Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Greater Manchester West Mental Health NHS Foundation Trust - HQ Prestwich hospital, Bury New Road, Prestwich, M25 3BL Tel: 01617739121 Date of Inspection: 15 July Date of Publication: August We inspected the following standards in response to concerns that standards weren't being met. This is what we found: Care and welfare of people who use services Safeguarding people who use services from abuse Staffing Supporting workers Assessing and monitoring the quality of service provision Met this standard Met this standard Met this standard Met this standard Met this standard www.cqc.org.uk 1
Details about this location Registered Provider Overview of the service Type of services Regulated activities Greater Manchester West Mental Health NHS Foundation Trust Greater Manchester West Mental Health NHS Foundation Trust (GMWMHT) is a provider of specialist health and social care services for individuals with acute, severe and enduring mental health and substance misuse needs. The trust manages services both in the community and in other NHS locations across Greater Manchester, as well as in reach services to HMP Forest Bank. Community based services for people with mental health needs Hospital services for people with mental health needs, learning disabilities and problems with substance misuse Community based services for people who misuse substances Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury www.cqc.org.uk 2
Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Care and welfare of people who use services 6 Safeguarding people who use services from abuse 9 Staffing 11 Supporting workers 13 Assessing and monitoring the quality of service provision 15 About CQC Inspections 17 How we define our judgements 18 Glossary of terms we use in this report 20 Contact us 22 www.cqc.org.uk 3
Summary of this inspection Why we carried out this inspection We carried out this inspection in response to concerns that one or more of the essential standards of quality and safety were not being met. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 15 July, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, reviewed information sent to us by other regulators or the Department of Health, were accompanied by a specialist advisor and used information from local Healthwatch to inform our inspection. We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service. What people told us and what we found We had received information of concern in relation to care and welfare of young people within the adolescent division at Prestwich Hospital. We made the decision to carry out an unannounced visit to the Gardener Unit and Junction 17 in response to these concerns. We spent time speaking with as many young people as possible to gain an understanding and feedback about their care and welfare. Comments included: "Staff are helpful, friendly and are always approachable" and "I do feel respected". Another person said: "They (the staff) are all very fair and not unkind in anyway". Young people told us staff were helpful and supportive but they were very busy. The trust had well established and robust safeguarding systems in place. There was an effective structure in place to protect patients and support staff. There were sufficient qualified, skilled and experienced staff to meet people's needs. Senior managers and senior ward staff acknowledged there had been issues earlier in the year, however the trust had taken action to rectify this issue. When we spoke with staff we were told they were very satisfied with the amount of training that was offered within the trust. Comments included: "One thing I like about working here, there is always opportunities for training", The trust had effective and robust systems in place to assess and monitor the quality of the services provided. People who used the service were asked for views about their care and treatment. www.cqc.org.uk 4
You can see our judgements on the front page of this report. More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. www.cqc.org.uk 5
Our judgements for each standard inspected Care and welfare of people who use services Met this standard People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Reasons for our judgement We had received some information of concern in relation to the care and welfare of the young people within the adolescent division at Prestwich Hospital. We made the decision to carry out an unannounced visit to the Gardener Unit and Junction 17 in response to these concerns. Junction 17 treated both male and female young people aged 13-18yrs with significant mental health needs and who may pose a high risk to themselves and others. The Gardener unit was a medium secure adolescent forensic unit for 10 males 13-18 yrs. The team included an Associate Specialist. This is someone with professional experience of this type of service. An Expert by Experience also contributed to the visit. This is someone who either has personal experience of a similar service or cares for someone who has. On both units the expert by experience spent time speaking with as many young people as possible to gain an understanding and feedback about their care and welfare. Comments included: "Staff are helpful, friendly and are always approachable" and "I do feel respected". Another person said: "They (the staff) are all very fair and not unkind in anyway". Young people told us staff were helpful and supportive but they were very busy. People who used the service were able to attend school or college on site and we were told by the young people they enjoyed attending. They said it helped maintain structure and normality within their routine. One person was studying A-level English Language and English Literature and he said "I love language and I really enjoy my studies". People told us they enjoyed the talking therapies and overall said "they felt settled" and they were "in the right place". Some young people said there was a lack of activities and they often felt bored. We discussed this with staff on duty and we were shown a range of activities, at various times, that young people could participate in. Outdoor facilities were www.cqc.org.uk 6
