Norfolk and Suffolk NHS Foundation Trust

Transcription

1 Norfolk and Suffolk NHS Foundation Trust Eating Disorder Quality Report Hellesdon Hospital Drayton High Road Norwich NR6 5BE Tel: Website: Date of inspection visit: October 2014 Date of publication: February 2015 Locations inspected Name of CQC registered location Location ID Name of service (e.g. ward/ unit/team) Postcode of service (ward/ unit/ team) Trust Headquarters Hellesdon Hospital RMY01 Community eating disorder services (CEDS) Adults Northgate Hospital NR30 1BL Trust Headquarters Hellesdon Hospital RMY01 Community eating disorder services (CEDS) Young People Mary Chapman House NR2 4HN This report describes our judgement of the quality of care provided within this core service by Norfolk and Suffolk NHS Foundation Trust. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Norfolk and Suffolk NHS Foundation Trust and these are brought together to inform our overall judgement of Norfolk and Suffolk NHS Foundation Trust. 1 Eating Disorder Quality Report February 2015

2 Summary of findings Ratings We are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings will always be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring data and local information from the provider and other organisations. We will award them on a four-point scale: outstanding; good; requires improvement; or inadequate. Mental Health Act responsibilities and Mental Capacity Act / Deprivation of Liberty Safeguards We include our assessment of the provider s compliance with the Mental Health Act and Mental Capacity Act in our overall inspection of the core service. We do not give a rating for Mental Health Act or Mental Capacity Act; however we do use our findings to determine the overall rating for the service. Further information about findings in relation to the Mental Health Act and Mental Capacity Act can be found later in this report. 2 Eating Disorder Quality Report February 2015

3 Summary of findings Contents Summary of this inspection Overall summary 4 The five questions we ask about the service and what we found 5 Background to the service 7 Our inspection team 7 Why we carried out this inspection 7 How we carried out this inspection 7 What people who use the provider's services say 8 Good practice 8 Areas for improvement 8 Detailed findings from this inspection Locations inspected 9 Mental Health Act responsibilities 9 Mental Capacity Act and Deprivation of Liberty Safeguards 9 Findings by our five questions 10 Page 3 Eating Disorder Quality Report February 2015

4 Summary of findings Overall summary We found differences in the way that specialised eating disorder services for adults and young people were organised and commissioned within the trust. This meant that there was not a unified service and the service received depended on where the person lived. There were safe systems in place to monitor and assess risk and safety. We saw that safeguarding and incident reporting mechanisms were well established. However some staff across teams were unable to describe reviewing and learning from incidents to prevent a reoccurrence. We saw that professionals worked together to ensure that the needs of people who used services were met. People received a service that was supported by evidence and research such as cognitive behavioural therapy (CBT) in the adult s team and the young person s team were using Family interventions. The provision of induction, training, supervision and for staff was established. People told us that staff were caring and supportive. There were opportunities for people to be involved in their care and treatment and we found evidence of person centred care planning. We found that trust records were not accessible out of hours to other agencies and trust teams when people had contact with crisis services. Staff across young person services in the trust reported a lack of inpatient beds for young people during crisis with an eating disorder. Trust services were not available in evenings and weekends to support young people with an eating disorder under 14 years in crisis. We saw a supportive culture within most teams. 4 Eating Disorder Quality Report February 2015

5 Summary of findings The five questions we ask about the service and what we found Are services safe? There were systems for staff to report incidents and systems in place for reviewing and learning to prevent reoccurrence. Risk assessments and management plans were in place. Staff worked alongside other community teams to support people and manage risks. Staff received training in safeguarding Staff reported adequate staffing for current caseloads. Are services effective? We found that staff assessed and planned care in line with the needs of the individual and people s physical health was routinely monitored. We saw that professionals worked together and young people received a service that was supported by evidence and research. People received support from staff which included therapeutic interventions in line with National Institute of Clinical Excellence (NICE) guidance. We found that different records systems were used across the trust which could impact on effective communication. Across Norfolk records were not always accessible out of hours. We saw that induction, training, development and supervision was available for staff. Are services caring? We found caring and committed staff who spoke about people in a respectful manner. People and their carers were involved in assessments and care plans. The service had gained positive feedback from people and carers about the effectiveness of the service provided. Are services responsive to people's needs? A single point of access was available. There were systems to monitor waiting times for assessment and treatment for people. Staff worked with a range of professionals to meet people s diverse and complex needs. Concerns were raised about commissioning agreements, which staff told us had led to fractured care pathways. 5 Eating Disorder Quality Report February 2015

