Cheshire and Wirral Partnership NHS Foundation Trust

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• 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 assessed a total of 5 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was requires improvement. Our rating for this key question is Requires Improvement. Staff showed good understanding of the Mental Health Act and Mental Capacity Act and this was integrated in to their every day practices. Staff had a clear understanding of patients' risks and care requirements. Staff could not observe patients in all areas of the ward, staff told us this was mitigated by patient observations. Patients that required a personal emergency evacuation plan had one in place, however these were not personalised or immediately available in an emergency. However, we found issues around the administration and management of medication on Cherry ward.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People felt safe and supported to understand and manage any risks.

Staff and managers had a clear understanding of safeguarding, mental capacity act and deprivation of liberty safeguards. Staff we spoke with could confidently describe what constituted a safeguarding and how they would protect patients from abuse. The trust had an internal safeguarding team that were able to provide advice and support to all staff, staff spoke highly of this team and the level of support they provided. Staff showed good understanding of the Mental Health Act and Mental Capacity Act and this was integrated in to their every day practices. They also knew where to seek further support or advice when required.

Observation of care showed an understanding of each patient's risks and their needs.

Appropriate systems and policies were in place to ensure people were safeguarded. Staff received appropriate training in safeguarding, however we noted inconsistent rates of compliance to training at some locations. Especially for Level 3 training where the lowest rate seen at one site was 60%.

People had no specific feedback on this area.

Staff had a good understanding of the process of risk assessment and when/how these should be completed. The service reviewed risk daily for all patients in relation to their observations on the ward. All staff were made aware of any ongoing or changing risk through the daily handovers on the wards.

Appropriate systems were in place around care planning and risk assessment. However, we found that risk reviews and safety plans in case notes were inconsistently completed and did not always reflect the level of care that was being provided.

People told us there were happy with the ward environments and found them clean and tidy.

Staff demonstrated that they knew about any potential ligature anchor points and lessened the risks to keep patients safe. 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 always carried personal alarms on them.

Staff could not observe patients in all areas of the wards. There were procedures to minimise risks where they could not easily observe patients. However, there were concerns of being able to effectively use these procedures due to staffing levels. Access and signage for fire extinguishers on the wards was inconsistent. Meadow Bank ward's fire equipment was stored behind a trolley. Cherry ward did not have the correct signage for fire extinguishers, meaning people would be unable to locate the equipment. None of the wards had a dedicated activities room for patient. Cherry ward had a sensory room however, this was being used as a storeroom. The ward also had a reminiscence room which was not fit for purpose. All wards were clean, tidy and well maintained.

Each ward we visited had safe systems and processes in place to support staff to keep patients 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 reduced identified risks and used ward-based heat maps, which detailed were all the ligature risks were located on each ward. Where a patient was identified as needing personal emergency evacuation plans, these were not up to date, personalised or readily available for staff to access.

Many patients told us that there were ‘plenty’ of staff on the wards and that they were supportive. However, some patients identified that night shifts had ‘skeleton staff’. Patients also told us that they had seen staff ‘shouting at each other’ or if staff got busy, they ‘can get irritated’. One patient told us that staff ‘have a habit of not turning up and leave us in the lurch’. Carers spoke highly of the staff on the ward and the level of care and engagement they provided.

Staff we spoke with commented on a recent positive change in staffing pressures, specifically for Silk ward. However, all staff we spoke to raised concerns over the movement of staff to cover other wards at the same site. They informed us that the level of personal care required for their patients was not being considered when looking at staffing levels on the wards. This was also echoed by ward managers, who had raised with senior leaders that personal care was not taking place as immediately as needed. Staff raised concerns around the levels of staffing on the wards at night, believing that if there was an unexpected increase in observations or an incident there would be insufficient staffing. Managers and Occupational Therapists informed us that they were often used in the numbers for the ward, with no change in their day-to-day activities. Staff also informed us that patient activities and appointments were regularly cancelled or not attended due to staffing pressures on the wards. As well as staff conducting back-to-back observations with no breaks, as per national guidance and trust policy. Staff were concerned that when receiving staff from other wards, they did not have the correct knowledge or training to manage the patient group. All staff we spoke with informed us that they were up to date with their mandatory training and supervisions. Staff were offered additional development and training opportunities through the service.

We observed sufficient staff to allow continuity of care and this was evident in care observations where patients were very familiar with staff, allowing for positive relationships to be built. However, we found this was not the case on our evening visit. There was minimal staff on the ward and there was limited patient interactions. We observed the staffing meeting for the wards, all staffing for the week is reviewed daily and rag rated in terms of risk. This was a comprehensive meeting.

Staffing levels for each ward were managed centrally to ensure safe staffing levels across all sites. Overall mandatory training completion rates varied from 71% to 97% across all three wards, the trust compliance target for mandatory training was 85%. Appraisal and clinical supervision compliance ranged from 40% to 87% for appraisal and 25% to 94% compliance for clinical supervision. Staff on the wards were qualified, skilled and experienced and had access to support. New staff on the ward were oriented to the ward and provided key information on all the patients. Meadowbank ward had the highest vacancy rate across all wards of 18%. Silk ward’s turnover rate was 11%, the highest of all wards. The sickness rate for Cherry ward was 17%, the highest on all of the wards.