also available on both units. We were informed all visits were supervised. We observed one person on "ground leave" being supervised during a visit and this was done in a non - obtrusive manner. The Mental Health Act Commission undertakes visits to hospitals where people are detained under the Mental Health Act 1983. Comments from a recent monitoring visit to Gardener unit included: "The multi-disciplinary team encourages each person who uses services to participate actively and responsively in their care and treatment". During the inspection we heard conflicting views about the involvement of young people in their care planning. One person said: "I can attend CPA (care programme approach) meetings and this makes me feel more stable", "I attend meetings and do feel involved in my care planning". However another said "I would like to be more involved in it". The trust may wish to note to provide individualised care the involvement of people in care planning should be consistent. We noted action had been taken following recommendations from the visit. Patients' rights had become an agenda item on staff and community meetings to ensure these had become embedded during planning and delivery of care. A new telephone line had been installed in a quieter area of the unit, however as this was close to the nurses office, privacy during calls could still remain an issue. Staff we spoke with assured us this was being monitored and would be raised at future community meetings. We found advocacy was provided by an external agency "Voice" and people who used the service had direct access to advocacy staff, who visited the ward frequently. We found advocates were also invited and attended ward community meetings. We noted an interpreter service was available when required. Young people confirmed their engagement with advocates. On Junction 17 we sampled four electronic care records. We found appropriate risk assessments of care needs had been undertaken. For people who were detained under the Mental Health Act 1983, we noted all information required in respect of their detention was recorded correctly and was up to date. Patients rights were clearly documented as being discussed with the individual and these had been appropriately reviewed. One young person had been on the unit for a week and there was evidence of on-going care and risk assessments. The young person had an admission plan which included observation levels and early risk indicators appropriate to the level of risk identified. On Gardener unit we sampled three electronic care records and found these to be detailed and these gave a clear understanding of the day to progress of the people who used the service. Each person had a 'recovery file'. This file accompanied the individual through the care pathway, with the person supported in taking more responsibility for their own care and treatment as treatment progressed. In all care records sampled there was evidence of ongoing review, maintaining contact with family and community professionals, and evidence of discharge planning. It was clear that risk management and reduction was viewed positively and patients were well supported in this. Some young people told us shortage of staff had meant the cancellation of escorted leave. We had also received some concerns about this. Senior staff we spoke with acknowledged www.cqc.org.uk 7
there had been some staff shortages due to sickness which had impacted on leave in the past few months, however we were satisfied that the staffing levels on the two units were now consistent after return of staff and newly recruited staff. We noted general health was assessed using a physical health improvement tool (PHIT). This gave a detailed health assessment of each young person. We noted these were completed in a timely manner. It was clear general medical conditions and health were managed effectively and reviews undertaken regularly. www.cqc.org.uk 8
Safeguarding people who use services from abuse Met this standard People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement The trust had well established and robust safeguarding systems in place. There was an effective structure in place to protect patients and support staff. The trust had appropriate lead named individuals as named Dr and Nurse as recommended within the health professionals intercollegiate document: 'Safeguarding Children and Young people: roles and competencies for health care staff". September 2010. There was an integrated safeguarding children and vulnerable adults committee, which was chaired by the executive lead nurse, who was also the director of nursing. An annual safeguarding report was presented to the board. The executive lead also sat on all local safeguarding boards of the local authorities who commissioned services with the trust. We sampled minutes from recent safeguarding boards which demonstrated active engagement, with representation from the trust on various sub groups. We found staff had received appropriate levels of safeguarding vulnerable adults and child protection training. We found when we spoke with staff they demonstrated a good understanding of safeguarding and the types of abuse that could occur. All staff who we spoke with were fully aware of the trust's safeguarding policy and procedure. They were able to identify the reporting structures in place within the trust to escalate safeguarding concerns. When we sampled care files we were able to track a recent safeguarding incident and this had been reported effectively via the internal systems and the appropriate external authorities had been informed. We were also informed by staff that following any escalation of violence, young people were supported in the option to pursue criminal action towards the perpetrator. We had received some concerns about the number of violent incidents on Gardener unit, however we were told by senior staff on duty, the level of violent incidents had reduced. We were informed seclusion was used less in recent months. www.cqc.org.uk 9