6 Summary of findings Lack of inpatient beds for adults and young people with an eating disorder resulting in out of area placements. Staff and carers told us there were difficulties accessing trust services in evenings and weekends when young people with an eating disorder were in crisis. Are services well-led? Disconnection between services for young people and adults The trust had systems to seek feedback from people and others using the service. Some staff felt disconnected from higher management and the trust strategy and did not feel engaged. Staff reported a well-led service at a local level but reported poor leadership, support and awareness of their service from the higher management such as the executive board. 6 Eating Disorder Quality Report February 2015

7 Summary of findings Background to the service Community eating disorder services (CEDS) are provided as part of specialist community mental health services for children and young people with specialist staff working across teams. A specific team is based in Central Norfolk CFYPS for young people. Staff also gave support to 5 Airey Close the trust s only children and young person's inpatient unit where some of the beds are used young people who receive assessment and treatment for moderate to severe eating disorders. Adults CEDS are based at Great Yarmouth and Waveney CFYPS. The trust does not receive funding at this time to provide a specialised eating disorder service for adults in other areas and a neighbouring NHS mental health trust provides this. The trust does not have any in-patient specialist beds for adults with an eating disorder. The CQC has not previously inspected the community eating disorder services. Our inspection team Our inspection team was led by: Chair: Joe Rafferty, Chief Executive Officer, Merseycare NHS Trust Team Leader: Julie Meikle, Head of Hospital Inspection (mental health), CQC Inspection Manager: Lyn Critchley, Inspection Manager, CQC The entire inspection team included CQC inspectors and a variety of specialist and experts by experience that had personal experience of using or caring for someone who uses the type of services we were inspecting. The team that inspected this service consisted of a CQC inspector and a specialist professional advisor with extensive recent experience in the management and treatment of eating disorders. Why we carried out this inspection We inspected this trust as part of our ongoing comprehensive mental health inspection programme. How we carried out this inspection To get to the heart of people who use services experience of care, we always ask the following five questions of every service and provider: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? Before visiting, we reviewed a range of information we hold about Norfolk and Suffolk NHS Foundation Trust and asked other organisations to share what they knew. We carried out an announced visit between 21 October and 23 October 2014.Unannounced inspections were also carried out on the late evening of 06 November During our visit the team: Held focus groups with different staff members Talked with 3 patients, 1 carer or family member. Looked at the personal care or treatment records of a sample of patients. Observed how staff were caring for people. Interviewed 14 staff members. Reviewed information we had asked the trust to provide. 7 Eating Disorder Quality Report February 2015

8 Summary of findings Attended multi-disciplinary team meetings. Collected feedback using comment cards. Visited three community resource services What people who use the provider's services say We spoke with people and carers who used these services provided by this trust through focus groups, attendance at community resources and individual conversations. People told us that they were treated with dignity and respect and received good care. They told us that there were opportunities to give their feedback on the service. Good practice We found examples of good multi-disciplinary team working within teams and with local agencies. This meant that young people received a holistic assessment and support to meet their needs. Areas for improvement Action the provider MUST or SHOULD take to improve The trust must ensure that sufficient numbers of suitably qualified, skilled and experienced staff are employed to ensure that the physical health care needs of people are being met. The trust must review its provision of duty and crisis services for young people with an eating disorder to also ensure that staff undertaking assessments have the appropriate skills to ensure this is carried out effectively. The trust should review its arrangements with commissioners for admitting people to inpatient services for treatment of an eating disorder to avoid out of area placement placements. The trust should review their consultation processes for staff for the responsive planning and delivery of specialised services- eating disorder for people across the trust. 8 Eating Disorder Quality Report February 2015

