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Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership

Mersey Care NHS Foundation Trust

Evidence appendix

V7 Building

Kings Business Park

Prescot

Liverpool

L34 1PJ

Tel: 0151 473 0303

www.merseycare.nhs.uk

Date of inspection visit:

29 October to 20 December 2018

Date of publication:

5 April 2019

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.

Trust-wide leadership

Facts and data about this trust Mersey Care NHS Foundation Trust provides specialist inpatient and community mental health,

learning disability and substance misuse services to adults in Liverpool, Sefton and Kirkby. It also

provides community health services to adults and children in Liverpool and South Sefton. The

trust provides specialist high secure and learning disability and autism secure beds to a much

wider population encompassing North West England, parts of central England, and Wales.

The trust was established on 1 April 2001 and granted NHS Foundation Trust status in May 2016.

The trust currently employs almost 8000 staff. The trust provides local mental health, learning

disability and community health services to a population of around 1.2 million people, and

specialist high secure and learning disability services to a population of around 11 million people.

On 1 July 2016 the trust acquired Calderstones NHS Foundation Trust. On 1 June 2017 the trust

acquired the parts of Liverpool Community Health NHS Trust that were providing services in South

Sefton, and on 1 April 2018 the trust acquired the parts of the same trust that were providing

services in Liverpool.

The trust has an annual turnover of £370 million.


At the time of our inspection the trust’s services were delivered through four divisions:

• Secure division comprising high secure services at Ashworth Hospital, medium secure

services at Scott Clinic, low secure services at Rathbone Hospital and mental health

services in HMP Liverpool.

• Specialist learning disability division comprising the low and medium secure wards, an

enhanced support ward and individualised packages of care at the trust’s Whalley site,

along with community, inpatient and respite services for people with a learning disability or

autism living in Liverpool, Sefton or Kirkby.

• Local division comprising the remaining mental health, learning disability and some social

care services provided to the adult population of Liverpool, Sefton or Kirkby.

• Community health division comprising community health services provided to the

population of Liverpool and South Sefton.

The trust’s services were commissioned by:

• NHS England and NHS Wales

• Liverpool, South Sefton, Southport and Formby, Knowsley, St Helens, Halton, West

Lancashire, East Lancashire, North Lancashire and Greater Manchester clinical

commissioning groups.

• Liverpool City Council, Sefton Metropolitan Council, Knowsley Metropolitan Council and

Halton Borough Council.

The trust is also part of the Health and Care Partnership for Cheshire and Merseyside (formerly

Cheshire and Merseyside Sustainability and Transformation Partnership).

The trust had 25 locations registered with the CQC (on 31 October 2018).

Registered location Code Local authority

Ambition Sefton (South) RW41R Sefton

Ambition Sefton North (Church Street) RW41T Sefton

Ashworth Hospital RW404 Sefton

Boothroyd Ward RW449 Sefton

Broadoak Unit RW433 Liverpool

Clock View Hospital RW41E Liverpool

Garston Walk in Centre RW4X1 Liverpool

HMP Liverpool RW4X6 Liverpool

Hesketh Centre RW403 Sefton

Heys Court RW435 Liverpool

Hope Centre RW446 Liverpool

Liverpool Walk in Centre RW4X5 Liverpool

Mersey Care NHS Trust Offices RW498 Knowsley


Registered location Code Local authority

Morley Road RW436 Sefton

Mossley Hill Hospital RW438 Liverpool

Old Swan Walk in Centre RW4X3 Liverpool

Rathbone Hospital RW401 Liverpool

Scott Clinic RW493 St Helens

Sid Watkins Building RW41K Liverpool

Smithdown Children's Walk in Centre RW4X2 Liverpool

Specialist Learning Disability Division RW41P Lancashire

Star Unit RW4W1 Liverpool

Ward 35 Intermediate Care Unit RW4W2 Liverpool

Wavertree Bungalow RW453 Liverpool

Windsor House RW454 Liverpool

The trust had 779 inpatient beds across 53 wards. The trust also had 2133 community physical

health clinics per month and 2195 community mental health clinics per month.

Total number of inpatient beds 779

Total number of inpatient wards 53

Total number of day case beds N/A

Total number of children's beds (MH setting) N/A

Total number of children's beds (CHS setting) N/A

Total number of community physical health clinics per month 2133

Total number of community mental health clinics per month 2042


Is this organisation well-led?