When we spoke with staff some concerns were raised. We were told: "Staffing is very low, even with the recent increase, for example, when a situation occurs and patients need to be restrained to do this correctly, three staff are needed, if more than one patient needs restraint, then this leave the ward vulnerable". We discussed this with the senior person who acknowledged that incidents were unpredictable, despite appropriate risk assessments, however they felt confident staffing levels and skill mix were sufficient. We noted risk management plans for young people included enhanced observations, increased therapeutic sessions and seclusion. We spoke about seclusion of young people with senior staff and were told this only happened at such times when the young person was unable maintain their own safety and the safety of others. We were informed the number of times young people required seclusion had reduced in recent months. There was prevention and management of violence and aggression (PMVA) training for staff, with updates available every six months. Structured Assessment of Violence & Risk in Youth (SAVRY) training was also undertaken. We spoke with a total of eight staff across the two units who confirmed they had received training in PMVA. One person explained they had yet to undertake the training since returning to the trust, but said a training date was confirmed. We spoke with young people across the two units who did not raise any concerns about safeguarding or feeling safe within the hospital. One person told us: "I am in the right place and I feel staff do everything they can to support me" and another said:" I feel settled now so yes, I feel a lot safer". We noted the safeguarding work plan with clear objectives in maintaining levels of training for staff, investigation of incidents and dissemination of learning from serious case reviews throughout the organisation and current policy and procedural guidance. www.cqc.org.uk 10
Staffing Met this standard There should be enough members of staff to keep people safe and meet their health and welfare needs Our judgement The provider was meeting this standard. There were enough qualified, skilled and experienced staff to meet people's needs. Reasons for our judgement We made the decision to assess this standard following concerns received about the level of staffing on Gardener Unit. On the day of the visit we found there were sufficient qualified, skilled and experienced staff to meet people's needs. The unit was supporting eight young males, who were admitted from a variety of settings including young offender Institutions, low secure care, police custody and were detained under the Mental Health Act 1983. Total numbers of staff on duty were five staff in the morning, six in the afternoon and four in the evening. Night duty was covered by one qualified and two support staff. We saw there was always at least two Registered Mental Nurses (qualified staff) on during the day shift. At times, due to clinical need, we were told staffing numbers were increased. Senior managers and senior ward staff acknowledged there had been issues earlier in the year when high levels of sickness, combined with retirements and staff reorganisation had caused some problems. The use of bank staff had increased during this period. When we reviewed staff personal files we noted sickness and absence was actively managed under the Trust's managing sickness absence policy. We found there had been active recruitment of qualified nursing and support staff. There was three additional Band 5 staff nurses and internal promotion, which meant an additional team leader had been appointed. We found the multi-disciplinary team consisted of two consultants, a social worker, a psychologist, an advanced or assistant advanced practitioner. Multi disciplinary meetings were held each week. During the inspection we reviewed staffing rotas for the last month on both units and found sufficient staff were allocated. When shortfalls had occurred these were covered by bank arrangements, usually from the staffing establishments on the units. We were told this meant that staff knew the young people well and did not disrupt care or treatment. When we spoke with staff, comments included: "I do feel that managers listen when we report shortages in staff, sometimes things are difficult but we get on with it", "I think staffing is very low, even with the recent increase, when there are incidents, it can be hard" www.cqc.org.uk 11
and "I think things have settled down now, it was tough at the start of the year but things have definitely got better". Young people we spoke with told us the lack of staff had led to some tension when leave was cancelled, This had resulted in occasional violent outbreaks. However it was confirmed these were dealt with quickly and in the" proper manner". www.cqc.org.uk 12