9 Norfolk and Suffolk NHS Foundation Trust Eating Disorder Detailed findings Locations inspected Name of service (e.g. ward/unit/team) Community eating disorder services (CEDS) Adults Community eating disorder services (CEDS) Young People Name of CQC registered location Trust Headquarters Hellesdon Hospital Trust Headquarters Hellesdon Hospital Mental Health Act responsibilities We did not monitor responsibilities under the Mental Health Act (MHA) as during our inspection none of the people who used these services were detained under the Act. Staff identified that they would contact the Mental Health Act administrative team if they needed any specific guidance about their roles and responsibilities under the Mental Health Act. We found that when required staff could contact the Approved Mental Health Professionals (AMHP) service to co-ordinate assessments under the Mental Health Act Mental Capacity Act and Deprivation of Liberty Safeguards Staff received Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training and evidence was seen of the involvement of people in decisions regarding their care and treatment. 9 Eating Disorder Quality Report February 2015

10 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm * People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse Summary of findings There were systems for staff to report incidents and systems in place for reviewing and learning to prevent reoccurrence. Risk assessments and management plans were in place. Staff worked alongside other community teams to support people and manage risks. Staff received training in safeguarding Staff reported adequate staffing for current caseloads. Our findings Community eating disorder services (CEDS) Adults Safe staffing The team was small with the equivalent of 3.2 whole time equivalent posts. There was a mix of staff as not all staff were allocated to work full time with the CEDS. The team included a clinical nurse specialist, clinical lead, cognitive behavioural therapist (CBT), dietician, assistant practitioner and psychiatrists. The team held a caseload of 20 people. Due to the small numbers of staff arrangements had to be made for support with other community teams when there was sickness absence. People were advised to contact the trust crisis line if they needed support outside of working hours. Assessing and managing risk to patients and staff The trust provided safeguarding training for staff. Staff had a clear understanding of safeguarding and their responsibilities in relation to identifying and reporting allegations of abuse and gave us examples of when they had done so. Staff knew who was the safeguarding lead for their area and felt able to contact them for advice when needed. We saw there were systems to monitor, review and report on safeguarding issues to senior managers and commissioners. Staff had undertaken prevention of management and aggression (PMA) training (breakaway and de-escalation) to help them manage any challenging behaviour. In an emergency crisis situation staff would call 999 for emergency services. Staff showed awareness of lone working policies and procedures. Across the teams the staff described how they followed up when people did not attend for appointments. These ranged from telephone contact, to home visits and requesting police to carry out welfare checks. They showed us how they recorded this and we noted that case studies were reviewed during weekly team meetings for advice on management. Within care records, we saw that risks some people presented to themselves and others had been assessed and reviewed regularly to ensure people received appropriate support. Risk management plans detailed the actions that were required to minimise the risk to the individual and any triggers/risk behaviours that people needed to be aware of, and strategies for coping with these. We found staff used two separate risk assessments (electronic and paper) and for one person we found discrepancies in recording the risks they posed. We found one person s risk assessment was out of date but staff were planning to review this at a care programme approach (CPA) meeting. There was evidence of information sharing between the team members and other services, such as GPs. Reporting incidents and learning from when things go wrong Staff were able to describe how they report incidents and accidents. Staff received bulletins with trust updates and alerts following learning from incidents and to communicate issues. However it was unclear how staff had access to information about learning incidents across teams. Some staff referred to de-briefs taking place following incidents. This assisted staff to reflect upon incidents and learn from these. Community eating disorder services (CEDS) Young People Safe staffing The team included a clinical nurse specialist, nurses, assistant practitioner and psychiatrists. The team held a 10 Eating Disorder Quality Report February 2015

