All inspections: Lincolnshire Partnership NHS Foundation Trust

Ash Villa is a 15-bed acute treatment ward for females. The service provides assessment or medical treatment for persons detained under the Mental Health Act 1983. This service opened on 1 March 2021, and this was the first assessment of the service. We carried out an onsite and off-site assessment. At the time of site visit 13 people were residing on the unit. Assessment activity started on 5 March and ended on 14 March 2024. We spoke to 8 staff members and 3 patients. Following this assessment, the overall trust rating remains good.

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

We have not updated trust-level ratings following this core service inspection because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

The trust responded in an extremely positive way to the improvements we requested them to make following our inspection in April 2017. At this inspection, we saw significant improvements in the core services we inspected and an impressive ongoing improvement and sustainability of good quality care across the trust as a whole. The senior leadership team had been at the fore front of delivering quality improvement and there was a true sense of involvement from staff, patients and carers towards driving service improvement across all areas.
Leadership had been invested in at all levels so that staff had the right skills, behaviours, knowledge and experience to challenge as necessary and to ensure quality and sustainability of service delivery. This was underpinned by a very strong senior leadership team that had identified priorities, driven cultural change at a pace and led by example. The trust board and senior leadership team displayed integrity on an ongoing basis. The trust’s non-executive members of the board challenged appropriately and held the executive team to account to improve the performance of the trust. The trust leadership team had a comprehensive knowledge of current priorities and challenges and took action to address them. The board were supportive to the wider health and social care system, with both the chair, chief executive and executive team taking up key roles in the local system including through Sustainability Transformation Programme. Reports from external sources, that include NHS Improvement and commissioners, was consistently favourable.
The trust had a clear vision and set of values with quality and sustainability as the top priorities which were robust and realistic. These had been co-produced with staff at all levels and patients. Values were fully embedded throughout the trust through recruitment, new initiatives, staff appraisals and staff wellbeing. At board and committee meetings discussions were consistently linked to the values. We were particularly impressed that each service had identified specific behaviours that aligned with each value so they had close alignment with their services. Each individual team across the trust had taken time to ensure that they understood what the values and behaviours meant for their individual teams and the patients that they provided care for. Local leadership across the trust was strong, visible and effective. Staff were particularly praising of the chief executive and the chair of the trust.
We found that there has been a continued and impressive cultural shift to an organisation that is truly inclusive, that enabled and empowered staff and patients to be heard and became part of the culture of change. The culture had truly been embedded and promoted an arena across the trust for shared learning and encouragement of staff to offer ideas to improve service delivery and patient experience. Staff showed pride and spoke passionately about their roles and working for the trust, their personal progression, opportunities to access specialist training and open and transparent relationships with senior colleagues.
The building of a continuous quality improvement and innovation culture has enabled the trust to move from a top down organisation to a system where staff were empowered to make decisions for improvement for the benefit of services to patients. The delivery of innovative and continuous quality improvement was central to all aspects of the running of the service. There was a true sense of desire to drive service improvement for the benefit of patients, carers, and the wider system, evident throughout the inspection. Staff included patients in service improvement and used their feedback to change practice. The trust actively sought to participate in national improvement and innovation projects, and encouraged all staff to take ownership, put forward ideas and remain involved throughout the process. The trust had improved their focus and the attention that they paid to innovation in the last 2 years which had yielded positive outcomes and national awards. Research was acknowledged as an asset in the trust. For the first time in 2018 the research annual report and outcomes was published highlighting the excellent work done across the organisation. The trust was proud to highlight the research and innovation conference which was attended by nearly 100 attendees. The conference encouraged staff to take their first step on research and understand what research can mean for them.
Engagement with both staff and patients was evident and was seen to be fundamental to the way that the trust makes decisions, changes and manages the services. Peer support workers, experts by experience and clinical apprentices were not only valued in teams but part of them and strengthen the voice and the participation of the patients. The trust had invested in these patients and provided training and mentorship to them. Staff, patients and carers were actively involved in a number of different ways and the trust prioritised engagement at every level and through all services. Patients, families and carers were encouraged to provide feedback on the care they had received by a number of routes, for example, via focus groups, questionnaires and a variety of engagement events.
Staff across all services spoke highly of the executive team and chair without exception. We observed that the vision and values of the organisation were truly embedded throughout the trust and reflected in all aspects of care delivery; including service re design. The commitment to equality and diversity was exemplary. The equality strategy had been produced to clarify the intentions and obligations of the trust and to openly show their commitment to equality and diversity. We were told about several examples of how the views of the members of the networks and individuals were fully integrated into defining the tone and philosophy of the trust. Throughout the year the trust had held equality Conferences to raise awareness of equality areas, jointly with Lincolnshire NHS providers and internal staff networks. The trust was proud to share with us the progression of the multi-agency LGBT+ conference. Staff network groups provided a platform for staff to voice their opinions and support the trust to improve working practices and services.
Staff showed caring, compassionate attitudes, were proud to work for the trust, and were dedicated to their roles. We were impressed by the way all staff in the trust embraced and modelled the values. The values were embedded in the services we visited, and staff showed the values in their day-to-day work. Throughout the trust, staff treated patients and each other with kindness, dignity and respect. The style and nature of communication was kind, respectful and compassionate and met the needs of the individual patients. Staff showed strong therapeutic alliances with their patients and carers and clearly understood their needs and wishes. Staff offered guidance and caring reassurance in all therapeutic interventions, but they were in particularly inspiring and skilled when they supported patients that felt unwell or distressed, confused or agitated. Overall, positive feedback was received from those patients, families and carers spoken with about the care and treatment received from staff. Patients told us that they felt safe across the trust. The trust promoted a person-centred culture and staff involved patients and those close to them as partners in their care and treatment. Staff provided positive emotional support to patients.
The trust had robust systems and processes for managing patient safety. Staff recognised when incidents occurred and reported them appropriately. The board had oversight of incidents, and themes and trends were identified and acted upon. Managers investigated incidents appropriately and shared lessons learned with staff in a number of ways. When things went wrong, staff apologised and gave patients honest information and suitable support. The trust applied the duty of candour appropriately. We reviewed serious incident reports and found investigations were thorough and included participation from family and carers; where appropriate. Staff had training on how to recognise and report abuse and applied it. The trust had effective systems for identifying risks and planning to eliminate or reduce them. We were particularly impressed with the trust focus on reducing dormitories style accommodation in the inpatient services. The trust was committed to improving services by learning from when things go well and when they went wrong.
The management of risk and the use of data has significantly improved since our last inspection. Data was being turned into useful information for all levels of staff to use to inform practices. We were impressed with the trust decisive and swift move from a RAG rating system of reporting to a statistical process control technique. In addition, this they had also implemented NHS Improvement summary icons to indicate the type of variation seen on each reporting indicator. This proactive and positive change has enabled the board to focus on changes in performance which merit discussion and potential interventions required.
The board had listened to staffs’ feedback about the patients’ electronic record and invested in replacing the system. The new system went live in September 2018. The new system supported staff to maintain clear records of patients’ care and treatment and ensured patient confidentiality was maintained. Staff we spoke with were pleased with the new system and felt the trust had delivered quality training to support them to use it. Whilst they acknowledged that it was still early days using the system they had all noted that the system was a vast improvement and supported them in their day to day work. Care and treatment records were clear, up-to-date and available to all staff providing care. The trust provided care and treatment based on national guidance. Patients had access to psychological support and occupational therapy. The physical healthcare needs of all patients were met. Patients that were admitted to acute hospitals were supported by mental health and learning disability practitioners during their admission and throughout the discharge process.
Staff were compliant with mandatory training across all services and staff had opportunities for further training to support care and treatment for patients. Managers ensured staff received supervision and yearly appraisals.
The trust ensured safe staffing levels were maintained. Staffing levels and skill mix across all core services was planned and reviewed so that people who used services received safe care and treatment. Managers ensured services across the trust increased staffing based on clinical need or made arrangements to cover leave, sickness and absence.
Trust premises across all mental health and community teams were clean and well maintained. Across services staff had completed environmental risk assessments. Where issues had been identified, staff mitigated these risks by carrying out additional checks or had taken other actions to resolve the issues. The trust had robust estate management processes and ongoing plans for improvements.
The trust had a clear oversight and had promoted the importance of wellbeing amongst their workforce. The wellbeing service demonstrated the responsiveness of the organisation to support the wellbeing of staff. The service had a dedicated psychological and occupational therapy service which included a dedicated counsellor for staff experiencing domestic abuse. Staff we spoke with throughout the inspection spoke highly of the wellbeing service and acknowledged that the trust had worked hard to deliver a service that met the diverse needs of the staff that worked across the trust.
We were pleased that the trust had reviewed the appropriateness of the governance arrangements in relation to the Mental Health Act administration and compliance. They had recognised that this was a key area to strengthen to ensure the best possible outcomes for patients detained under the Mental Health Act. This review led to the implementation of a policy document and flowchart being devised and implemented in both clinical division and corporate teams to highlight the correct procedure for the administration of the Act. Heat maps were produced to identify to teams the proactive reading of patients’ rights, reviews of sections and the completeness of the detention paperwork. Audits for Mental Health Act and Community Treatment Orders were clearly documented.
Systems for the safe management and administration of medicine were in place. Incidents and errors within the trust were reported and investigated and outcomes and learning shared with staff. The pharmacy team were now involved in the reviewing of serious incidents when medicines were involved.