Supporting workers Met this standard Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was meeting this standard. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Reasons for our judgement The trust had a comprehensive training prospectus in place, which staff were able to access to undertake a wide range of training, relevant their roles and responsibilities and personal development. Training was provided either face to face or by e learning. The Recovery Health and Wellbeing Academy had recently been opened and this offered a range of learning opportunities for staff, people who used the service and their families or carers. Training courses were facilitated by health professionals as well as people who had experience of using the service. A newsletter was also available to staff and people who use the service across the trust to keep them updated with courses and training available. When we spoke with staff we were told they were very satisfied with the amount of training that was offered within the trust. Comments included: "One thing I like about working here, there is always opportunities for training", "Yes we have plenty of training, both mandatory stuff and for personal development" and "I hadn't attended training since returning to the trust, but dates have been arranged now". We were able to review four clinical supervision records of staff. We found these were detailed and demonstrated staff were given the opportunity to raise any concerns or comments. Training opportunities for professional development were documented as well as training undertaken. We noted performance issues were appropriately managed. In addition to individual supervision we were informed staff could access support from immediate managers, senior management and appointments with the staff counselling service. We were told support was readily available for those staff who were affected by any incidents. When we spoke with staff about supervision we were told:" We have supervision at least every 6 to 8 weeks, it's trust policy and this is more or less adhered to", "We do have regular supervision, we also have debriefs and "We are able to discuss issues". Community meetings were held on both units weekly. We sampled two meeting minutes www.cqc.org.uk 13
and these gave an opportunity for staff and young people give feedback, to raise issues and make comments about the service. Team leader meetings and staff meetings were also held and when we reviewed the minutes we found staff had the opportunity to discuss issues. There were designated actions to be completed and reported back at the next meeting. Appraisals were undertaken annually and staff we spoke with confirmed they had completed an appraisal. A departmental target for the two units was to undertake all staff appraisals by June. This had been achieved Staff spoke very positively about the team working on the units and said they felt supported and cared about. www.cqc.org.uk 14
Assessing and monitoring the quality of service provision Met this standard The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. Reasons for our judgement The trust had effective and robust systems in place to assess and monitor the quality of the services provided. People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. There was evidence the trust sought patient experience feedback on a regular basis. There was a well established governance committee that had directorate representation from all clinical directorates and from the individual services across Greater Manchester. It was clear assurance was gained in respect of quality of care and treatment from audits that included: measuring compliance with key trust policies and Mental Health Act (MHA) audits and monitoring reports. This included Care Programme Approach (CPA) audits, capacity and consent audits, patient experience surveys and video diaries. There were mechanisms in place to monitor and analyse key performance indicators. The Commissioning for Quality and Innovation payment framework (CQUIN) is a system where a proportion of a trust's income is dependent on the trust reaching goals agreed between it and the organisations commissioning services from the trust. The trust achieved all of its targets for the year /13. These included: Physical health: Development of a physical health shared care agreement, 75% of service users on CPA, or their carers, have been given an information pack, have been given or offered a copy of their care plan, had their views taken into account when their care plan is produced and had the side effects of their medication discussed. There was evidence learning from incidents and investigations took place and appropriate changes were implemented. Information was recorded, collated and analysed centrally. There was evidence of regular meetings for senior nurses and middle-management staff where they discussed learning from incidents and developed action plans to address issues. www.cqc.org.uk 15
Staff confirmed they felt information and learning from serious untoward incidents was appropriately disseminated across the trust. The trust took account of complaints and comments to improve the service. An annual complaints report was presented to the board and the 2012-13 report showed overall that complaints had slightly decreased in the adolescent units in particular. We found when a complaint was upheld an action plan was developed to set out the improvements required. Progress against action plans was monitored by the customer care team. We found staff had appropriate systems in place to give comments and raise concerns. We had received concerns about a recent television programme "Don't call me crazy", which documented the day to day lives of young people being treated in Junction 17. Concerns were raised about the impact the programme may have on the young people featured and the ethical issues raised. During the inspection we were able to verify the comprehensive planning that had taken place prior to the filming of the programme. The programme had been two years in planning and we were satisfied the trust had been extremely vigilant in ensuring appropriate consent had been obtained from the young people, their families and staff involved, prior to filming and during filming. www.cqc.org.uk 16
About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. www.cqc.org.uk 17
How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. www.cqc.org.uk 18
How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. www.cqc.org.uk 19
Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. www.cqc.org.uk 20
Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. www.cqc.org.uk 21
Contact us Phone: 03000 616161 Email: enquiries@cqc.org.uk Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: www.cqc.org.uk Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk 22