Leadership

The trust had the leadership capacity and capability to deliver high quality, sustainable care. Board

members had the skills, knowledge, experience and integrity needed to lead the trust. They

understood the challenges to quality and sustainability and could identify the actions needed to

address them.

The board comprised a chief executive, chair, executive director of finance (who was also deputy

chief executive), executive director of communications and corporate governance, executive

director of workforce, executive director of nursing and operations and medical director. The trust

also had a non-voting director of strategy. All executive directors had experience at board level

prior to joining the trust. The chief executive had been in post since 2012 and had previously been

chief executive at another NHS organisation. Non-executive directors had managed at very senior

level within private and/or public sector organisations. Two non-executive directors were clinicians

with executive experience in the NHS, four non-executive directors had strong backgrounds in

business and finance, and one non-executive director was a clinician with public health

experience.

NHS Improvement told us that the board was well-established and stable, with a broad range of

experience and skills appropriate to the delivery of high quality care. NHS Improvement also told

us that they had confidence in the director of finance and finance department. Commissioners told

us that the executive team were experienced and open to challenge.

During our well-led review we spoke with all of the board members and the trust secretary.

Executive and non-executive directors had an in-depth understanding of the running of the trust.

The trust’s chief executive and senior leadership team were also well-sighted on national and local

issues that impacted on service provision.

We reviewed all of the board members’ personnel files and undertook a detailed review of the

recruitment process for the most recently appointed executive and non-executive. There were

effective systems in place to ensure that board members were fit for the role on appointment and

throughout their employment. This included fit and proper person checks.

We attended two board meetings. We saw that discussion on issues was balanced and effective,

and that decisions were informed by consideration of quality, performance and strategy. Non-

executives provided constructive challenge and expertise.

The trust also had effective divisional and professional leadership in place. There was a chief

operating officer for each of the four divisions, and professional leads for nursing, psychology,

allied health professionals, social work, pharmacy and medics.

Leaders ensured that they were visible and approachable. Staff who spoke with us during focus

groups and during our inspections of core services knew who the chief executive and chair of the

trust were. One member of staff told us that the chief executive had visited their ward to see how

the staff were after a number of difficult incidents, and another said that the chief executive had

sent them a personal letter of thanks. Board members each engaged in a programme of visits to


services. Many staff told us that senior leaders had visited and worked in their services as part of

‘free up Fridays’. ‘Free up Fridays’ meant that leaders kept Fridays free of meetings so that they

could visit operational teams and work alongside staff. The trust had put this in place following the

results of NHS staff surveys.

The trust had implemented an additional programme of board member and chief operating officer

visits to community health services both before and after the acquisition to ensure that they were

listening to staff and acting on their concerns.

The chief executive published a weekly blog on the trust website. The blogs provided updates on

national, local and trust-level issues. Through his blog, the chief executive consistently gave

positive and motivational messages about staff commitment to ‘go the extra mile’, achievements in

line with trust strategy, and meaningful patient/carer involvement. All people, including staff,

patients, carers and members of the public were able to tell the chief executive what they thought

about the trust through the ‘tell Joe’ email address.

There was evidence of ‘collective leadership’. The King’s Fund define collective leadership as

‘everyone taking responsibility for the success of the organisation as a whole’. The trust had

distributed leadership power according to individuals’ expertise, capability and motivation. This

included patients taking on leadership roles in values-based recruitment and reducing restrictive

practice. We saw and heard about individuals with supportive, enabling and empowering

leadership styles from board level to core service level.

Commissioners told us that the chief executive and executive director of nursing and operations

were accessible and responsive.

There were clear priorities for sustainable, compassionate, inclusive and effective leadership. The

trust had a leadership development programme, which included succession planning.

The trust had undertaken a recent review of the capacity of the board, prompted by the acquisition

of Liverpool Community Health NHS Trust and by the departure (on secondment) of the previous

director of nursing. The role of director of operations was combined with the role of director of

nursing, and many of the previous responsibilities of the director of nursing were distributed

among the rest of the executive team.

The board had considered the implications in detail before combining the director of operations

and director of nursing roles. The chief executive and the director of nursing and operations

explained that the decision was made so that the director would have the authority to facilitate

rapid change in an area (community health) that employed 60% of the trust’s nurses. The chief

executive also explained that he was keen to provide challenge and development to the rest of his

leadership team, and that the spread of the portfolio played to people’s strengths. We saw

evidence of this in some of our interviews, for example the executive director of communications

and corporate governance was passionate and knowledgeable about the trust’s estate. However,

there was also evidence of directors still working to gain full oversight of some of their new

responsibilities.