11 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm caseload of 130 which were case managed as a team. Staff told us that they work extra hours to make the service work and were concerned that it was not sustainable, commenting that, The organisation as a whole relies on good will. Assessing and managing risk to patients and staff The trust provided safeguarding training for staff. Staff had a clear understanding of safeguarding and their responsibilities in relation to identifying and reporting allegations of abuse and gave us examples of when they had done so. Staff knew who was the safeguarding lead for their area and felt able to contact them for advice when needed. We saw there were systems to monitor, review and report on safeguarding issues to senior managers and commissioners. Staff had undertaken prevention of management and aggression (PMA) training (breakaway and de-escalation) to help them manage any challenging behaviour. In an emergency crisis situation staff would call 999 for emergency services. Staff showed awareness of lone working policies and procedures. The trust provided safeguarding training for staff. Staff had a clear understanding of safeguarding and their responsibilities in relation to identifying and reporting allegations of abuse and gave us examples of when they had done so. Staff knew who was the safeguarding lead for their area and felt able to contact them for advice when needed. We saw there were systems to monitor, review and report on safeguarding issues to senior managers and commissioners. Potential risks young people with an eating disorder presented to themselves and others had been assessed and reviewed regularly to ensure that they received appropriate support. This was documented in care records. Risk management plans detailed the actions that were required to minimise the risk to the individual and any triggers/risk behaviours that people needed to be aware of, and strategies for coping with these. There was evidence of information sharing between the team members and other services, such as GPs. We found examples of staff intensively supporting young people with an eating disorder and working with other specialist community mental health services to offer daily visits as part of their risk management approach. Staff told us there were opportunities to have complex case reviews with peers for professional advice and guidance. Reporting incidents and learning from when things go wrong Staff were able to describe how they report incidents and accidents. The system ensured senior managers within the trust were alerted to them promptly and could monitor the investigation and response to these. Staff told us they received bulletins with trust updates and alerts following learning from incidents and to communicate issues. Staff told us root cause analysis (RCA) took place following investigations and gave us examples of learning from incidents to prevent reoccurrence and had reflective practice sessions. 11 Eating Disorder Quality Report February 2015

12 Are services effective? By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Summary of findings We found that staff assessed and planned care in line with the needs of the individual and people s physical health was routinely monitored. We saw that professionals worked together and young people received a service that was supported by evidence and research. People received support from staff which included therapeutic interventions in line with National Institute of Clinical Excellence (NICE) guidance. We found that different records systems were used across the trust which could impact on effective communication. Across Norfolk records were not always accessible out of hours. We saw that induction, training, development and supervision was available for staff. Our findings Community eating disorder services (CEDS) Adults Assessment of needs and planning of care We found that staff assessed and planned care in line with the needs of the individual with specialist assessment documentation. People s readiness to engage with treatment was not always documented. One person s care plan was out of date and was due to be reviewed at a CPA meeting. We saw that people s physical healthcare needs were being assessed and addressed by staff or the person s GP such as for blood tests, electrocardiogram (ECG). Where necessary tests (such as bone density scans) or admission of people was arranged to the local acute NHS trust. Best practice in treatment and care We saw limited use of outcome measures such as mental health clustering tools: Health of the Nation Outcome Scales (HONOS), Staff had links with eating disorders diagnostic and treatment network (EDNET) and referenced The Maudsley Model of working with young people with an eating disorder, but it was not apparent that other outcome measures other than weight measurements were used to measure outcomes for people. Staff provided evidence based practice in line with MARSIPAN (management of really sick patients with anorexia nervosa) guidance. People s weight and body mass index (BMI) were documented and reviewed to check weight stabilisation. Sit up Squat Stand tests were carried out (to detect muscle weakness). Staff provided some therapeutic interventions in line with National Institute of Clinical Excellence (NICE). For example we found staff used cognitive behavioural therapy (CBT). Family based therapy (FBT) was available from another team provided service. Skilled staff to deliver care Systems were in place for new or temporary staff to receive inductions to the trust and the service. There were systems for monitoring staffs attendance at the trust s mandatory training. Staff showed us the LARA staff training booking system and told us they received s about available training. We saw from staff training records that not all staff had up to date mandatory training and plans were in place to address this. We did not see a specialist training plan. We found some in house training to maintain and develop specialist skills such as family therapy training was available. We learnt a training day for CEDS took place in July 2014, with presentations from clinical staff across the region on the latest research and advances in eating disorders. Staff said they received management and clinical supervision opportunities as well as peer supervision with a family therapist and yearly appraisals. Staff reported having links with the East Anglia eating disorder network and doctors confirmed that quarterly in house meetings were held to give professional peer support. A newer member of staff told us they had to complete statutory training before they were allowed to book onto specialist ED training. Sometimes there were difficulties being able to book onto the statutory training. Multi-disciplinary and inter-agency team work Staff provided support and advice to staff on acute medical wards caring for people who required physical health care treatment, as a result of the side-effects of their eating disorder. Staff told us that they offered support and guidance to colleagues in primary care and secondary mental health services where required. Staff reported working with agencies such as MIND (mental health charity) and the trust s recovery college. Staff reported that records were not always accessible such as out of hours to share information between agencies such as crisis services about young people with high risks. Staff told us there were paper and electronic records. We found that staff were relying on communication from post, 12 Eating Disorder Quality Report February 2015