However:

The trust continued to have difficulties in recruiting substantive consultant and medical staff. It remained above the budget of medical agency expenditure to cover consultant vacancies.
The recording of staff supervision remained an issue. Whilst we recognise that, since the last inspection, the trust had taken action in order to promote staffs experience and compliance with supervision, the recording systems were not robust and did not capture staffs’ compliance with supervision. However, we note the compliance figures were on an upward trajectory and were confident that this would continue to increase.
In the near future they were going to be some very significant changes in the senior leadership team in the upcoming months. Whilst we acknowledge how this is being thought through, planned and managed over time, we have some concern that this could potentially be de-stabilising.

The summary for this service appears in the overall summary of this report.

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

Staff had not completed risk assessments consistently. Risk assessments were not all in date and varied in detail and format. Some staff were not aware of patient risk before seeing patients for the first time.
Staff did not complete or record mental capacity assessments consistently.
Trust data for compliance with supervision was unclear prior to January 2017, when the trust had introduced a new system to record this. Data showed variance in compliance between teams.
Staff did not consistently record physical healthcare needs and assessments in patient notes.
Staffing numbers in the south hub at Spalding were significantly under establishment due to long-term sickness and vacancies.
Alarms in clinic rooms in Lincoln were not operational and staff could not summon help quickly in an emergency.
Compliance with mandatory training did not meet the trust’s target. Training compliance for level three safeguarding children was 59%.
Staff did not engage in clinical audits.

However:

Multi-disciplinary team working was an integral part of all the teams and supported patients and staff effectively, through regular referral meetings and multi-disciplinary case discussions. Teams communicated effectively and understood their role.
There was rapid access to a psychiatrist when needed.
The teams had effective lone-working policies and followed them.
Staff monitored waiting lists and patients and their carers could contact staff if their condition deteriorated.
Staff reported incidents on the trust’s electronic recording system. Staff investigated incidents when necessary and lessons learned were shared within teams. Staff knew how to recognise abuse and make safeguarding referrals to the local authority.
Staff were passionate about getting the best possible outcome for the patients they worked with and about providing them with high quality care.
Staff knew their patients well and could demonstrate an understanding of their needs. Teams spoke about patients in a person centred way.
Staff encouraged patients and their families to feed back about the service and that feedback was very positive.

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.

We rated the trust overall as good because:

The trust had responded in a positive way to the improvements we asked them to make following their last inspection. Improvements in most core services were noted across the trust.
Patient care environments were clean, in good decorative order and appropriately furnished. Services had sufficient rooms for the safe care and treatment of patients, including private areas for patients to receive 1-1 support from staff or see visitors. All inpatient services had activities programmes for patients. There was access to activities over a seven day period. Each ward had timetables visible so that patients knew what was on offer. Patients could personalise their bedrooms and had lockable storage for their possessions. The trust was meeting Department of Health guidance for eliminating mixed sex accommodation.
The trust had made significant improvements to the external courtyards on the adult acute wards since our last inspection. For example, installation of closed circuit television and two way intercom systems and removal of ligature risks. Works were still on-going. In the inpatient ward for children and young people, innovative observation panels were fitted on bedroom doors, which had privacy frosting on them that was removed electronically when staff pressed a button.
The trust was opening a psychiatric intensive care unit for males in the summer of 2017 and had plans to provide a psychiatric high dependency unit provision for females.
The trust had reviewed its management of ligature risks within services. Staff were aware of the risks in their environments and ligature assessments were re-assessed regularly. On inpatient wards, staff had quick access to ‘heat maps’, specific to their area, to assist in the safe management of patients presenting with high risk of self harm or suicide.
Throughout the trust, staff treated patients with kindness, dignity and respect. Consistently, staff attitudes were helpful and understanding. Staff used kind and supportive language that patients would understand. Staff encouraged patients to give feedback about their care in a variety of ways. Information leaflets were available in easy read formats and we saw evidence of a variety of information available to patients, for example on how to access interpreters, make complaints, access to advocacy and Mental Health Act information.
The trust employed suitably qualified and experienced staff to deliver safe care and treatment to patients and provided them with training and development opportunities. The trust had supported healthcare support workers to undertake training to become registered nurses, provided a robust induction programme and supported clinical apprenticeship to encourage young people to seek employment with the organisation. The trust utilised a values based recruitment checklist during their interview process and revisited this during staff induction. The trust also operated a rewards and recognition system, including individual and team recognition, thank you cards, hero’s awards and annual awards ceremonies.
Managers ensured staffing levels across all core services were planned and regularly reviewed. The majority of services across the trust increased staffing based on clinical need and made arrangements to cover leave, sickness and absence. Local managers had authority to make these decisions. The trust employed bank or agency staff to fill vacancies. Where possible, managers ensured temporary staff were familiar with the patients and teams in which they worked. This ensured continuity of care for patients. Bank staff received appropriate training for their roles.
Staff received mandatory and role specific training. As at 31 March 2017, the overall compliance across all core services was 92%. Staff had access to additional specialist training, relevant to their role and medical staff had protected time for training and development.
Staff received an annual appraisal. As at 31 March 2017, 92% staff were compliant.
The trust reported a reduction in staff sickness rates. In December 2015, staff sickness was reported as 5.1%. In February 2017, this had reduced to 4.5% as a 12-month average.
The trust regularly reviewed caseloads for staff working in community teams. Where caseloads were high, staff were able to explain the rationale for this.
Crisis teams were meeting commissioned targets for contacting patients within four hours. As of February 2017, 99% of patients were contacted within this time. Crisis teams had good working relationships with the local Police
The trust had a robust governance structure in place to manage, review and give feedback from complaints. Staff consistently knew how to handle complaints, and managers investigated complaints promptly Patients and carers received timely responses and outcomes.
The trust had safeguarding policies and robust safeguarding reporting systems in place and described how they worked with partner agencies to protect vulnerable adults and children.
The trust used an electronic system for reporting incidents. Trust staff knew what incidents needed to be reported and how to report them. Managers monitored the reporting and recording of incidents. The trust had robust systems for sharing lessons learned from incidents. We saw evidence of compliance with duty of candour guidance related to investigations from serious incidents and complaints. Patients, families and carers were fully involved and informed throughout all processes. The trust board encouraged candour, openness and honesty from staff. Staff knew how to whistle-blow and staff felt able to raise concerns without fear of victimisation.
The trust had robust process to monitor the fitness of senior staff to work within the service, under the principles of fit and proper persons requirements.
Senior managers told us there had been much organisational change and transformation of care within the trust. Staff told us they accepted change and positively embraced the opportunity it provided. They felt supported by the board to work with change and felt able to provide feedback about their experiences. Overall, we found significant improvement to staff morale across most teams.
The trust had robust systems in place to manage the prescribing, storage and administration of medication. We found good working practices between the pharmacy team and staff across all services.
Overall, we saw good multidisciplinary working and generally patients’ needs, including physical health needs, were assessed and care and treatment was planned to meet them.
Staff had a process in place to submit concerns and issues to the local risk registers which fed in to the trust wide risk register where appropriate.