At the time of inspection, the medical director was seconded to NHS England and NHS

Improvement for two and a half days a week. He also worked as a clinician for one day a week,

which left him one and a half days to fulfil his responsibilities as medical director, Caldicott


guardian, controlled drugs accountable officer, executive lead for Mental Health Act, executive

lead for quality improvement and innovation, executive lead for quality assurance and executive

lead for high secure services. There was no evidence that the medical director did not have

capacity to fulfil his role in the trust. The medical director was skilled, knowledgeable and had

reasonable oversight of all areas within his portfolio. He was well-supported by a team of

associate medical directors and by the director of patient safety. The potential risk of the medical

director being unable to fulfil his role in future was mitigated by the NHS Improvement secondment

coming to an end in March 2019, and by a planned restructure of medical posts within the trust.

The trust planned to commission a well-led and board skills review in 2019. The trust had also

appointed a new director of corporate transformation, directly reporting to the chief executive.

The trust’s leadership development pathway was open to all staff and included three values-based

core programmes: ‘strive’ for bands 5 and below, ‘thrive’ for bands 5 to 7, and ‘drive’ for 8a and

above. The Kirkup review into failings at Liverpool Community Health NHS Trust had identified a

lack of leadership skills at senior and management levels. Mersey Care NHS Foundation trust was

in the process of developing leadership skills for staff in community health teams through their

existing programme (‘thrive’, ‘strive’ and ‘drive’), training new ‘team coaches’ and including staff in

trust leadership forums.

The executive board had 0% Black and minority ethnic (BME) members and 50% women. The

non-executive board had 0% BME members and 43% women. The board recognised that it did

not reflect the demography of the population it served (around nine per cent of Liverpool’s

population is Black or minority ethnic). The board planned for governors to take a lead role in

involving local communities to make services more responsive to those with protected

characteristics.

BME % Women %

Executive 0 (0%) 3 (50%)

Non-executive 0 (0%) 4 (57%)

Total 0 (0%) 7 (64%)

Vision and strategy

There was a clear vision and set of values, with quality and sustainability as the top priorities. The

vision, values and strategy had been developed using a structured planning process in

collaboration with staff, people who use services and external partners.

The trust’s vision was ‘to strive for perfect care and a just culture’. Perfect care was defined as

‘setting our own stretching goals for improvements in care’, ‘getting the basics of care right every

time’ and ‘helping people try improvements, learn from their mistakes and apply what works more

rapidly’. A ‘just culture’ was about supporting and empowering staff to learn when things did not go

to plan, rather than feeling blamed. Staff knew and understood what the vision, values and

strategy were, and their role in achieving them.


In 2018 the trust refreshed their values (continuous improvement, accountability, respect and

enthusiasm) as part of their people plan. The trust had prioritised the alignment of the trust and the

community health team’s values at a very early stage of the acquisition, as they had identified that

staff in Liverpool Community Health NHS Trust had not been working to values. To this end the

trust held a large-scale consultation and engagement event for all staff. The outcome was that a

fifth value was added, ‘support’. Trust values were integral to recruitment processes, staff

appraisals and staff awards. Many of the staff we spoke with during our inspection of services

were able to tell us what the values meant to them and their teams.

There was a robust, realistic strategy for achieving the priorities and delivering good quality

sustainable care. A ‘strategic wheel’ illustrated how the trust intended to achieve its vision through

empowered teams and empowered service users. The trust had four priorities, which were zero

suicides, no force first (reduction in restrictive practice), physical health and a just culture. The

trust had an overall operational plan 2018/2019 with an overall priority to deliver safe care while

developing integrated services. The trust had nine ‘top quality improvement priorities’ underpinned

by clear targets.

NHS Improvement told us that the trust developed robust financial plans for NHS Improvement in

line with national requirements. These plans were aligned to the trust’s overall strategy, with ‘our

resources’ one of the four aims within the operational plan.

The trust’s medicine optimisation strategy aimed to establish a working plan for the expanded

trust. The strategy was based on the four key principles from The Royal Pharmaceutical Society. It

provided a detailed action plan and timeframe necessary to achieve the necessary outcomes from

the strategy.