13 Are services effective? By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. telephone calls, faxes and s. We learnt that the trust was planning to use an integrated electronic patient record across services and that staff and people using services were being consulted about this change. We found detailed progress notes for example documenting risk and work undertaken with a person in crisis with evidence of liaising with other professionals. Staff reported that they had effective communication systems and daily handovers. Adherence to the MHA and the MHA Code of Practice Staff were aware of the circumstances when it may be necessary to arrange a Mental Health Act assessment and told us that they were able to access appropriate support to undertake one. Good practice in applying the MCA Staff received Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training and evidence was seen of the involvement of people in decisions regarding their care and treatment. Community eating disorder services (CEDS) Young People Assessment of needs and planning of care We found that staff assessed and planned care in line with the needs of the individual with specialist assessment documentation. Staff reported that motivational interviewing to check readiness to engage with treatment was not always documented. This was bought to the attention of senior staff during our inspection. We saw that people physical healthcare needs were being assessed and addressed by staff or the person s GP such as for blood tests, electrocardiogram (ECG). Where necessary tests (such as bone density scans) or admission of people was arranged at the local acute NHS trust. Staff reported psycho educational work such as undertaking home visits to observe family meal for 12 weeks, developing meal plans for inpatient and community patients. Other examples included, working with young people on trips out for food shopping, hiring swimming pools for giving people individualised support with managed exercise and working with them on their body image. Best practice in treatment and care Staff provided evidence based practice in line with junior MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) guidance. People s weight and body mass index (BMI) were documented and reviewed to check weight stabilisation. Ensuring vitamin and mineral supplements were prescribed as required. Sit up squat stand tests were carried out (to detect muscle weakness). e received therapeutic interventions in line with National Institute of Clinical Excellence (NICE) such as cognitive behavioural therapy (CBT) and family based therapy (FBT) and family interventions. Staff referenced The Maudsley Model of working with young people with an eating disorder. We saw use of outcome measures such the Eating Disorder Inventory (EDI) a self-report questionnaire and reference to using the child outcomes research consortium (CORC). The central Norfolk child and adolescent eating disorders service (CEN-CAEDS) had achieved the national Beat assured quality standard. Beat is a UK charity supporting people affected by eating disorders, carers and others. Skilled staff to deliver care Systems were in place for new or temporary staff to receive inductions to the trust and the core service. There were systems for monitoring staff attendance at the trust s mandatory training. Staff said they received management and clinical supervision opportunities as well as peer supervision and yearly appraisal. This was supported by those records seen. Multi-disciplinary and inter-agency team work Staff provided support and advice to staff on acute medical wards caring for people who required physical health care treatment, as a result of the side-effects of their eating disorder. Staff told us that they offered support and guidance to colleagues in primary care and secondary mental health services where required. Tier 2 services for people with a mild or moderate eating disorder were provided outside of the trust. Staff gave an example of working closely with a dietician based at the acute hospital trust and development of meal plans for people with an eating disorder. We found that additional support was provided to the trust inpatient unit, GPs and schools. Staff reported that records were not always accessible such as out of hours to share information between agencies such as crisis services about young people with high risks. Staff told us there were paper and electronic records. We found that staff were relying on communication from post, 13 Eating Disorder Quality Report February 2015

14 Are services effective? By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. telephone calls, faxes and s. An example was given where they were intensively supporting a young person with different agencies and were ing notes between teams regarding their daily contacts. We learnt that the trust was planning to use an integrated electronic patient record across services and staff and people using services were being consulted about this change. Adherence to the MHA and the MHA Code of Practice Staff were aware of the circumstances when it may be necessary to arrange a Mental Health Act assessment and told us that they were able to access appropriate support to undertake one. Good practice in applying the MCA Staff reported receiving Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and involving people in decisions regarding their care and treatment. We saw use of a standardised consent form for recording the consent of young people across the trust. 14 Eating Disorder Quality Report February 2015