However:

Whilst there had been significant progress since the last inspection in 2015, the trust had not fully addressed all our previous concerns.
The trust could not always provide a bed locally for patients who required admission to adult acute mental health beds. This meant that patients often received care and treatment outside of the trust. Between March 2016 and March 2017, there were 306 out of area placements from the trust to other providers of acute adult inpatient care. The trust did not have psychiatric intensive care unit (PICU) beds. Therefore, if a PICU bed was required, patients were placed out of area. Between February 2016 and February 2017, 63 patients were transferred to other providers when intensive care was required.
Bed occupancy rates were above 100% on the adult acute wards. We saw that patient numbers exceeded the number of beds available on wards. Therefore, there were no beds available if patients returned from leave.
The majority of beds within the adult acute admission wards were located in bays sleeping either four or five patients. These areas offered limited space and privacy.
Within the forensic inpatient secure ward we found patients did not have free access to the garden. This was a blanket restriction. We were also concerned about the safety of the security fencing in the garden area. We raised this with the trust who made immediate plans to have this replaced.
In the inpatient ward for children and young people, most doors on the ward were locked, this included bedrooms, toilets and bathrooms, dining room, the female only lounge and doors to the garden. There was no clinical justification for this practice and it was not individually care planned. This was a blanket restriction. We raised these concerns with senior managers and when we returned on 20 April, the trust had taken action to ensure patients were provided with wrist bands, programmed to allow access to specified areas.
The trust had identified they need to take further actions to ensure the health based place of safety fully met the Royal College of Psychiatrist standards.
Not all patients had timely access to psychological therapies as recommended by the National Institute for Health and Care Excellence.
Information from April 2016 to March 2017 showed 242 patients were discharged from the health based place of safety within 72 hours. On 127 occasions, staff had not completed the patient’s discharge time on records.
The trust provided data for staff compliance with clinical supervision; however, this showed significant variance in compliance across teams. The trust told us they had introduced a new method of recording supervision, which was not yet fully embedded. Clinical and managerial supervision data was not collected separately. However, data provided showed overall compliance with clinical supervision across all core services ranged from 7% in October 2016 to 88% in March 2017, with an overall average compliance across all core services of 48%, against the trust target of 95%. From data provided and on site findings, we were unable to determine how supervision was delivered, for example how often staff received one to one support, or whether managerial supervision was provided in accordance with the trust policy. It was equally unclear how outcomes from staff supervision were reviewed or acted upon. We were not, therefore, assured the trust had clear oversight of compliance with management supervision. The trust could not be sure that all performance issues, training requirements or professional development had been identified for staff working in the service.
Not all staff had completed mandatory training in line with the trust target. For example, on the acute wards for adults only 58% of staff had completed safeguarding children level 3 training. We were concerned that only 63% of staff were compliant with basic life support training, meaning they might not have the required or up to date skills to support patients in an emergency. Equally, only 61% had completed conflict resolution (restraint) training, meaning they might not have the required or up to date skills to safely manage patients requiring physical interventions.
The trust policy on the management of violence and aggression did not contain guidance from the Mental Capacity Act relating to the use of prone restraint and did not reference up to date National Institute for Health and Care Excellence guidelines. We found an increase since our last inspection in both incidents of restraint and the use of prone (face down) restraint.
We found some errors on community treatment order paperwork. Seclusion paperwork did not always meet the guidance in the Mental Health Act Code of Practice and medical assessments were not always fully completed or recorded. Staff did not complete seclusion care plans for patients nursed in seclusion on the adult acute wards.

We rated child and adolescent mental health wards as good because:

The ward was clean, tidy and well maintained. Observation mirrors and closed circuit television was used to assist nursing staff with observations.
The ward had an up to date ligature risk audit, staff mitigated the risk on the ward by observing patients. Staff mitigated the risks posed in the garden area by accompanying patients when they wanted to access the garden.
The ward had sufficient staff to provide good care and treatment to patients.
The ward met the criteria for eliminated mixed sex accommodation in line with guidance contained in the Mental Health Act code of practice.
Staff were 98% compliant for mandatory training.
Staff undertook a risk assessment with every patient upon admission. Care plans were comprehensive, personalised, holistic, and recovery orientated.
Staff provided a range of therapeutic interventions in line with the National Institute for Health and Care Excellence guidelines and there was a full education programme in place.
Staff read detained patients their rights on admission and regularly thereafter. Staff gave patients an information leaflet explaining their rights and responsibilities as an informal patient.
Overall, 100% of non-medical staff had an up to date appraisal.
There was a well-functioning multidisciplinary team. Staff discussed patients’ care and treatment weekly in ward round. Parents told us that they felt involved in the care and treatment.
Patients told us that they felt supported to make their own decisions and staff treated them with dignity and respect. Patients said they were involved in their care plan.
Staff interacted with patients in a positive way. All staff demonstrated a good understanding of patients’ individual needs, including care plans, observations and risks.
The ward had a range of rooms and equipment to support treatment and care. There was a large garden; with an area that had been made secure. Patients could personalise their bedrooms and could choose from a choice of bedding.
There was a family room for parents, carers and siblings to visit. Visits within the community and the garden area were also encouraged.
There was access to activity across the week with primarily nurse led sessions over the weekend. Patients worked with the activity coordinator to plan activities that they would like to do.
All staff demonstrated the trust values in their behaviour and attitude. Staff we spoke with were passionate about helping patients with mental illness. Staff were proud of the work that they carried out and the care that they provided to patients.
Managers told us they had sufficient authority to complete their role and they felt supported by senior managers.

However:

Staff kept most doors on the ward locked. There was no clinical justification for this practice and it was not individually care planned. This was a blanket restriction.
Seventy-one per cent of staff had undertaken training in clinical risk assessment and management. This was below the trust target of 95%.

We rated Lincolnshire Partnership NHS Foundation Trust specialist community mental health services for children and patients as outstanding because:

Patients and carers told us that everyone was caring, compassionate, kind and treated them in a respectful manner. All feedback surveys collected by the trust were consistently positive about the way that staff treated patients.
The service had established an innovative model of working using outcome measures at each appointment. This model was patient centred and holistic based around the child or young persons’ strengths and goals.
Staff were open and transparent in relation to incidents and complaints. They acted on lesson learnt from incidents and complaints. They strived to continually improve the service they delivered by working closely with commissioners and other stakeholders.
Managers and senior staff including board members were visible and approachable. Staff expressed they felt able to raise concerns without fear of reprisal. The managers and team co-ordinators were passionate about delivering high quality care and treatment and had funded 17 clinicians to undertake children and young people’s improving access to psychological therapies training. They had managed to recruit to the 17 vacancies with substantive posts therefore increasing the level of staffing within the service.
Risk assessments and care plans were comprehensive and well written. They were developed in collaboration with the patient and, where appropriate, their carers. Staff were able to refer patients to the crisis and home treatment and resolution service within CAMHS if they were concerned about a young person’s presentation out of hours and at weekends. This service had been praised highly by senior staff at the local hospitals in relation to the responsiveness of the team Communication between the teams was excellent.
The service had introduced an animal assisted therapy service to group work for patients.