One of three deputy directors of nursing held responsibility for infection prevention and control.

There were systems in place to manage and monitor the implementation of the trust’s infection

prevention and control strategy.

The strategy was aligned to local plans in the wider health and social care economy. Services had

been planned to meet the needs of the relevant population. The trust’s original bid for community

health services emphasised a model of integrated care, ‘breaking down barriers between physical

and mental health and…addressing the holistic needs of the people using services’. The trust’s

vision was to address the wider factors impacting on poor health and shift towards prevention and

early intervention. We saw evidence of the trust starting to put this vision into action, for example

through the creation of ‘provider alliances’ in Liverpool and Sefton in November 2017 and

February 2018 respectively. Provider alliances were chaired by the trust and facilitated

collaboration between health, social care, voluntary sector and housing organisations who were

linked to or impacted by community services.

The trust was actively involved in the Health and Care Partnership for Cheshire and Merseyside

(formerly Cheshire and Merseyside Sustainability and Transformation Partnership). The trust’s

strategy was closely aligned to local plans in the health and social care economy, particularly in

terms of increased place-based delivery of services. The trust intended to merge its local and

community health divisions, developing integrated community care teams for populations of 30

000 – 50 000. Staff within these teams would be trained to deliver ‘biopsychosocial’ interventions,

with additional support available from specialist colleagues and ‘extended teams’ of voluntary


sector, community provider and hospital services. The trust had originally planned to roll out its

new community model in April 2019 but had amended its timescale to April 2020 following the

recommendations of an external post-acquisition review.

Culture

There was a culture of high-quality, sustainable care. The trust’s culture was centred on the needs

and experience of people who use services. The conversations that we observed at the trust

board meetings focused on the patient experience and the vision to strive for perfect care.

Staff felt supported, respected and valued. They also felt positive and proud to work in the

organisation. Many of the staff in the focus groups told us how passionate they were about

providing high-quality care to patients.

The trust had set up a system for colleagues, patients and/or carers to submit a ‘thank you’ to a

member of staff through the trust intranet. The thank you would also automatically go to the staff’s

manager and on their personnel record. A number of staff we spoke with during our focus groups

said that these ‘thank you’ messages meant a lot to them.

Staff at the trust’s Whalley site voiced some frustration and uncertainty about their future following

NHS England’s decision to close the hospital. Many of the staff from medium secure learning

disability wards spoke positively about the trust’s efforts to promote the new medium secure unit

(Rowan View) being built on the Maghull site. The trust had provided transport for groups of staff

to visit the site. Some staff told us they were now more likely to want to work there following the

closure of the learning disability services provided at Whalley. They said that the journey had not

been as difficult as they expected, and that they looked forward to providing services in the ‘state

of the art’ facilities. Staff from low secure learning disability wards were uncertain about their future

but still told us that communication from the trust had been good. They said that their uncertainty

was outside the trust’s control.

In the 2017 NHS Staff Survey the trust had better results than other similar trusts in six key areas:

Key finding Trust score Similar trusts average

KEY FINDING 20. Percentage of staff experiencing discrimination at work

in the last 12 months

11% 14%

KEY FINDING 16. Percentage of staff working extra hours 69% 72%

KEY FINDING 24. Percentage of staff / colleagues reporting most recent

experience of violence

97% 93%

KEY FINDING 27. Percentage of staff / colleagues reporting most recent

experience of harassment, bullying or abuse

70% 61%

KEY FINDING 31. Staff confidence and security in reporting unsafe

clinical practice

3.79 3.71

KEY FINDING 2. Staff satisfaction with the quality of work and care they

are able to deliver

3.88 3.83


In the 2017 NHS Staff Survey the trust had worse results than other similar trusts in 12 key areas: Key finding Trust score Similar trusts average