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.

Patients were supported to receive their medicines in a way which met their individual needs. Care and treatment were regularly discussed with a multidisciplinary team and the patient. Patients were supported to receive medicines covertly or ‘when required’ (PRN). However, on Cherry ward we found PRN medicines did not have records that showed they were being used appropriately. Patients were sometimes receiving sedating medicines over the maximum allowed in a 24-hour period. We could not be assured people on Cherry ward were always receiving medicines safely and effectively. Where patients were prescribed ‘when required’ (PRN) medicines to manage anxiety and/or agitation including the use of rapid tranquilisation (RT), staff usually recorded why the patient was experiencing distress, what non medicine options were tried first and if a medicine was needed and if it had been successful. However, on Cherry ward these records were missing or incomplete and we could not always be assured people were being supported with medicines appropriately. People on Cherry ward were sometimes being administered PRN medicines above the maximum allowed within 24 hours. This put people at risk of over sedation and side effects. People prescribed medicines with known physical health risks, such as the anti-psychotic clozapine, had specially designed monitoring booklets in place, so staff could support and monitor them effectively. There were patients on each ward who received their medicines covertly (hidden in food or drink). Staff on Meadowbank and Silk wards ensured this was done in a patient’s best interest and completed the required documents, checking necessity and reviewed regularly. Patients on covert administration were given opportunities to take their medicine overtly wherever possible. Medicines were reviewed regularly as part of a multi-disciplinary team meeting including the patient. Pharmacy provided expert clinical advice to the prescribing team.

Staff were suitably trained to administer medicines. On Meadowbank and Silk wards the pharmacy team worked closely with the multi-disciplinary team (MDT) to support safe and effective use of medicines. However, the pharmacy team on Cherry ward were not fully included as part of the MDT at the time of the inspection. Staff on Cherry ward said low staffing levels had directly contributed to medicines administration errors and prevented staff from being able to follow the Trust’s processes. Staff we spoke to were aware of people’s needs when managing anxiety and/or agitation. They could describe de-escalation techniques for everyone on the ward and would use the least restrictive option available to them where possible. Staff received training on medicines optimisation through a mix of annual e-learning and face to face sessions from pharmacy around specific topics. The Trust employed a physical health team as well as tissue viability nurses to support the physical health needs of older people alongside their mental health needs. We were told there was a high use of agency staff on Cherry ward and some agency staff were unable to administer medicines. Low staffing levels had also been a contributing factor to some medicines administration errors which had occurred on Cherry ward. The pharmacy team on Cherry ward were not included as part of the multi-disciplinary team supporting the consultant when reviewing patients' care and treatment with medicines.

We observed knowledgeable staff. Medicines were dispensed in a person-centred way. Staff supported patients to understand what medication they received, meeting individual needs. The pharmacy team provided quick reference guides which were available on the ward in the clinic room so staff could access information quickly. Staff were patient, kind, and offered alternative ways to give medicines such as with yoghurt if a patient was struggling to swallow a tablet. Staff told us that if they noticed repeated issues with swallowing difficulties, they would make a SALT (speech and language therapy) referral to ensure they were meeting the needs of the patients under their care. Clinic rooms were used to store medicines safely. Room temperature and fridges, where medicines were stored, were routinely checked. MHA consent to treatment documents were accessible to staff at the point of administration. Prescribing of medicines was in line with T2, T3 or section 62 paperwork. Electronic copies were available. Protocols were in place for certain procedures including rapid tranquilisations. Staff received advice on what was expected of them and had a quick reference guide for how to safely dilute certain injections such as lorazepam. Each ward had access to emergency medicines including flumazenil (a medicine administered intravenously for the reversal of a benzodiazepine overdose). The pharmacy team taught staff how to administer the medicine. Staff ensured each person's physical health was monitored regularly. They made use of the National Early Warning Scores (NEWS2) to improve detection of and response to clinical deterioration.

Processes were in place to ensure patients received medication as prescribed. Pharmacy had developed cards to ensure that use of rapid tranquilisation (RT) was completed safely and were monitored afterwards. Processes were in place to identify errors and near misses and learning was shared throughout the Trust. However, medicines were not always being given at the recommended times, reducing effectiveness. On Cherry ward procedures to give medication covertly were not followed and medication plans weren’t always person centred. Medicines with complex treatment requirements or titrating doses were identified and mapped onto the electronic prescribing and administration (EPMA) system. Prescribers could initiate treatment promptly. Treatment regimens were reviewed and updated routinely. An administration and monitoring card was used for RT. Once completed the card would be checked to ensure that policy was followed, and information uploaded to the electronic system. Robust processes were in place to identify and learn from errors and near misses. Learning was being shared throughout the Trust. Issues with dispensing medication at correct times was raised with the pharmacy team during inspection and we asked them to review specific medicines. Covert administration of medicines on Cherry ward did not have the same governance and oversight as the rest of the Trust. Best interest decision documentation was missing. We were not assured that discussion and consensus around the suitability to administer medicines in this way was being done. Some patients had medicines given covertly regardless of their clinical significance and not in line with recognised best practice. Covert administration was not routinely reviewed and lacked guidance. We reviewed a medicine error where someone had overdosed on a controlled drug. The trust did not inform the patient's relatives and was recorded as not required.