However:

Only 68% of staff had undertaken the children’s safeguarding training level 3B.This was below the trust target of 95%.
Staff supervision rates were lower than the trust expectations and managers did not always keep a record of supervision sessions.

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

The trust had taken actions to improve the environment of the health based place of safety and to increase the range of multi-disciplinary staff in crisis teams following our last inspection.
Staff completed risk assessments for all patients and updated them as the level of risk changed.
Many patients felt their mental health had improved as a result of the service they received from the crisis and home treatment teams.
The trust took action to address the changes to the Policing and Crime Act 2017 and had identified inpatient beds to ensure patients were not kept longer in the health based place of safety than needed.
Managers reviewed discharge processes for inpatients to ensure they did not remain in hospital longer than was needed. For example, they reviewed the use of the crisis house, improved communication with discharge coordinators and bed managers.
The trust arranged crisis team support based out of hours with the police to signpost patients to mental health services.
The trust met commissioned targets for contacting patients within four hours.
The trust had plans to develop a clinical decisions unit in 2018 to further support patients in crisis needing hospital admission.
Grantham crisis and home treatment team had achieved the Royal College of Psychiatrists home treatment accreditation scheme.

However

The trust had not ensured that staff regularly received clinical and managerial supervision.
Patients and carers did not have copies of their care plans explaining the support teams would give them.
Staff did not consistently document that they had assessed patients’ physical health care needs.
Crisis team staff said that patients could wait for hours to be transferred to out of area placements due to delays with the contacted transport service being able to respond and escort them.
Crisis teams did not include psychologists which meant assessments of patients at the point of crisis were not fully multi-disciplinary.
Staff morale in Louth was lower than other teams because of increased work due to the community mental health teams and difficulty accessing medical cover.
The trust had not ensured that all staff completed mandatory training for their role.
Trust information from April 2016 to March 2017 showed staff had not completed the patient’s discharge time on records on 127 occasions.

Ligature points (places to which patients intent on self-harm might tie something to strangle themselves) were identified as part of the monthly environmental risk assessment audit and actions had been identified to reduce the risk to patients. These included enhanced observation levels. Wards complied with the Department of Health’s eliminating mixed sex accommodation guidance, which meant that the privacy and dignity of patients was upheld.
Cleaning rotas had been completed and the wards were visibly clean and tidy. Nurse call systems were in place in bedrooms, communal and office areas.
Staffing levels were appropriate to meet the needs of patients. There were low levels of both qualified and unqualified nursing vacancies. Ward managers were able to adjust staffing levels to take account of clinical need and said senior managers never refused a request for additional staffing if required. Escorted leave and activities were rarely cancelled due to staff shortages.
Staff followed National Institute for Health and Care Excellence (NICE) guidelines in relation to practice and when prescribing medications. These included regular reviews and physical health monitoring. Patients were supported to access specialists when required for physical healthcare needs. Hydration and nutrition were monitored regularly and recorded in care records.
Staff and patients interacted well. Staff managed distressed patients in a calm and responsive way and supported them to talk about the issues affecting them. Staff knew the patients very well and were passionate about patients' needs. Patients told us that they had good relationships with staff and they were very helpful, understood their problems and were always available. They said they felt safe and that staff took the time to listen to them when they had a problem.
Hot drinks and snacks were available on request 24 hours a day. Patients were able to personalise their bedrooms.
Staff told us who the most senior managers in the trust were and that they had visited the wards. Ward managers told us they felt well supported by their line managers.

However:

Staff did not always review risk assessments following incidents.
There was limited access to psychological therapies. The service had one whole time consultant psychologist and one whole time assistant psychologist for both community and inpatient older adult services.
Trust data showed supervision rates across the service between January 2017 and March 2017 to be 66%. The trust could not be assured that performance issues and training needs were identified or acted upon.
Capacity assessments were not decision specific, forms included more than one question.
One patient was receiving covert medication, we did not find a capacity assessment form for this.
There was little evidence of patient participation in care plans and risk assessments. Four patients reported that they had not seen or been provided with a copy of their care plan.
Patients had a lockable drawer in their bedroom; however keys were not available for patients to lock the drawer.

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

All patient information was stored electronically and was accessible to staff.
The service followed National Institute for Health and Care and Excellence (NICE) guidance in prescribing medication and reviewing patients who had dementia.
Patients were consistently positive about the centres and about the staff, patients felt understood and cared for.
Patients told us that they felt involved in their care planning and that they had been offered a copy of their care plan.
Staff were able to prioritise and see urgent referrals quickly.
There was a safeguarding champion available to support staff with safeguarding concerns and safeguarding posters were displayed in the reception areas at each of the locations.
Staff learned from incidents, complaints and patient feedback via the bi monthly lessons learned bulletin, at team meetings and during supervision. We saw examples of lessons learned and changes in practice as a result of this.
Leaflets were available in different languages and information was available in different formats on request.
Staff were passionate about their jobs and used the trusts’ vision and values in their everyday work.
Senior managers were visible and known to staff. They visited the locations to update staff on changes within the service and the trust.
Sickness and absence rates were low and clear strategies were in place to cover any staffing shortfalls.

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

Bed occupancy rates were over 100%. Staff were using leave beds frequently to accommodate new admissions. There were a number of identified delayed discharges across the service. There were high numbers of patients in out of area beds at the time of inspection. There were 32 re-admissions to hospital within 28 days of being discharged, with half of all patients returning to the same ward they were discharged from. Fifty-five per cent of patients did not have discharge care plans in place.
Sleeping areas consisted mostly of bays sleeping four or five patients. These areas offered limited space and privacy.
Staff did not always assess or monitor the physical health of the patients. They did not always have a care plan in place for patients who had identified physical health problems. Staff did not always follow National Institute for Health and Care Excellence guidelines or trust protocol around the administration of rapid tranquillisation.
Detained patients accessed leave without qualified staff having completed a risk assessment immediately prior to leaving the building.
Staffing levels at weekends were lower than in the week. This affected staff capacity to escort patients who had leave.
There had been an increase in the use of restraint and prone restraint across this service, since the last inspection.
Compliance with mandatory training was below the trust’s own target, and some compliance fell below 75%.
There was absence of care plans for patients being nursed, or had been nursed in seclusion across the service. We reviewed 18 records of seclusion. No patients had a care plan in place to reflect they were being nursed by staff in seclusion
Clinical staff did not receive regular supervision.
Not all staff had received an annual appraisal.

However:

Ligature assessments were robust and management plans were in place to manage risk.
Clinic rooms were well equipped. Nursing staff checked emergency medications and equipment regularly.
There were no blanket restrictions across the service. Any restrictions were individually risk assessed.
Staff had a good knowledge of what constituted a safeguarding concern and the reporting process.
Staff were trained to use restraint as a last resort. Staff used verbal de-escalation before resorting to physical contact.
Doctors completed an initial physical health assessment for all new admissions where possible. If the patient declined, staff recorded this and attempted again at the earliest opportunity.
The trust provided additional training for staff development to enhance their roles.
There was good access to advocacy services, which was utilised by patients.
There was appropriate involvement of families and carers.

We rated Long stay/r ehabilitation on mental health wards for working age adults as good because:

All wards had detailed ligature risk assessments. Staff knew where the risks were and how they should manage them. Patients said they felt safe on the ward.
The majority (94%) of staff had received training in safeguarding adults and were able to identify what abuse was.