15 Are services caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Summary of findings We found caring and committed staff who spoke about people in a respectful manner. People and their carers were involved in assessments and care plans. The service had gained positive feedback from people and carers about the effectiveness of the service provided. Our findings Community eating disorder services (CEDS) Adults Kindness, dignity, respect and support During our visit we did not have the opportunity to speak to adults using the service. From our contact with staff we found good examples of caring and committed staff who spoke about people in respectful manner. The involvement of people in the care they receive We saw evidence of people being involved in their assessments and care plans, such as signatures. Staff told us they gave explanations of the care and treatment available to them. We saw that the service had gained positive feedback from people about the effectiveness of the service provided through a range of cards an s. Community eating disorder services (CEDS) Young People Kindness, dignity, respect and support During our visit with staff we found good examples of caring and committed staff who spoke about people in respectful manner. We observed staff treating a young person and carer with dignity and respect. We saw that staff had person centred discussions of how to meet the needs of young people and their carer s. Staff told us they were mindful when seeing the young person to check if they had eaten that day and offer a drink or snack as required. The involvement of people in the care they receive We saw evidence of young people and their carers being involved in assessments and care plans. Staff told us they gave explanations of the care and treatment available to people and encouraged carers to get involved in activities such as meal preparation and eating with young person. Staff offered flexible home visits and support in schools, and accommodated the wider family as relevant. Young people were encouraged to develop meal plans by identifying their eating rituals and likes and dislikes. Staff told us that young people were involved in the recruitment and selection of staff through Young People s panels. We saw that the service had gained positive feedback from people about the effectiveness of the service provided. A carer gave feedback that the family get a lot of support and their relative felt a lot better after seeing the consultant and attending the self-esteem group. They informed us they received good care. However said that waiting times were a bit long. A carer told us they were seen within two weeks and were, very happy with the care that they felt involved and their relative was improving. They told us they could not be more grateful. A young person gave us positive feedback about the team and service they were receiving, and that it was meeting their needs. 15 Eating Disorder Quality Report February 2015

16 Are services responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. Summary of findings A single point of access was available. There were systems to monitor waiting times for assessment and treatment for people. Staff worked with a range of professionals to meet people s diverse and complex needs. Concerns were raised about commissioning agreements, which staff told us had led to fractured care pathways. Lack of inpatient beds for adults and young people with an eating disorder resulting in out of area placements. Staff and carers told us there were difficulties accessing trust services in evenings and weekends when young people with an eating disorder were in crisis. Our findings Community eating disorder services (CEDS) Adults Access, discharge and bed management A single point of access was via the access and assessment (A&A) service, which triaged referrals to determine the most appropriate course of action. This included assessment and signposting to other agencies as relevant. A member of staff told us that sometimes there was not much information from the referral information passed on to them necessitating more work to assess and the potential of the person repeating the assessment. There were systems to monitor waiting times for assessment and treatment for people. We learnt that people were seen within three to four weeks from referral. Staff told us that they had not discharged any person they had worked with and were at the maximum caseload capacity. This meant that they were unable to respond quickly to new referrals. Staff reported that unless the person was receiving support from another trust service they had to request the GP to make a referral for other services. Staff told us a commissioning review had taken place, but were unclear about the future plans for the service as commissioners were not funding adult CEDs services across the trust localities. The team was line managed via Children, Family and Young Person Services managers and not adults. Staff we spoke with had developed links with other hospitals in the East of England to share practice and help to develop their service; however we noted that some staff had limited awareness of specialist ED networks. We found that outcome measures other than weight monitoring were not being used to inform and plan services. Concerns were raised by some staff in relation to commissioning agreements, which staff told us had led to fractured care pathways. Staff were concerned that they were commissioned to work with people who presented with moderate to severe eating disorders (with a BMI of less than 15 and/or have the psychopathology of an eating disorder) and there was little opportunity for preventative or outreach work before they reached crisis or their illness had worsened. Staff provided intensive support to people to try and prevent hospital admissions and could undertake a specialist assessment/motivational interviewing follow up after hospital admission. Staff reported that they considered this to be a disjointed pathway. Some senior staff told us they would like to develop a life span service supporting people with an eating disorder from young person to adult pathways. Staff reported a lack of inpatient beds for adults with an eating disorder during crisis. They told us there had been difficulties with gaining local adult acute hospital placements as not all acute staff such as the local accident and emergency (A&E) department understood people s needs. Staff told us people had to be placed at times a long way from their home area which made it difficult for family and staff to keep contact with them. Meeting the needs of all people who use the service Staff gave an example of working closely with midwives for pregnant women. They explained how they worked with adult community services undertaking joint work where people had complex needs such as substance misuse issues. They told us they were flexible in their work with people and had worked with a person aged 17 ½ years to avoid the person being treated by a variety of teams. Listening to and learning from concerns and complaints Systems were in place such as suggestion boxes for people using the service, staff and others to make complaints and give feedback on the quality of care. Patient advisory liaison services (PALS) and advocacy services information was displayed for people in the service. The trust website 16 Eating Disorder Quality Report February 2015