KEY FINDING 18. Percentage of staff attending work in the last 3 months

despite feeling unwell because they felt pressure from their manager,

colleagues or themselves

55% 53%

KEY FINDING 15. Percentage of staff satisfied with the opportunities for

flexible working patterns

56% 60%

KEY FINDING 22. Percentage of staff experiencing physical violence from

patients, relatives or the public in last 12 months

27% 22%

KEY FINDING 23. Percentage of staff experiencing physical violence from

staff in last 12 months

3% 3%

KEY FINDING 7. Percentage of staff able to contribute towards

improvement at work

70% 73%

KEY FINDING 12. Quality of appraisals 3.05 3.22

KEY FINDING 13. Quality of non-mandatory training, learning or

development

4.01 4.06

KEY FINDING 30. Fairness and effectiveness of procedures for reporting

errors, near misses and incidents

3.70 3.75

KEY FINDING 4. Staff motivation at work 3.87 3.91

KEY FINDING 8. Staff satisfaction with level of responsibility and

involvement

3.85 3.88

KEY FINDING 9. Effective team working 3.76 3.84

KEY FINDING 10. Support from immediate managers 3.85 3.95

The Patient Friends and Family Test asks patients whether they would recommend the services

they have used based on their experiences of care and treatment.

The trust scored between 87% and 92% for patients who would recommend the trust as a place to

receive care between March 2018 and August 2018. July 2018 saw the highest percentage of

patients who would recommend the trust as a place to receive care with 92%.

The trust was better than the England average in terms of the percentage of patients who would

not recommend the trust as a place to receive care in four of the six months and scored the same

in the remaining two months.

Trust wide responses England averages

Total eligible Total responses

% that would

recommend

% that would not

recommend

England average

recommend

England

average not

recommend

Aug 2018 12,362 408 87% 3% 90% 3%

Jul 2018 12,542 449 92% 2% 89% 4%

Jun 2018 13,282 438 87% 4% 89% 4%

May 2018 14,207 488 91% 2% 89% 4%

Apr 2018 13,997 411 90% 3% 89% 4%

Mar 2018 14,402 388 87% 3% 89% 4%


The Staff Friends and Family Test asks staff members whether they would recommend the trust

as a place to receive care and as a place to work.

The percentage of staff that would recommend the trust as a place to work in Q1 18/19 stayed

about the same when compared to the same time last year.

The percentage of staff that would recommend the trust as a place to receive care in Q1 18/19

increased when compared to the same time last year.

There is no reliable data to enable comparison with other individual trusts or all trusts in England.

The table below gives an overview of trust staffing levels. It provides data on substantive staff

numbers, vacancies and sickness, and use of bank and agency staff. This data was provided to us

by the trust in August 2018 and covers the period 1 August 2017 to 31 July 2018.

Definition

Substantive – All filled allocated and funded posts.

Establishment – All posts allocated and funded (e.g. substantive + vacancies).

Substantive staff figures Trust target

Total number of substantive staff July 2018 6283 N/A

Total number of substantive staff leavers August 2017 – July 2018 640.94 N/A

Average WTE* leavers over 12 months (%) August 2017 – July 2018 13% N/A

Vacancies and sickness

Total vacancies overall (excluding seconded staff) July 2018 634.64 N/A

Total vacancies overall (%) July 2018 -9% 5%

Total permanent staff sickness overall (%) July 2018 8% N/A

August 2017 – July 2018 7% N/A

Establishment and vacancy (nurses and care assistants)

Establishment levels qualified nurses (WTE*) July 2018 2218.5 N/A



Establishment levels nursing assistants (WTE*) July 2018 1652.3 N/A

Number of vacancies, qualified nurses (WTE*) July 2018 180.1 N/A

Number of vacancies nursing assistants (WTE*) July 2018 190.0 N/A

Qualified nurse vacancy rate July 2018 8% 5%

Nursing assistant vacancy rate July 2018 12% 5%

Bank and agency use

Hours bank staff filled to cover sickness, absence or vacancies

(qualified nurses) August 2017 – July 2018 114766 N/A

Hours filled by agency staff to cover sickness, absence or

vacancies (Qualified Nurses) August 2017 – July 2018 63806 N/A

Hours NOT filled by bank or agency staff where there is

sickness, absence or vacancies (Qualified Nurses) August 2017 – July 2018 32534 N/A

Hours filled by bank staff to cover sickness, absence or

vacancies (Nursing Assistants) August 2017 – July 2018 230748 N/A


vacancies (Nursing Assistants) August 2017 – July 2018 94847 N/A

Hours NOT filled by bank staff where there is sickness,

absence or vacancies (Nursing Assistants) August 2017 – July 2018 16859 N/A

*Whole-time Equivalent

The trust reported a 12% vacancy rate for nursing assistants, an 8% vacancy rate for registered

nurses and a 19% vacancy rate for consultants. The trust had 794 posts in the recruitment

process, for which 443.74 offers of employment had been made and/or start dates agreed. The

trust told us that the number of posts in the recruitment process was higher than the number of

vacancies to account for staff who had resigned but not yet left the organisation. The trust’s

overall vacancy rate, 7%, was the same as that reported prior to our previous inspection of March

2017.