We looked at 15 patient records. The multidisciplinary staff team completed thorough, detailed assessments prior to and on admission. Staff updated these regularly.
We saw staff treating patients with kindness and understanding.

There were programmes of activities, both on and off the wards, with weekly plans for each patient. The service offered a programme of paid work opportunities for patients. These included jobs as a gardener and car valet. There was a patient run café at Discovery House. The café had recently employed a previous patient in a contracted paid role.

Patients had access to independent mental health advocates. There were posters displaying this information on noticeboards in the ward. Staff asked all patients if they would like to be referred to the advocacy service.

Staff were able to describe how they would apply the principles of the Mental Capacity Act in their roles. Patients had decision specific capacity assessments in their care records.

Ten patients said they were aware of how to make a complaint and would be able to do so if they felt they needed to.
Staff used a range of tools to measure patient outcomes. These included the recovery star, depression ratings, clustering and national early warning scores.
Morale within all teams was high. Staff worked well together within a multi-disciplinary approach.
Managers carried out audits of their ward performance, care records and safeguarding.
The service had participated in the Accreditation for Inpatient Mental Health Service (AIMS). All wards had been accredited as excellent up to October 2017 when the review was due.

However:

At the time of our visit, Vale ward reported a vacancy rate for qualified staff of 15%. The manager advised she had raised this as a risk issue and had put forward a proposal to block book regular agency staff to keep staffing levels safe.
Staff raised concerns at Maple Lodge about medical cover not being sufficient.
Supervision rates were slightly below the trust target of eight supervisions a year in two of the five wards.
On two wards food fridge temperatures were above the acceptable range.

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

Care plans were not always personalised, holistic or recovery focussed.
Regular medication reviews and physical healthcare monitoring for patients did not take place consistently.
The trust did not use any formal outcome measures to assess patient progress.
Individual patient’s risk assessments were not reviewed consistently.
We identified errors and omissions in Community Treatment Orders and this documentation was not fully audited by the trust.
The service did not have an effective governance system. The balanced scorecard used to gauge the performance of the team was inaccurate and not shared with front line staff.
Managers did not have an effective audit system in place to audit Mental Health Act paperwork.
The trust had not proactively addressed the long waits for psychological therapies by some patients.
There was no local risk register.

However:

All teams had safe staffing levels, and ensured sufficient care co-ordination time for all patients.
Patients had a thorough risk assessment completed at their initial assessment.
Teams had good multi-disciplinary and interagency working, with close links to other teams within the trust and the local community.
Local leadership was effective within teams. Staff felt supported and received supervision and appraisal in line with trust policy.

We rated forensic inpatient/ secure units as good overall because:

Francis Willis was a slightly dated but pleasant environment. There were clear lines of sight throughout the ward. The trust has completed detailed ligature risk assessments and plans were in place to appropriately manage these risks within the unit.
The defibrillator and essential safety equipment had been serviced and regular checks were undertaken.
There was sufficient staffing during weekdays and the unit had medical support at all times. Staff had undertaken mandatory training and received regular supervision and appraisal
Nursing staff on the wards were enthusiastic in their approach and patients spoke positively about them. The clinical team contained full multi-disciplinary representation.
All admissions were planned following pre admission assessments. Local risk assessments were also carried out after admission. Patient care plans were personalised and based around the individualised risk.
All patients had their physical healthcare needs met and there was an effective health care recording system
Leadership on the unit was highly visible and managers had a positive presence on the ward.
Areas of concern highlighted following our previous inspection had been addressed.

However:
We remain concerned about the safety of the garden area of the ward. This contained potential ligature points and additional safety risks that had not been addressed through environmental risk management plans. Staff managed these risks through restricting patient access.
We found some other examples of blanket restrictions. These included access to mobile phones and set vaping times.
While patients had a good level of activity and escorted leave during weekdays there were limited activities available at weekend.

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.

We rated Lincolnshire Partnership NHS Foundation Trust as Requires Improvement overall because:

Not all services were safe or effective and the board needs to take action to address areas of improvement.
Some of the wards did not provide an environment that was safe or that preserved patients’ dignity or privacy. The layout of some wards and ward garden areas meant that staff could not easily observe patients who might be at risk. We were concerned about the design of the place of safety and seclusion facilities at some units. Some wards had fixtures and fittings that people at risk of suicide could use as a ligature anchor point; the trust had not addressed these risks adequately. Not all wards met the requirements of single sex accommodation guidance or the Mental Health Act (MHA) code of practice. Some seclusion rooms and dormitory areas did not promote privacy and dignity.
Restrictive practices that amounted to seclusion were not reported or safeguarded appropriately.
Staff on the acute, forensic and child and adolescent wards imposed blanket restrictions that were not based on an assessment of the risks of individual patients.
Some wards in the rehabilitation, forensic and children’s mental health services had too few staff on duty at times to keep patients safe and others relied heavily on the use of bank and agency staff.
Staff were not always receiving supervision in line with the trust policy.
We were concerned that information management systems did not always ensure the safe management of people’s risks and needs.
Access arrangements needed improvement. There was a lack of availability of acute beds. There were delays for assessment from community adult teams and there was limited access to psychological therapy.
While performance improvement tools and governance structures were in place these had not always brought about improvement to practices.
While the board and senior management had a vision with strategic objectives in place, morale was found to be poor in some areas, particularly community teams, and some staff told us that they did not feel engaged by the trust.

However:

Staff showed us that they wanted to provide high quality care, despite the challenges of staffing levels and some poor ward environments. We observed some very positive examples of staff providing emotional support to people.
Services were clean with good infection control practices.
There had been significant work on reducing restrictive intervention.
Procedures for incident management and safeguarding where in place and well used. The trust was meetings its obligations under Duty of Candour regulations.
The trust had participated in a range of patient outcome audits, research and accreditation schemes.
The trust had an involvement policy which set out the trust’s commitment to working in partnership with service users. The trust told us about a number of initiatives to engage more effectively with users and carers.
Complaint information was available for patients and staff had a good knowledge of the complaints process.
Overall we saw good multidisciplinary working and generally people’s needs, including physical health needs, were assessed and care and treatment was planned to meet them.

We rated Lincolnshire Partnership NHS Foundation Trust child and adolescent mental health wards as requires improvement because:

We were concerned about the physical environment of Ash Villa. The unit was noncompliant with same sex accommodation guidance and no action had been taken by the trust to address this, despite being aware of the issue for at least two years. The trust had not addressed known ligature points in the unit or made the garden area safe and fit for purpose, despite identifying that it was not suitable for the young people. The ligature audits and environmental risk assessments undertaken by the service had failed to identify significant risks. These included ligature points, a large number of issues in an unsafe garden area, blind spots in the building and electrical plant equipment in the clinic room.

Staffing levels were low and potentially unsafe, particularly at night.

The governance systems were not robust. Where risks were identified by the trust they were not always addressed, in particular the lack of compliance with the same sex guidance and the isolation of the unit at night.

There was no clear strategic leadership for the service. Senior staff within the unit did not meet to discuss issues affecting the service.

However:

Ash Villa had a committed and effective clinical team which cared for the young people.
The service was effective, with young people using the service achieving good outcomes.
Staff were skilled in de-escalation with low levels of restraint.

Staff were caring, positive and enthusiastic, with a focussed patient orientated approach.

The service was innovative in its use of a discharge liaison nurse and a ward therapy dog.