17 Are services responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. gave additional information for people. Examples of other was staff encouragement the family and friends test and asking for verbal feedback from people. We saw that service satisfaction questionnaires had positive feedback from people. Community eating disorder services (CEDS) Young People Access, discharge and bed management A single point of access was via the access and assessment (A&A) service, which triaged referrals to determine the most appropriate course of action. This included assessment and signposting to other agencies as relevant. The young person service had a criteria of working with young people with a primary eating disorder such as anorexia nervosa, bulimia nervosa or EDNOS (Eating Disorder not otherwise specified).there were systems to monitor waiting times for assessment and treatment for people. We learnt that there was not an identified dietician working with this service however staff reported liaising with an acute hospital dietician to develop meal plans. Staff across specialist community mental health services for children and young people in the trust reported a lack of inpatient beds for children and young people during crisis such as if they had complex needs or risks or were male. There were guidelines for the admission of young people under 18 to adolescent mental health units and a bed management process. However staff told us that there were challenges in finding a suitable placement. Staff told us that some young people had to be assessed and treated a long way from their home area which could make it difficult for family and staff to keep contact with them. We saw that staff had identified a need for young people to have increased support during the summer vacation from school. Initiatives included development of social group trips out. We found that a healthy weight programme at Silverwood, Great Yarmouth and Waveney CFYPs had been commissioned by a local acute hospital to work intensively with six young people offering support to young people and carers. Staff told us there were difficulties accessing trust services when young people were in crisis and services to support young people under 14 years were not available in evenings and weekends. A consultant child and adolescent psychiatrist were available to contact by telephone for crisis team staff for advice and support out of hours We found examples of young people going to the local acute trust to A&E to get help. Meeting the needs of all people who use the service We learnt that planned admissions had taken place for young female with an eating disorder at Airey close. Plans were being developed to increase the number of beds available and extend the service to males. Staff worked with teams such as the intensive support team (IST) to prevent admission of young people to hospital where possible. Listening to and learning from concerns and complaints Trust waiting areas had a comments box for young people and others to post their ideas and views anonymously Staff reported opportunities for people to attend the parent and carer group monthly working with beat. Systems were in place such as suggestion boxes for people using the service, staff and others to make complaints and give feedback on the quality of care. Patient advisory liaison service (PALS) and advocacy services information was displayed for people in the service. The trust website gave additional information for people. Examples of other trust engagement was staff encouragement of people and their carers to complete the trust s newly introduced family and friends test and we saw that staff encouraged for verbal feedback from people about the care and treatment provided. We noted that a youth council meeting took place where people met to give feedback across services. Staff reported an increase in complaints during the restructure. We saw evidence of complaints being discussed with staff at team meetings regarding learning points and actions. Staff also reviewed compliments and feedback from comment cards and s that young people and carers had sent to the service. Staff responded to young people s feedback in their refurbishment of the clinic room at Mary Chapman House and by arranging appointments with young people at their preferred venue. 17 Eating Disorder Quality Report February 2015