The trust had a workforce plan that included consideration of the impact of anticipated staff

retirement on specific services. The trust had a number of recruitment and retention initiatives,

including a ‘retire and return’ mentorship scheme, full use of the apprenticeship levy, funded nurse

training for band 4 staff, investment and development of band 5 staff and a partnership with the

Department of Work and Pensions to offer work-based learning to local people.

As at 31 May 2018, the training compliance for trust wide services was 87% against the trust

target of 90% - some courses had a target of 95%. Of the training courses listed, 30 failed to

achieve the trust target and of those, 14 failed to score above 75%. The training compliance

reported for the trust during this inspection was lower than the 90% reported in the previous year.

Action was taken to address behaviour and performance that was inconsistent with the vision and

values, regardless of seniority. We reviewed six staff disciplinary investigations. Each followed the

trust policy. Investigations were thorough, with information from multiple sources being gathered

and reviewed before decisions were made. Staff members were advised of their rights to


representation and kept informed throughout the process. Five of the investigations had been

resolved in a timely manner. The trust provided valid reasons for the delay in resolving the sixth

investigation.

The culture encouraged openness and honesty at all levels within the organisation, including with

people who use services, in response to incidents. Leaders and staff understood the importance of

staff being able to raise concerns without fear of retribution. Appropriate learning and action was

taken as a result of concerns raised.

The trust had multiple ways for staff to report concerns – through the freedom to speak up

guardian, by following the whistleblowing policy, using ‘tell Joe’ (an email address for the chief

executive) or through their staff side representative. The chief executive told us that this had on

occasion resulted in more than one investigation into the same issue. The trust planned to move to

a single point of triage to ensure consistency.

The trust had two freedom to speak up guardians, a freedom to speak up (whistleblowing) strategy

and a freedom to speak up (whistleblowing) policy. The policy met the standards set out in NHS

Improvement’s ‘freedom to speak up: raising concerns (whistleblowing)’ policy (2016). The

freedom to speak up guardians had the training and experience to be able to perform their roles.

They raised awareness through the trust website/intranet, posters (many of which we saw during

our inspection) and by visiting service sites. Staff we spoke with on inspection and in focus groups

knew who at least one of the guardians were and said that they felt confident to approach them

with any concerns. Staff also told us that they knew how to use the whistleblowing process and felt

confident to raise concerns without fear of retribution.

The trust undertook seven whistleblowing investigations in 2018. We reviewed five of them.

Investigations were thorough and objective. Outcomes and lessons learned were shared with

relevant individuals, including the original whistleblower where their identity was known.

The trust’s culture encouraged candour at all levels and candour was central to organisational and

personal learning. The trust duty of candour policy met the requirements of the regulation. During

our inspection we undertook a detailed review of six incidents where the trust had applied duty of

candour. Staff had followed the trust policy. They had informed people of the incident and provided

an apology, truthful information and reasonable support.

The trust monitored the application of duty of candour against the regulation. Between April 2018

and December 2018, the trust applied the duty of candour to 75 patient safety incidents. There

were 34 deaths, four incidents of severe harm, and 37 incidents of moderate harm. The severe

and moderate harms mainly related to self-harm for the local and secure divisions, and to pressure

ulcers for the community division. A family liaison manager or clinical lead was appointed to

manage each case. A letter of apology was sent to 63 patients or families. There were no contact

details in five of the cases, and no reply to contact from the trust in a further seven cases.

Commissioners told us that they were not confident that the trust was applying duty of candour to

moderate harm incidents. We found some evidence to corroborate this during our inspections of

community health services. When we looked into this further we found that the trust had recently

re-assessed a number of incidents occurring between April 2018 and October 2018. They had

originally identified only two moderate harm incidents; following their review this increased to 28.

The trust had also made some changes to their policy to clarify thresholds for patient safety


incidents and appointed a single member of staff to manage duty of candour in the community

division.

