social workers and support workers. Staff told us and we saw that they attended their review meetings. We found that there was not enough input from occupational therapy services as there was only a part time post. Multi-disciplinary working and working with others We observed good collaborative working within the multidisciplinary teams. This was supported in all areas we inspected. We found that staff worked well together and the healthcare professionals valued and respected each other s contribution into the planning and delivery of patient s care. We saw examples of linking with GPs, hospitals, ambulance, district nursing, community support teams and social care. We observed effective communication, appropriate information sharing and decision-making about a patient s care. The information was shared across different types of services involving both internal and external to the organisation. However, we noted one case where a follow-up with the GP was not pursued when one patient had gone over one year without blood tests when presenting with risk factors for delirium. The patient was referred to GP and no blood tests were carried out. This meant that the patient at risk of delirium was not further assessed for indicators of delirium. This appeared to be an isolated case. The community teams had developed strong links with GP practices and the local care homes to implement a common vision for timely, flexible and responsive care services. Adherence to the MHA and the MHA Code of Practice Staff received training and updates in regard to the Mental Health Act. We saw records for people subject to section 117 after care. These were reviewed and updated appropriately. Staff told us that social workers and AMHPs in the teams provided guidance on the Mental Health Act to support compliance. Good practice in applying the MCA Capacity to consent to care and treatment was addressed as part of the assessment routine and this was documented. The legislation and the assessment of mental capacity had been used appropriately to ensure that people s rights were respected and that they exercised control over their lives. We saw that people had access to an IMHA. All staff had received training in the MCA. Carlton Court Great Yarmouth & Waveney Assessment of needs and planning of care There was a comprehensive assessment of people s needs on initial contact which covered all aspects of care as part of a holistic assessment. Care plans showed regular updates to reflect progress in achieving aims. There was evidence of physical health monitoring in records. Staff told us that physical health checks were undertaken. We saw that physical health was discussed initially and further assessment of these needs had been offered. Best practice in treatment and care NICE guidelines were followed in respect to medication prescribed and in delivering psychological therapies, particularly around memory treatment service. The teams had established a therapeutic base for interventions. Staff showed us evidence of clinics held, which included CBT. The teams had all staff trained in CBT. The nature of the 19 Community-based mental health services for older people. Quality Report February 2015

20 Are services effective? Good By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. issues people presented with often led to referral on for psychological therapies following assessment. People were assessed by a specialist to determine a diagnosis of dementia. The teams worked closely with the GP surgeries. A dementia pathway was in place and patients had an ACE- R examination so any intervention could be made. If the assessment showed they were at risk of cognitive impairment, they were referred to the psychiatrists and memory team where appropriate. There were effective handovers between services. Information on patients subject to the CPA and section 117 after care was readily accessible to both health and social work staff on secure computer data. This meant that the assessing and coordinating of care for people with complex needs was shared with external professionals. Skilled staff to deliver care Staff we spoke with understood their aims and objectives in regard to performance and learning. These objectives were being revisited and reviewed on a monthly basis throughout the year in supervision sessions. We saw records and staff told us that regular caseload or line management supervision took place regularly. We saw that staff received the training they needed and where updates were required, this was monitored through an IT training system that highlighted needs. Staff told us that they received further training in different areas of their specialities that benefited and addressed the needs of people who used the service. The team had nurses specialising in areas such as nurse prescriber, safeguarding lead, lead and research champion. Support workers were seconded to have training in mental health foundation degree to become assistant practitioners. The team consisted of nurses, consultants, junior doctors, psychologists, OT, social workers and support workers. Staff told us and we saw that they attended their review meetings. Multi-disciplinary and inter-agency team work We saw evidence of effective multi-disciplinary working with social workers in the teams and proactive referral to district nurses for physical health issues. Patient notes selected at random demonstrated the input of various therapists and referrals to GPs, hospitals, other community mental health teams, independent sector and local authority. Staff spoke of good relationships with other teams and told us how transfer between teams involved working in partnership and where possible undertaking joint visits. Other teams we met with during our visit described effective collaborative working with DIST and DCLL staff. Transfer of care between teams and shared care within teams was effectively managed. This enabled smooth transition between teams for the patient as part of their ongoing recovery. Staff were clear about the lines of accountability and who to escalate any concerns to. There were integrated pathways with independent care. The DIST team worked in partnership with external agencies. Staff told us that they had worked closely with a care home that had six beds and was used as alternative to hospital admission. However these beds were now closed as a result of the care home being unable to safely manage patients who were placed there. Adherence to the MHA and the MHA Code of Practice Staff received training and updates in regard to the Mental Health Act. We saw records for people subject to section 117 after care. These were reviewed and updated appropriately. Staff told us that social workers and AMHP in the teams provided guidance on the Mental Health Act to support compliance. Good practice in applying the MCA Capacity to consent to care and treatment was addressed as part of the assessment routine and this was documented. The relevant legislation and the assessment of mental capacity had been used appropriately to ensure that people s rights were respected and exercised control over their lives. We saw that people had access to an IMHA. All staff had received training in the MCA. Woodlands Unit - East Suffolk Assessment of needs and planning of care Records sampled showed that comprehensive assessments had been completed of the patient s needs and risks at initial contact with the team. Care plans and risk assessments were comprehensive, personalised and regularly reviewed and updated. They showed that people and their families, where appropriate, had been involved in developing the care plans. 20 Community-based mental health services for older people. Quality Report February 2015