18 Are services well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Summary of findings We saw a supportive culture within most teams. Disconnection between services for young people and adults The trust had systems to seek feedback from people and others using the service. Some staff felt disconnected from higher management and the trust strategy and did not feel engaged. Staff reported a well-led service at a local level but reported poor leadership, support and awareness of their service from the higher management such as the executive board. Our findings Community eating disorder services (CEDS) Adults Vision and values Information was available for staff via bulletins, and posters for people who use the service and others regarding the trust s vision and strategy. Trust staff appraisal documents referenced employee s performance against the trust vision and values. Some staff reported feeling disconnected from higher management and the trust strategy. It was not apparent that there was a connected specialised service for young people and adults with eating disorder across the trust with an overall strategy due to the differences in commissioning of services across the localities. We found there was clear criteria for the referral to adult and young person CEDS such as the GP pathway to access youth mental health services. Good governance We saw evidence of systems for governance to monitor and improve teams performance. The trust had systems to seek feedback from people, although the results of these were not available to see if improvements had taken place. We saw that a regular business team meeting took place however minutes showed no standard agenda such as for disseminating learning following incidents. Leadership, morale and staff engagement Staff reported a well-led service at a local level but reported less leadership, support from and awareness of their service from the higher management such as the executive board. We found a supportive culture within the team. Some staff expressed concern that there was not a trust lead for the ED service. A staff member told us that the trust s chief executive spoke to new staff at the induction which they felt was positive. Some staff reported uncertainty about knowing the future plans for the adult CEDS and had written to the previous chief executive. Staff told us the trust had previously submitted a bid to provide additional services across Norfolk without consulting the adult CEDs and the outcome of this was unclear to them as were future plans. We saw opportunities for people and others to have your say self-adhesive leaflets which could be completed and sent via freepost and opportunities to complete the family and friend test were available. Posters encouraging people to give feedback were available were available, such as help us better serve your needs. Commitment to quality improvement and innovation There were regular performance meetings attended by senior staff from the team, where performance indicators such as meeting assessment and times to treatment, incidents, and plans for improvement were discussed. Any specific highlighted risks for the service were communicated from the trust to front line managers through key performance indicators, which was then communicated to staff. There were systems for monitoring and tracking the team s performance for example recording staff s attendance at training and sickness. Staff reported having weekly team/case management meetings and monthly business meetings to review their practice and identify areas of good practice and for improvement. Community eating disorder services (CEDS) Young People Vision and values Information was available for staff via bulletins, and posters for people who use the service and others regarding the trust s vision and strategy. Trust staff appraisal documents referenced employee s performance against the trust vision and values. It was not apparent that there was a unified specialised service for young people and adults with eating disorder 18 Eating Disorder Quality Report February 2015

19 Are services well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. across the trust with an overall strategy due to the differences in commissioning of services across the localities. We found there was clear criteria for the referral to adult and young person CEDS such as the GP Pathway to access youth mental health Services. Senior staff told us that trust vision was embedded in team senior clinician meetings (SCOM) away days however it was not apparent that there were links with other teams. We learnt there was a plan to establish a cross team programme board to develop coherence and vision. Good governance We saw evidence of systems for governance to monitor and improve teams performance. The trust had systems to seek feedback from people, although the results of these were not available to see if improvements had taken place. We saw that a regular business team meeting took place which included disseminating learning following incidents. Leadership, morale and staff engagement Staff reported a well-led service at a local level but reported poor leadership, support from and awareness of their service from the higher management such as the executive board. We found a supportive culture within the team. Some staff expressed concern that there was not a trust lead for the ED service. Commitment to quality improvement and innovation There were regular performance meetings attended by senior staff from the team, where issues such as performance such as meeting assessment and times to treatment, incidents, and plans for improvement were discussed. Staff spoke of quality champions in service lines to lead on the improvement and of services. Any specific highlighted risks for the service were communicated from the trust to the manager through key performance indicators, which was then communicated to staff. There were systems for monitoring and tracking the team s performance for example, assessment and referral waiting times. Staff reported having weekly team/case management meetings and monthly business meetings to review their practice and identify areas of good practice and areas for improvement. 19 Eating Disorder Quality Report February 2015