The Care Quality Commission (CQC) has told Tees, Esk and Wear Valleys NHS Foundation Trust to make urgent improvements following inspections which took place from June to August.
They carried out an unannounced inspection of forensic inpatient wards due to concerns around unsafe staffing numbers and poor culture within the service. We also looked at how well-led the trust is overall.
In the Harrogate District, they currently operate:
- CAMHS stands for Children, Adolescent Mental Health Services
- CMHT stands for Community Mental Health Teams
- Two wards in the Briary Unit, but now closed
Short notice announced inspections were also carried out at community mental health services for working age adults, crisis services and health-based places of safety, as well as community child and adolescent mental health services (CAMHS). This was due to concerns raised about the safety and quality of these services.
Following this inspection, the crisis services and health-based places of safety had improved and is now rated good, previously it was rated requires improvement.
The overall rating for the trust remains as requires improvement. Community CAMHS also remains rated as requires improvement, and community mental health services for working age adults has gone down from good to requires improvement. The forensic inpatient wards have dropped from good to inadequate.
Brian Cranna, CQC’s head of hospital inspection (mental health and community health services), said:
When we inspected the trust, we found that the leadership team displayed an open and honest culture, however we were concerned regarding the culture within forensic inpatient wards. Due to these concerns we issued the trust with a warning notice, which identified specific areas they must improve in forensic inpatient wards and also improvements required in community child and adolescent mental health services by a set deadline.
During our visit to forensic inpatient wards, we found a poor culture, and staff told us they didn’t feel respected or supported. We found issues with staffing levels which impacted on the quality of care being provided and patients were upset their planned leave didn’t always happen due to this.
Although the trust had commissioned an external review of the culture within the forensic inpatient wards, actions taken to improve it had not been effective. This culture has a negative impact on patient care and must be addressed by the leadership team as a matter of priority.
We were concerned about staffing issues in the community child and adolescent mental health services. People were waiting a long time for autism assessments, and there was a lack of support for people waiting for an appointment. However, we were told the treatment was good quality and staff had provided helpful advice.
The trust has started to address our concerns and know what further improvements are needed to have better oversight of what’s happening across the organisation and improve the culture. We will continue to monitor them and return to inspect on their progress.
In response to the report, trust chief executive Brent Kilmurray said:
We fully accept that there remains much work to be done and we are already taking the steps necessary to address the issues highlighted in this report.
The common factor in most of the issues raised by the CQC is staffing pressures. Easing this pressure is our biggest challenge and we are working extremely hard to resolve this. There is an NHS-wide staff shortage, and the problem is particularly acute in this region. This comes at a time when demand for our services is particularly high and we have invested in recruitment for a range of vacancies and new roles to meet demand.
The pandemic has meant that staff absences due to sickness have been at an all-time high over the last 18 months. It is against this backdrop that our staff are striving to deliver the best possible care.
Our crisis teams – the first port of call for those in urgent need – have performed particularly well to improve their ratings to Good in really difficult circumstances.
That said, we apologise unreservedly for the instances where the high standards we set ourselves have not always been delivered. We are determined to change for the better.
We are taking the culture issues extremely seriously and have put new management arrangements in place to address this, putting our values of respect, compassion and responsibility at the heart of everything we do, all aimed at making this a great place to work.
In the meantime, we will work with the CQC to positively ensure that their requirements are met.
- There were not always enough staff in some services who knew patients well enough to keep them safe. In some services this impacted on the safety and quality of care and meant that staff were not always meeting the needs of patients.
- There were high waiting times in community mental health services for children and young people. There was a lack of oversight of the waiting list management process and risks to children and young people were not reviewed.
- Although overall compliance with mandatory training was good, there were some poor compliance. This meant that some staff did not have the required essential skills needed to deliver safe care.
- Systems and processes to escalate performance and risk issues from ward/team level to board were not effective.
- Staff did not always report and record incidents appropriately.
- Patients were not always appropriately safeguarded from abuse and there was no trust-wide policy for safeguarding adults.
- The trust required continued improvement in its approach to equality and diversity. Staff with disabilities or from a black and minority ethnic background were more likely to experience harassment, bullying or abuse.
- Investigations into complaints and serious incidents were not always carried out in line with trust policies.
- The board had approved further workforce investment for inpatient services and there was an ongoing recruitment process in response to staffing challenges.
- The trust had taken action in response to enforcement action following our inspection of acute and psychiatric intensive care wards. As a result, simplified and introduced more effective systems to assess and manage patient risks within inpatient services.
- There was good engagement with staff, governors and external partners.
- The trust had established a new committee of the board (people, culture and diversity committee) and appointed an executive director for people and culture, to embed a more strategic approach to people and culture within the trust.
- Staff completed annual appraisals, which included discussions on development and career progression.
- There were robust systems in place in relation to the effective management of medicines and controlled drugs.
The trust says it is already making progress with its ‘Our Journey to Change’ strategy. It is improving leadership, working with patients and carers in developing care packages, recruiting a wider range of different professions and disciplines to strengthen teams, using the latest assistive technology and fundamentally working to embed its new values to influence culture change.