We gave an overall rating for mental health crisis services and health-based places of safety as requires improvement because:

Environmental risks in the health based place of safety (HBPoS) identified in our previous monitoring visit and S136 in May 2015 remained. The room was small and only had one door which created a risk that staff would not be able to exit the area quickly if needed. Staff were not able to maintain line of sight observation in all areas. The furniture in the suite was not weighted. This meant that it could be picked up and thrown or used as a barricade. There was nowhere for professionals to talk privately. A new HBPoS was being built to address these concerns at the time of this inspection.
Some staff we spoke with were mistaken about the point of time that a person was detained under S136 and we observed this in one of the S136 records reviewed. This could result in an incorrect calculation of the period of detention and time the S136 would expire. We raised this as an area for improvement in our previous monitoring visit.
Staff working in the HBPoS had access to resuscitation equipment, but only 50% had had training in immediate life support.
People detained under S136 were usually, instead of exceptionally as set out in the MHA Code of Practice, transported to the HBPoS by police rather than by ambulance.
There was no medicine storage in the HBPoS. Medicines were being stored at 26 degrees celsius in the Boston crisis resolution team which is above the recommended temperature for safe storage of medicines.
The crisis resolution teams in Louth and Lincoln did not always have rapid access to a psychiatrist when required.
The crisis resolution teams did not include or have access to the full range of mental health professional backgrounds. There was no occupational therapist or psychologist in any of the teams. There was no social worker in Grantham, Louth or Boston crisis resolution teams.
Waiting lists for treatment in the integrated care teams, and the lack of a care pathway for people with a personality disorder, had led to the crisis teams experiencing difficulties in discharging people who were ready to move on to other mental health services.
There was no mental health crisis helpline available.
Personal safety protocols, including lone working practice, were in place. However, staff often undertook initial assessments alone. Some staff said that they felt unsafe at times and that mobile phone coverage was poor in some areas.
Staff morale was generally low. Some staff did not feel supported by senior managers and said their concerns were not being addressed.
Unqualified staff in the single point of access had not had access to specialist training for their role.

However:

The trust had set safe staffing levels and these were followed in practice.
Dedicated staffing was in place for the HBPoS.
Staff undertook risk assessments at initial assessment and updated these regularly.
Staff completed comprehensive assessments and reviewed these in a timely manner. Interventions included support for housing, employment and benefits. Staff considered people’s physical health needs and discussed these at the point of assessment.
People who used the service were very positive about how staff behaved towards them. Many felt their mental health had improved as a result of the service they received.
Urgent referrals were seen quickly by skilled professionals. Staff took proactive steps to engage with people who found it difficult or were reluctant to engage with mental health services.
The introduction of street triage had improved access to services for people with a mental health crisis.
There was effective team working and staff felt supported by this.

We rated Lincolnshire Partnership Foundation NHS Trust community mental health services for people with learning disability or autism as good because:

Risk assessments were completed, with patients being encouraged to identify their own risk management plans.
Staffing levels were good within the service. Patients had regular access to staff for support.
Staff received regular supervision and appraisal from the management team. The team had a variety of skills, experience and professional training. Patients were able to access support from people with a variety of skills and expertise.
Staff were passionate and enthusiastic about the difference they could make to service users and carers lives.
There were good working relationships with other agencies, such as social services.
The service offered appointments to patients at a variety of different times and locations to facilitate attendance at appointments.
Service user feedback forms showed multiple positive comments.
Complaints had been investigated and acted upon quickly and there were good systems in place to share learning from complaints throughout the service.
All of the Learning Disability Community Mental Health Team bases had adequate clinic rooms, and, or interview rooms and most areas were clean and well maintained.

However:

There were two electronic record systems in operation within the community learning disability teams that did not interface with each other. Important information could be missed.
Care plan wording was not recovery focussed.
The speech and language therapy service was struggling to meet its referral to assessment targets of two weeks for urgent referrals and 18 weeks for routine referrals. There were 53 patients on the waiting list, five of whom had breached the 18 week target. The service was only able to offer urgent dysphagia assessment two days per week.
Some community services did not display easy to read documentation for patients with a learning disability.

We rated this core service as ‘good’ because:

Staff told us they received regular supervision and appraisal.We saw schedules in place, and staff told us that managers were always available to advise and support.
There was a high level of morale and job satisfaction in all the teams. Staff throughout the services were positive about the trust, their work and their local management
The teams engaged with people who found it difficult to engage with the services. Two people would visit where risk assessments showed this was beneficial. Visits were able to be arranged outside of the home, if a person wished for this.
All teams had a duty system that was able to respond to urgent referrals and had good access to psychiatrists in emergencies.Patients we spoke to said they could access help urgently when required.
The services were committed to ensuring patients had the opportunity to feed back about their care and treatment. The older adult community teams use the “Making Experiences Count” patient feed-back questionnaire. This is being used across all of the older adult community Teams and the services have a high level of returns in terms of overall Trust numbers.
We observed staff to be respectful, responsive and supportive of patients needs.
Each team had an allocated “neighbourhood team” member whose responsibility was to attend the Lincolnshire health and care“neighbourhood meeting”.This initiative has been developed with the support of the local Clinical Commissioning Groups to help support older adults living in the community and is aimed at promoting independence.
Staff demonstrated a good understanding of safeguarding and the processes for reporting were clearly displayed in each of the services.
Staff told us they received feedback from investigations, and were debriefed following incidents.

However:

The trust had identified on the older adult risk register in 2013, excessive service and staff caseload size within the older adult’s CMHT. Since then there have been progressive attempts to reduce the case load for nurses and band 4 workers throughout 2014 and 2015. However, their caseloads remained high at the time of the inspection. This added an additional pressure to their ability to care for the patients.
On reviewing care records, we found that staff had not completed risk assessments for all patients.

Staff did not always up date all patients care plans and regular reviews were not always taking place.
Staff did not always document patients’ mental capacity. It was unclear whether staff assessed patients capacity when needed or if they just did not record the assessment of capacity.
The older adult community teams only had access to one psychologist across the six teams. Staff told us there was a 12-18 month waiting list for access to psychological therapies.

We were told by staff, patients and carers that none of the older persons community teams were currently running patient or carers support groups.
Key Performance Indicators were not used by the trust to measure the performance of older persons teams.

We rated Lincolnshire Partnership NHS Foundation Trust specialist community mental health services for children and young people as outstanding because:

Young people and carers told us that everyone was caring, friendly, compassionate and positive with them. All feedback including surveys collected by the trust was consistently positive about the way staff treat people. Other agencies said that there was a visible child centred culture within the teams. Staff consistently worked to empower young people to have a voice in their care.

Staff were positive and enthusiastic about their roles in the service. Staff were committed to the young people and demonstrated an in-depth knowledge of their circumstances and empathy. All staff, both clinical and non-clinical, displayed a passion to meet young people’s needs.Morale in the service was very high with low sickness and vacancy rates.

Managers and leaders were passionate about the service, their staff and the care of young people.They were respected and appreciated by staff who said they were very supportive. There was good development and support for managers and future leaders were identified and nurtured.

The service was actively involved in research and developing areas of best practice. Staff within the trust had developed “outcomes oriented child and adolescent mental health service”. This evidence based model focussed on the outcomes for young people and had been recognised in NHS innovation awards. This demonstrated clear positive outcomes for young people using the service. Other CAMHS services were adopting this model.

Access times were short for young people with mental health problems. There was good crisis provision with plans to expand this into home treatment assertive outreach teams.

Incidents and complaints were well managed with good duty of candour.There was clear learning and actions taken.

Psychological therapies in line with NICE guidance were evident including consideration of appropriate interventions when reviewing referrals. There were comprehensive clear treatment pathways in both services. There was innovation in how to meet individual young people’s needs with the service being responsive and creating new interventions tailored to them.

Comprehensive assessments were completed and care records, were up to date, considered the young person’s needs with clear recovery-orientated care plans. Risk assessments were of a good standard with very good crisis plans.

Other agencies described excellent relationships and partnership working.Social workers and school staff described good outcomes for young people who had used the service.