The trust considered the safety and wellbeing of staff. The trust’s overall sickness rate was 8%,

which was the same as the sickness rate reported prior to our March 2017 inspection. The trust’s

overall sickness rate is higher than the average for mental health and learning disability trusts

(which is 5% according to figures published by NHS Digital). A number of the staff that we spoke

with during our focus groups said that high levels of staff sickness impacted on their workload and

morale. Some staff said that it was difficult to take breaks and holidays as they were required to

cover for colleagues who were absent.

The trust had plans in place to reduce sickness absence. These included the development of a

sickness absence reduction plan based on the Department of Health ‘5 high-impact changes’, an

audit to identify and plan support for individual teams reporting sickness absence higher than 6%,

additional short-term investment in staff support services.

The medical director told us that there had been no breaches of safe working hours for junior

doctors. The British Medical Association representative said that there were very few rota gaps.

However, some of the junior doctors working at the trust told us that they were not encouraged to

report when their actual work had varied from an agreed work schedule. We spoke with the

guardian of safe working hours, who confirmed that he believed that junior doctors were working

over their hours on occasion but not making exception reports. This meant that the trust could not

be assured that risk of staff fatigue was being adequately mitigated against. The guardian stated

that exception reporting was encouraged at the junior doctors’ induction, by email and through the

junior doctors’ forum. The minutes of the most recent junior doctors’ forum confirmed this, however

the meetings were not well-attended.

Equality and diversity were promoted within and beyond the organisation. The trust had an

equality, diversity and human rights strategy and an equality committee chaired by a non-

executive director. The director of workforce was the executive lead for equality and diversity. The

trust had recently undertaken a full review of their equality and diversity strategy in conjunction

with staff networks. All trust policies included an equality impact assessment.

The trust had recognised that having a single equality and diversity network for staff was not

effective, so they had re-established specific networks for Black and minority ethnic staff, LGBTQI

staff, disabled staff and women. At the time of the inspection the Black and minority ethnic and the

women’s network had very recently launched and the LGBTQI was due to launch in January 2019.

Staff within the networks had agreed that part of their role would be to ensure services were

accessible to all, as well as supporting colleagues within the trust. The Black and minority ethnic

staff network was co-producing the workforce race equality standard action plan alongside the

trust’s human resources team.

The trust had a reciprocal mentoring scheme for Black, minority ethnic and disabled staff. The

trust had also invited Roger Kline (author of research into discrimination in the NHS) to speak to

the board and members of the Black and minority ethnic network.

The trust had plans in place to recruit more staff from Black and minority ethnic communities in

Liverpool. The trust was keen to ensure that the ethnic make-up of its staff reflected that of its


patients, particularly in high secure services where a higher proportion of patients were from Black

and minority ethnic backgrounds.

There were cooperative, supportive and appreciative relationships among staff. Staff and teams

worked collaboratively, shared responsibility, and resolved conflict quickly and constructively.

One of the trust priorities was the ‘just and learning culture’. The aim of the just and learning

culture was to value all safety concerns as integral to learning and improvement. The just and

learning culture had only just been added to the trust vision when we last inspected the trust in

2017. When we returned, we saw that it had become embedded at all levels from board to service

delivery. Trade union representatives told us that they had seen a significant shift in the way that

staff felt about the trust’s approach to serious incidents. The trust told us that the number of

disciplinary investigations had reduced by 54% since 2016. The trust’s just and learning culture

initiative had won the 2018 Healthcare People Management Association award for partnership

working, had been referenced by the British Medical Association and NHS Improvement as best

practice, and had featured in a number of healthcare magazines and a short film.

We spoke with representatives of six different trade unions. Representatives were all positive

about the work that the trust had done to include staff as an integral part of trust strategy and

reduce the numbers of staff disciplinaries. Representatives told us that trust executives always

took the time to listen and explain.

The trust had appointed to a staff side lead ‘just and learning’ post, whose main responsibility

would be to further embed the just and learning culture within community health services.

There were mechanisms for providing all staff at every level with the development they needed,

including high-quality appraisal and career development conversations. The trust’s target rate for

appraisal compliance was 95%. As at 31 July 2018, the overall appraisal rate for non-medical staff

was 86%. Fifteen of the 18 core services achieved the trust’s target appraisal rate. The rate of

appraisal compliance for non-medical staff reported as of 31 July is higher than the 74% reported

for the previous financial year.

