Cheshire and Wirral Partnership NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed the learning culture, safe systems, pathways and transitions, involving people to manage risk, safe environments and the safe and effective staffing quality statements for the safe key question. Safe systems, pathways and transitions: The Trust provided safe care and treatment through established systems and processes. Monitoring and assurance processes were in place. Continuity of care was not consistently in place for patients during hospital admissions. Safe and Effective Staffing: The Trust did not have safe levels of staff for the number and acuity of patients. Staff were qualified, skilled, and experienced with access to support patients. Involving people to manage risk: Patients told us they understood the different levels of observations in use on the ward and there were items that were considered unsafe and were not allowed on the ward and had to be locked away safely. Restricted patients told us they understood they could be restricted when detained under the Mental Health Act, and this included being monitored through the observation levels in place on the wards. Learning culture: Mandatory training for basic life support, safeguarding and restraint training were below the Trust target of 85%. Staff supervision rates were low, with the highest being 51% for one ward. Staff appraisal rates were also low with the highest being 58% for one ward. The trust were working on an improvement plan, and during our well-led review we observed the pan by attending the Trust our quality committee and noted complaince rates had improved. Safe systems and processes were not in place to support staff to keep patient safe. Staff identified staffing as risk to their safety and told us they did not have time to read important information about learning from incidents. Safe environments: The wards were safe, clean, well equipped, furnished and maintained. The layout of two wards made safe observation of patients difficult.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the people we spoke to expressed they were generally happy with their care, our assessment found elements of care did not meet the expected standard. For example, patients were not routinely involved in coproducing their care and treatment plans . We reviewed care records and found examples of staff using risk assessments for each patient on admission. However we saw examples where staff used risk assessments completed by the community mental health team were being used by ward staff, which were not up to date and did not reflect the patient's risk at the time of admission.

Staff shared their experiences of safe staffing levels and at times they felt unsafe due to the increase in the acuity of patients' mental health and being on back to back observation of patients. Staff said this was leading to staff burnout and/or increased staff sickness. When observation levels increased safe staffing levels were impacted as well by requests to cover other wards so staff could take breaks, patients needed to attend external appointments or required escorted leave. Staff highlighted each ward had to designate a staff member on each shift who was to respond to incidents on other wards when alarms were sounded. Staff said in their experience there was not always sufficient staff to respond to requests for help. Staff told us when they raised concerns about staffing and safe management of patients their concerns were not acted upon.

Staff completing safety observations were able to tell us what and why they were carrying out observations. On all three wards staff knew about any potential ligature anchor points which lessened the risks to patients. For example, staff were positioned at key observation points such as communal areas to monitor known ligature anchor points. Staff monitored patients on four different levels of supportive observation and engagement. These were level one, when patients were observed every hour, intermittent, when patients were observed within a specific timescale, one to one when observed by a staff member or level four when supervised by a staff member at all times. We reviewed the records of patients on the four different levels of supportive observation and engagement across the three wards; there were common themes we noted in recording. Examples we saw were staff signing they had observed a patient, but there were no details of what they had observed. Staff were recording the level of observation with no detail or signature of which staff completed the observation form. The most concerning example we saw was staff recording observations at regular timespans of 10 or 15 minutes. For example, on the hour, quarter past, half past and quarter to the hour. This was contrary to Trust policy to avoid patients with higher levels of risk to themselves. The Trust policy stated 'observing individuals at predictable times can provide them with opportunities to plan or engage in harmful activities'. At the time of the inspection the trust had an improvement plan in place to address where there were inconsistencies in the recording of observations. Information was shared with staff, patients and carers about the work of the Trust via the intranet, bulletins, newsletters and carers' meetings. For example, the trust used a bulletin called the ‘safety soundbite’, which each staff member was meant to read and sign they had understood the learning from an incident.

Patients reported receiving the standard of care described in the quality statement. Patients told us they had named nurse sessions and contributed to their risk and safety care plans, but their involvement could be improved if care plans were written using their words. We observed patients could be recalled back to the service when they were being treated on a community treatment order.

We did not receive feedback from staff and leaders on this topic.

We did not receive feedback from partners on this topic.

Patients had access to information in different formats, languages and to interpreters when English was not their first language. Patients were referred to psychologists, occupational therapists and physiotherapists when needed. Families and carers attended multidisciplinary meetings when patients agreed to their involvement in their care. Patients who were detained under the Mental Health Act had the support of an advocacy service.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

There was some variation in patients' experiences of the standard of care described in the quality statement. We reviewed 9 care records of patients over the 3 wards. Our findings were that whilst all patients had a risk summary in place these summaries did not provide enough information about each patient to ensure staff monitored and mitigated risk to them and others. For example, a patient harmed themself in December 2023, and their risk screening was not completed until March 2024. In addition, the risk to self or self-neglect was marked as 'yes' with no further detail explaining what the risk was and how it would be managed. In addition risk summaries were not conducted in a timely manner for 3 out of the 9 patients. Staff did not have access to a clear description of patients' risks which placed the patients and themselves at significant harm.

Staff informed us during our assessment that wards were no longer able to conduct a risk assessment before a patient is admitted to the ward. This means that ward managers did not have the autonomy to monitor the risks across the wards and the impact on patients and staff of new admissions.

Of the 9 patient records provided by the Trust we were unable to see a clear and concise and recently updated risk assessment completed, in line with the trust’s own policy, for any of the patients.

A patient told us they found the environment on Beech ward was too harsh for them, and they experienced sensory overload due to lighting and echoing noise created by doors and other sounds. Staff were aware of the patient's sensory needs and encouraged the patient to use the quiet room and their bedroom when they informed staff about their sensory needs.