However:

Young people with learning disabilities in Lincolnshire had delays of up to eight months in accessing a service.

Staff and managers in Lincolnshire felt disconnected and uncertain about the service redesign and more could be done to communicate the changes and vision to them by the trust and commissioners.

Safeguarding training compliance was lower than expected due to the trust using local authority safeguarding board training in line with recommended practice. The safeguarding board was not providing sufficient training to meet the service’s needs. Despite this staff displayed excellent safeguarding knowledge.

We rated this core service overall as ‘requires improvement’ because:

Staff vacancies and sickness impacted on their ability to deliver a service.
Some risk assessments and care plans were basic and review dates were not always recorded.
Some health and safety checks were not always completed.
The ICMHTs had not been routinely involved in the development serious investigation action plans and staff had difficulty relating the learning from incidents to their work.
Records did not show that patients received regular physical healthcare examinations.
Teams were not always meeting trust targets for staff training, supervision and appraisals.
Records did not show that patients had their rights regularly explained to them when subject to a community treatment order.
There were delays with staff providing timely patient assessments and treatment.
Staff told us they had not received adequate communication from the trust regarding restructuring and changes to the service.
Staff were not aware of any action plans to address areas of poor performance identified following a national Care Quality Commission CMHT survey.

However:

Staff were aware of their individual responsibility in identifying any safeguarding concerns.
We observed effective patient assessments and reviews, with staff gaining the patients’ history, current needs and risks.
Staff treated patients with respect.
Patients and carers told us that staff supported them with their individual needs.
Staff were proud of their work with patients, despite the challenges they had with staffing resources.
Teams prioritised urgent referrals and worked closely with crisis teams.
A ‘heat map’ and identified service risks.
Teams had staff champions leading on specific areas to improve the quality of service.
Staff told us their line managers were approachable and supportive.

We rated inpatient rehabilitation wards as requires improvement overall because:

We had serious concerns about leadership and safety.
There were a number of environmental safety concerns. All services contained ligatures risks, some of which had not been identified or managed. Not all wards met the requirements of single sex accommodation guidance or the Mental Health Act code of practice.
Staff did not always complete formalised multi-disciplinary admission assessments prior to patients’ admission to highlight risks. Not all clinical risk assessments and care plans had been undertaken or reviewed meaning patients risks and needs were not always known or addressed.
All rehabilitation services had low staffing, particularly at night. We were concerned that there was insufficient staff to safely manage the service in emergency situations.
Not all teams were multidisciplinary. Some services had minimal psychological therapies for patients and occupational therapy input. Medical cover was not sufficient.
Not all services undertook audits to evaluate the outcomes of any of the interventions used on the ward.
We found that while governance structures were in place these had not always brought about improvement to practices.
Morale was found to be poor in some areas and some staff told us that they did not feel engaged by the trust.

However:

Patients told us that staff treated them well and with respect. Staff were observed to be supporting patients appropriately.
The wards were clean and each patient had their own bedroom. The furnishings were of good quality.
Procedures for incident management and safeguarding where in place and well used.
Complaint information was available for patients and staff had a good knowledge of the complaints process.

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

Patient safety and dignity was compromised. Langworth ward did not meet the Department of Health guidance and Mental Health Act 1983 Code of Practice in relation to the arrangements for mixed sex accommodation. Brant ward and Rochford unit dormitories lacked privacy and dignity, with some beds separated by curtains. This did not provide privacy and dignity.
We found some ligature risks withinBrant ward, which were not effectively managed. Rochford ward had limited outdoor space and was located on the first floor by a stair case or lift.
Langworth and Brant wards, and Manthorpe ward were covered by CCTV in communal areas, but patients, carers and their relatives were not informed of this.
Some wards had what were described as comfort rooms. Patients were cared for away from others and could not leave the room. These rooms appeared to be used for the purposes of seclusion.When patients used the comfort rooms for de-escalation these incidents were recorded on an electronic recording system. We sampled these records on Langworth ward and found staff had difficulty locating and tracking these incidents. There were gaps in recording. This meant risks for individual patients with challenging behaviour using the comfort room was not well managed.
There was a heavy reliance on agency staff on Langworth, Brant and Manthorpe wards.
Medication was not managed effectively on Manthorpe ward and Rochford Unit. We found errors when we looked at medication records and a wound swab was found in the drugs fridge. Staff had not accurately recorded in medicines charts for patients being discharged. Staff did not know how to obtain medicines if they did not stock them.
Access to nurse call systems was limited in the dormitories on Brant ward. One nurse call bell was shared between four patients and was not easy to locate. This meant patients would not find them accessible in an emergency.
Staff were unable to access safeguarding or dementia awareness training at the time of the inspection. Staff told us this was booked up until 31 March 2016. This service provides care, treatment and support for older people with dementia and other health difficulties. The trust had not identified this training need. Training figures showed that 87% staff had attended adult safeguarding training over the past year.
Shift working patterns impacted on staff capacity to attend team meetings and undertake training. Staff told us that working a 12 hour shift impacted on their wellbeing.
Patient discharges were delayed because of limited places to move patients on to.
The multidisciplinary team meetings on Rochford unit were often short and did not allow sufficient time for full discussions of patients’ needs.
Patients were unable to make phone calls in private in the Manthorpe centre. There was no payphone at the Manthorpe centre and patients would ask staff to use the office phone.
Two patients from Langworth ward and the Rochford unit did not receive required follow up for eye care.
Staff did not respond with meaningful feedback from community meetings on Brant ward.
Staff felt a disconnect with the senior management team. Staff told us that senior managers within the trust had not visited the wards.

However:

The service employed sufficient numbers of staff. There was a good ratio of qualified staff to unqualified staff.
Clinical areas and ward environments were clean and hygienic.
We reviewed 13 care records and found comprehensive assessments. Care plans were holistic with evidence of patient involvement. There were effective physical health care assessments with good access to health screening and follow ups.
Staff responded to patient needs, showing discretion and respect.
A weekly timetable of on-site occupational activities was provided by a range of therapists, occupational therapists and activity coordinators.
Carers and family members were regularly invited in for special events with patients.
Effective and appropriate signage on wards provided information to patients in a way they could understand.
Staff felt supported to raise concerns without fear of victimisation and told us that morale and job satisfaction was good.
Staff were provided with opportunities for leadership training at ward management level.
Ward managers had sufficient authority to run the ward and administration support to help them.
Staff sickness and absence rates were low on the Rochford unit. We saw a positive working culture within this team.

We rated forensic inpatient/secure units as good overall because:

Francis Willis was a slightly dated but pleasant environment to live and work in.
There were clear lines of sight throughout the ward.
Nursing staff on the wards were enthusiastic in their approach and patients spoke positively about them.
All admissions were planned following pre admission assessments. Local risk assessments were also carried out after admission. The Historical Clinical Risk management (HCR-20) tool was used. These were completed and reviewed appropriately.
All patients had their physical healthcare needs met and there was an effective health care recording system
Leadership on the wards was highly visible and managers had a positive presence on the ward.
The clinical team contained full multi-disciplinary representation.

However:

We were concerned about the safety of the garden area of the ward. This contained potential ligature points that had not been identified through environmental risk audits.
The defibrillator had not serviced for 20 months. This had not been picked up through equipment audits.
Staff and patients felt unsafe at night due to low staffing levels.
Not all mandatory training had been completed.
Patients reported that the food was of very poor quality. Patients were also unhappy with food access arrangements.

