All inspections: North Staffordshire Combined Healthcare NHS Trust

Following two serious incidents on the acute wards and psychiatric intensive care unit in January and October 2019, trust investigations had led to recommendations to improve the use of clinical observations and clinical risk management. In the absence of a routine re-inspection of the wards due to Corona Virus the CQC carried out a focused inspection of the service on 17 March 2020 for assurances that these improvements had been put in place. We found:

Staff assessed and managed risks to patients and themselves well. Comprehensive risk assessments were completed for all patients, regularly reviewed and updated when new incidents occurred.
Risk information was effectively handed over between staff, verbally at a meeting at the beginning of each nursing shift, in a written handover document and in the main case notes for each patient. The handover information was updated each shift to reflect any changes in a patient's presentation.
Staff understood the trust's policy on performing supportive clinical observations. They had received training at induction or following the updates made to the trust policy in the summer of 2019. They understood the different levels of observation and how to record their observations and evidence engagement with the patient or signs of life when asleep.
The approach taken to patients with a history of self harming behaviour in using flexible intermittent observations, as observing patients at predictable times can provide the opportunity to plan or engage in harmful activities, was well understood. We found staff followed the trust policy and recorded observations to reflect the changing times.
The wards had a good track record on reviewing incidents. The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

Our rating of the trust improved. We rated it as outstanding because:

We rated safe, effective, and well led as good, caring and responsive as outstanding. Following this inspection, one of the trust’s 11 services are rated as requires improvement, seven are rated good and three as outstanding. In rating the trust, we took into account the previous ratings of the eight services not inspected this time.
The trust had met the requirement notices we set out in our previous report. Medicines safety had improved on the wards for older adults and the community teams. Staff in the community teams now inspected emergency equipment as a matter of routine.
There was good leadership across the trust from the board to front line managers. Managers had the right skills to undertake their roles. The board had good understanding of performance.
The trust ensured that risk assessments were completed and updated regularly. Staff updated risk assessments for each patient to understand how to best support them. Staff had good access to patient records and stored them safely. Staff knew how to keep patients safe and reported incidents, including abuse, when necessary. Staff learnt lessons from incidents.
A range of care and treatment interventions was delivered in line with guidance from the National Institute for Health and Care Excellence (NICE).
The majority of staff had good knowledge of the Mental Health Act, the Mental Capacity Act and the Deprivation of Liberty Safeguards. Staff were up to date with training in the Mental Health Act and Mental Capacity Act.
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and supported their individual needs.
Staff involved patients and those close to them in decisions about their care, treatment and changes to the service. Throughout their recent management of change project, the trust had listened and acted on the feedback of patients, their families and carers.

However:

The trust had not met its responsibility to make all required notifications to the CQC. There had been no notices made of the outcomes of applications to authorise Deprivation of Liberty Safeguards. We had reminded the trust of this obligation in our last report.
The stability of the senior leadership of the trust was at risk with changes in the executive team. The new chief executive, chairperson and remaining board members recognised an opportunity to reflect on their structures, processes and external relationships.
Enhanced reporting on clinical activity in community teams had recently been introduced, which provided assurance to the Board and service managers, but required development to fully establish its reliability and usability
The trust’s pharmacy team was still developing its strategic plan. The team had made some progress in the last year through development of the team’s capacity and skill base.
Some community service’s environmental risk management plans lacked detailed mitigation of identified risks.
There were some omissions in community and crisis services patient care plans related to crisis plans, physical care plans.

Our rating of this service went down. We rated it as requires improvement because:

Care plans were not all individualised. On Ward 6, we found three records where partial identical information had been duplicated across three different patient’s care plans, including the wrong patient’s name. Two records on Ward 4, two did not contain a care plan relating to specifically to factor identified in the risk assessment, for example, fall risk and diabetes.
Ward 7 had two multiple occupancy dormitories which restricted the privacy of patients accommodated in those rooms .

However:

The service provided safe care. Wards were safe and clean. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Wards had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

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

Clinical premises where patients were seen were clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high and staff managed waiting lists well to ensure that people who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multi-disciplinary team and with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The service was easy to access. Staff assessed and treated people who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The service did not exclude people who would have benefitted from care.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

The management plan on how to reduce the risk of identified potential ligature risks was not detailed enough to identify how all the risks were to be mitigated.

We found:

There was no evidence to support the claims made that staff left patients at risk from falls or neglect of their personal care needs.
Patients were all appropriately dressed and had access to the aids they required to reduce their risk of falling. All patients had shoes, slippers or non-slip socks on their feet.
Staff were attentive to patent’s needs and supported patients in maintaining their dignity.
Patients were involved in activities in groups or as individuals. The activity workers had designed a programme of activities that would engage and stimulate the patients on the ward.
Staff addressed the continence needs of patients discretely and offered support when needed. There was no evidence that staff had left any urgent continence need unattended.
The use of restraint was at a low level. Staff were trained in a recognised method of restraint which took into account the potential frailties of the older patient. When staff used restraint they recorded detail of the incident and offered support to the patients afterwards.
The ward was clean and free of any offensive odours. We found all bedrooms to be clean and ready for use.
All permanent staff were trained in safeguarding adults and knew how to identify and report any suspected abuse. The ward manager had acted responsively to the concerns raised and concluded an initial investigation.

However:

There was a failure to effectively monitor the nutrition and hydration of patients identified at risk by medical staff, dietician or through use of the Malnutrition Universal Screening Tool. When fluid input was recorded at less than the prescribed target level no actions were taken to support hydration.
There was no evidence of any individualised assessments of continence needs despite the use of continence aids for the majority of patients on the ward.
Bowel movements had been recorded for some patients. However, there was no evidence that staff regularly reviewed these records to consider if a patient was constipated. In patients with an established cognitive deficit, constipation may make that confusion worse and become the cause of delirium.

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