Staff completing safety observations were able to explain the observation process. On all three wards, staff knew about any potential ligature anchor points and lessened the risks to keep patients safe. For example, staff were positioned at key observation points such as communal areas to monitor known ligature anchor points.

Staff could not observe patients in all areas of the wards but followed procedures to minimise risks where they could not easily observe patients, including through individually risk assessed patient observations and placement of mirrors. The Trust had changed a number of bedrooms to anti ligature. For example, on Juniper ward 6 of the 24 beds had a fixed base, so ligature points were reduced in these bedroom areas.

Each ward we visited had safe systems and processes in place to support staff to keep patient safe. Processes in place included a ligature management plan, ligature risk snapshot report and ligature risk dashboard. In addition, there were ward observation layouts to identify areas of risk and audit of communal areas and bedrooms highlighting where ligature risks were present. Staff had easy access to alarms and patients had easy access to nurse call systems so they could summon assistance when needed. All bedrooms were fitted with alarms. Staff carried personal alarms on them at all times. Staff used ward-based heat maps, which detailed where all the ligature risks were located on each ward to reduce the risk of patients having unsupervised support when a patient’s risk of self harm increased. During the inspection we reviewed both environmental and ligature risk assessments. These were generally well written. Staff on all of the wards we visited knew about any potential ligature anchor points and lessened the risks to keep patients safe. Fire risk assessments were completed for the wards visited and there were fire evacuation plans specific to each ward.

Patients told us occupational therapists were used to support them having leave from the ward and this reduced the opportunities for other patients to have access to ward based activities, when occupational therapy staff were not available and ward based staff were busy with observing other patients.

Staff shared their experiences of staffing levels and at times they felt unsafe due to the increase in the acuity of patients' mental health and being on back-to-back observation of patients. Staff said this was leading to staff burnout and or increased staff sickness. When observation levels increased staffing levels were impacted as well by requests to cover other wards so staff could take breaks, patients needed to attend external appointments or required escorted leave. Staff highlighted that each ward had to designate a staff member on each shift who was to respond to incidents on other wards when alarms were sounded. Staff said in their experience there was not always sufficient staff to respond to requests for help, nor were staff from other wards familiar with patients on the ward they were responding to. The Trust provided us with information that between Beech, Juniper and Willow wards there was a total of 7 staff on sick leave, 11 staff on extended leave, 3 staff on restricted duties, 1 staff suspended and 4 preceptors, 1 of which was included in the sickness figures. The Trust information about restricted duties included why identified staff had restrictions in place and was shared with ward managers. Feedback from staff was restricted staff were still moved to cover other wards. Staff told us they had high vacancy rates and were not coping. We saw that modern matrons, clinical leads and allied health professionals were covering wards and ward activities but were not included in staff numbers. Staffing vacancies provided by the trust for the three wards indicted low vacancy rates. For example, Beech ward had 4 whole time equivalent (WTE) staff vacancies, including qualified and unqualified nursing staff. Juniper ward had 5.14 WTE staff vacancies, including qualified and unqualified nursing staff, and Willow ward had 6.67 WTE vacancies including qualified and unqualified nursing staff. Staff vacancies were covered by bank and agency nurses.

Our observations were that ward managers were regularly counted in staffing numbers. We observed a staff meeting which included senior clinical leads, head of service and ward managers. This meeting reviewed the staffing figures across the Bowmere site. Staffing was adjusted across the site in relation to observation levels, and despite the meeting reviewing staffing levels it still identified areas were there were still high risks, for example, a preceptorship nurse was left in charge of one ward as the only registered nurse on the ward, while the ward manager attended the meeting. Whilst this maintained minimum staffing levels this did not mean patients received consistent safe care and treatment. The Trust provided us with information on what the trust referred to as safe staffing levels used for planned staffing numbers across the three wards. For Beech ward between 0800 and 2000, these numbers included two Registered Mental Health Nurses (RMN) and four care support workers (CSW). Between the hours of 2000 to 0800 the staffing numbers were two RMNs and three CSWs. This included observation of one patient on level 3 (one to one) observation. For Juniper ward between 0800 and 2000, the planned staffing numbers were two RMNs and four CSWs. Between the hours of 2000 to 0800 the staffing numbers were two RMNs and two CSWs. This included observation of one patient on level 3 (one to one) observation. For Willow ward between 0800 and 2000, the planned staffing numbers were a ward manager (RMN - 0900 to 1700) two RMNs and four CSWs. Between the hours of 2000 to 0800 the staffing numbers were two RMNs and three CSWs. This included observation of one patient on level 3 (one to one) observation.

In addition to ward-based staff the Trust used a third-party provider, which was commissioned by the integrated care board (formerly clinical commissioning group) contracted to support conveyancing of patients from acute hospitals into mental health units following assessment when inpatient admission was required. They also support observations in emergency departments for people detained under section 136 of the Mental Health Act. We saw staff raised their concerns with clinical leads about the availability of these staff when wards were experiencing increased levels of patient risk, observations were increased, and staff were redeployed to other wards when they had staffing shortfalls. The Trust did not have enough nursing and support staff due to vacancies and sickness rates, but maintained minimum staffing levels, however this did not make sure patients were kept safe. The Trust provided us with information on the number of agency and bank staff used in the six months prior to our inspection. During that period 142 bank staff had completed 1439 shifts and 52 agency staff had completed 2713 shifts, so were reliant upon bank and agency staff to maintain minimum staffing levels. An additional risk was due to the Trust’s own bank staff who were employed by the Trust were working additional hours. The Trust used a central team that coordinated the use of bank and agency staff to fill vacancies and shortfalls on ward-based staff rosters. Managers calculated and reviewed the number and grade of registered nurses, and clinical support workers for each shift to maintain minimal staffing levels. The trust provided us with information on how they met minimum staffing levels. However, this did not mean minimum staffing levels were safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.