We rated acute wards for adults of working age and psychiatric intensive care units as ‘requires improvement’ because:

There were features of the ward environment that were unsafe.We identified potential ligature anchor points that had not been included in the trust's ligature risk audits. The trust had identified other ligature risks but in some areas had no plans in place to manage patient safety. The seclusion room on Ward 12 contained ligature points in the toilet facilities. Staff could not observe patients in this area and entered the room to ensure patient safety. This was a risk to both patients and staff. There were further ligature points in patient bedroom areas and anti-ligature wardrobes had not been secured to walls. There were also ligature points in the courtyards. The floor of one courtyard was uneven.There was no nurse call system for patients to summon assistance if needed.We reported our findings to the trust.At the time of the follow-up inspection, the trust was making plans to take action to rectify these issues.
Most beds were situated in bays. Some patients told us they did not feel safe and these areas lacked privacy.
Bed occupancy rates were often over 100%. This meant that staff needed to use leave beds for new admissions.
We found different protocols and working practices in operation across the acute wards. This also meant that some informal and detained patients had restricted access to fresh air at night.
Some Mental Health Act (MHA) paperwork used to record patient’s rights was out of date and MHA patient leave forms lacked clarity.
Compliance with mandatory training was below the trust’s own target. Compliance with Mental Capacity Act and MHA training was particularly low with 35% and 66% of staff having been trained respectively. The trust could not be sure that staff had received appropriate training for their role.
Staff did not always receive supervision in a timely manner. The trust could not be sure that professional and developmental issues were discussed with staff.
The trust had no psychiatric intensive care (PICU) beds. Staff told us there were often delays in transferring patients to suitable PICU beds. The trust had plans to provide PICU facilities in the near future.
Patients told us the food was of good quality however, there was no hot meal in the evening. Patients told us they disliked having sandwiches every evening. This did not meet the recommendations of the Hospital Food Standards Panel.

However:

Wards were clean and had ample rooms for activities and patient visits. The trust provided activities on all wards, including at weekends.
Patients had individualised risk assessments, with plans in place to manage risks. Care plans were comprehensive and holistic, and addressed a full range of needs and problems.
Patients received regular monitoring of their physical healthcare needs.
Clinical nurse leads undertook relevant audits and there was good evidence of effective multi-disciplinary team working. There were good medicines management processes and clinic rooms were clean and tidy. Good systems were in place for reporting and recording incidents and complaints.
Staff were professional and respectful. Most patients told us staff were caring. Staff showed a good understanding of the care and treatment needs of patients and we observed good interactions between patients and staff.
All three wards had achieved accreditation under the Royal College of Psychiatrists AIMS standards.

We rated Lincolnshire Partnership Foundation NHS Trust substance misuse services as requires improvement because:

Staff did not see people who were accessing substitute prescriptions within the 12-week guidelines set by the service. This meant the safety and suitability of medication was not being reviewed. Managers did not monitor attendance rates at appointments. Staff did not always make timely contact with people when they failed to attend appointments. Staff did not see clients accessing a prescription every 12 weeks to review their medication and ensure clients were safe to continue with this. We raised this with the management team.
Staff completed risk assessments when people started treatment but they did not always review them regularly or update them when risk to people changed. Staff did not always review people’s recovery plans when a lapse occurred and they used illicit drugs but continued to prescribe medication.
Doctors did not follow guidelines for prescribing diamorphine, as described in the Drug Misuse and Dependence: UK Guidelines on Clinical Management (2007).
Staff did not maintain comprehensive care records and it was difficult to access clinical information. Doctors did not keep comprehensive records following medical reviews. This meant that records lacked detail and did not include an assessment of the person’s prescribing treatment plan. Service user records were kept in three different formats, which made it difficult to review records in detail. Managers had not set consistent guidelines for staff on how medical appointments were recorded on the electronic case recording system. This made records difficult to navigate to find evidence that staff saw clients.
The Lincoln service did not have any fire marshals, owing to staff sickness. Not all rooms across the service were soundproofed to an appropriate level

Managers did not meet the development needs of staff. They did not record any substance misuse specific training that staff completed. Supervisors did not provide regular supervision to staff. Seventy eight per cent of staff had completed their mandatory training. The trust target was 95% compliance. The service manager post had been vacant for six months, which meant that the locality managers had not received the appropriate level of support and supervision.
Staff recorded clinical entries from home as late as 0:17am which raised concerns about staff’s work life balance. Managers were not aware of this practice despite this having been a matter for scrutiny in the recent past.

However:

There were sufficient staff numbers to meet the needs of people who used the service.
The service provided comprehensive support for people’s healthcare needs associated with substance misuse. Staff supported people with blood-borne virus testing and vaccination programmes. Electrocardiograms were recorded for all people receiving high doses of methadone, to monitor the effect on their hearts. The service communicated regularly with people’s GPs.
People could access the service quickly and easily. Staff were able to provide assessment appointments within 21 days of a person being referred to the service. Staff saw people in places close to their home to reduce the need for people to travel to the main offices.
Peer advocates provided a variety of support to people and were developing ways to engage people with the treatment system.
Staff discussed discharge plans with people from assessment. This included asking people how long they wanted to be in treatment so they could plan appropriate treatment goals.
Managers referred staff appropriately for support from occupational health and the trust wellbeing service when it was required.
The trust gave staff opportunities for leadership and development across the different roles within the service. Poor performance was dealt with, but not recorded in staff notes.

Our findings at The Francis Willis unit were:

Risk assessments and management plans were available for patients and a current ligature audit risk assessment was seen. A local risk register was in place and this was used to identify any wider trust learning from incidents. These had been investigated appropriately and any lessons learnt had been shared through the trust’s reporting systems. This meant that the trust had taken steps to ensure the safety of patients and others.

Staff received additional role specific training. For example, forensic services, substance misuse and reinforce the appropriate and implode the disruptive (RAID) training had been provided for front line staff. Different professions worked effectively to assess and plan care and treatment programmes for patients.

Patients were positive about the support which they received on the unit. We saw good examples of effective staff and patient interaction and individual support being provided.

Clear assessments were in place to ensure that the unit’s admission criteria were being met. The trust reported responsive joint working with the commissioners of this service. Each patient had a weekly occupational therapy programme. Evidence was seen of monitoring arrangements to ensure that patients were offered at least 25 hours of activity per week.

Staff reported positive morale and good peer support. The unit was a member of the Royal College of Psychiatrist’s quality network for forensic mental health services. The last review had taken place in March 2013.

But we also found:

There was an inconsistent approach to the updating and review of some risk assessments and care plans.
There was no dedicated family and child visiting room on the unit.

Our findings at the Peter Hodgkinson Centre were:

Patients told us that they usually felt safe on the unit. Staff reported incidents/accidents and there was a system in place for reviewing and learning from them to prevent a reoccurrence. Systems were in place to ensure adequate staffing levels and appropriate skill mix on both wards to meet the needs of individual patients.

Staff provided a range of therapeutic interventions in line with National Institute of Clinical Excellence (NICE). Regular team meetings took place and staff told us that they felt supported by colleagues. Health care assistants were receiving training in order to obtain the care certificate. Staff reported receiving effective training opportunities.

Patients knew who their primary nurse was and felt able to talk to them. They told us that they felt involved in their individual care and that they met with their doctor regularly.

Clear admission assessments were in place. Patients were being supported to access Section 17 leave supported by staff. We found that patients had discharge plans where appropriate. The average length of stay on this unit was three months.

Staff reported good morale and positive peer support and told us that their line manager was supportive and provided clear guidance. Both wards had the accreditation for in-patients mental health service (AIMS). This is a standards-based accreditation programme designed to improve the quality of care in inpatient mental health wards and is managed by the Royal College of Psychiatrists Centre for Quality improvement.

But we also found:

The trust did not have a psychiatric intensive care unit (PICU) and this meant that patients who needed this service received this out of area.
Two male patients were being nursed out of area whilst awaiting a bed on Connolly ward.

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

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

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

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

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