Core Service

Total number of

permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

% of non-medical

staff who have had

an appraisal

MH - substance misuse 32 32 100%

MH - Other Specialist Services 84 82 98%

MH - Long stay/rehabilitation mental health

wards for working age adults 57 55 96%

CHS - End of Life Care 18 17 94%

MH - Community mental health services for

people with a learning disability or autism 189 175 93%

MH - Wards for people with learning

disabilities or autism 562 520 93%

MH - Community-based mental health 126 116 92%


Core Service

Total number of

permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

% of non-medical

staff who have had

an appraisal

services for older people

MH - Acute wards for adults of working age

and psychiatric intensive care units 306 279 91%

MH - Secure wards/Forensic inpatient 280 255 91%

CHS - Urgent Care 76 69 91%

CHS - Sexual Health 73 66 90%

MH - Wards for older people with mental

health problems 153 134 88%

CHS - Community Dental 71 61 86%

MH - Forensic (high secure) 824 705 86%

MH – Crisis 85 72 85%

CHS - Children, Young People and

Families 210 175 83%

CHS - Adults Community 1629 1343 82%

MH - Community-based mental health

services for adults of working age 790 624 79%

Total 5565 4780 86%

The trust’s target rate for appraisal compliance was 95%. As at 31 July 2018, the overall appraisal

rate for medical staff was 79%. The trust did not supply appraisal data for permanent medical staff

for core services other than those in the table below. One of the three core services achieved the

trust’s target appraisal rate. The one core service failing to achieve the trust’s appraisal target was

CHS Community Dental (77%). The rate of appraisal compliance for medical staff reported as of

31 July 2018 is higher than the 66% reported for the previous financial year.

Core Service

Total number of permanent

medical staff requiring an

appraisal

Total number of permanent

medical staff who have had

an appraisal

% of medical staff

who have had an

appraisal

CHS Sexual Health 7 7 100%

CHS Adult Community 0 0 N/A

CHS Community Dental 26 20 77%

Total 33 27 81%

The trust’s target for staff compliance with clinical supervision was 90%. The relevant trust policy

stated that clinical staff must have a minimum of 6 supervision sessions annually unless there are

mitigating circumstances authorised by the service manager. According to the data the trust

provided to us, as at 31 July 2018, the overall clinical supervision rate was 32%. Excluding

community health services and looking only at the divisions (secure, specialist learning disability


and local) that had been part of the trust for a substantial period, the overall supervision rate was

48%.

The trust’s target for staff compliance with clinical supervision was 90%. The table below shows

the level of compliance by each core service.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different

ways. It is important to understand the data they provide.

Core Service

Formal supervision

sessions each identified

member of staff had in the

period

Formal supervision

sessions should each

identified member of staff

have received

Clinical

supervision

rate (%)

MH - Substance misuse 15 15 100%


services for older people 128 140 91%

MH - Other Specialist Services 142 173 82%

MH – Crisis 153 200 77%

MH - Wards for older people with mental

health problems 181 238 76%

MH - Acute wards for adults of working age

and psychiatric intensive care units 435 626 69%

MH - Forensic (high secure) 1039 1734 60%

MH - Long stay/rehabilitation mental health

wards for working age adults 76 133 57%


services for adults of working age 1842 3794 49%

MH - Secure wards/Forensic inpatient 296 646 46%

MH - Community mental health services for

people with a learning disability or autism 50 116 43%

MH - Wards for people with learning

disabilities or autism 333 1932 17%

CHS - Children, Young People and

Families 134 2688 5%

CHS - Adults Community 26 2274 1%

CHS - End of Life Care 0 53 0%

CHS - Sexual Health 0 93 0%

CHS - Urgent Care 0 226 0%

Other 253 0 0%

TOTAL 4850 15334 32%

The data presented above is from a trust system that was in development at the time of

inspection. The trust told us that central collection had only been possible for three months, not 12

months.


We calculate trust staff’s compliance with clinical supervision by comparing the number of

sessions attended with the number that should have been attended over a given period (in this

case, one year). Mersey Care NHS Foundation Trust calculate compliance by comparing the

number of staff who have attended clinical supervision within the last eight weeks to the number of

staff who have not. Mersey Care’s own figures give a compliance rate of 54% for secure, specialist

learning disability and local divisions in June 2018 and a compliance rate of 67% for the same

divisions in July 2018. By December 2018, the compliance rate was 85%.

The trust said that local managers had advised them that the figures relating to August 2017 – July

2018 did not reflect the true picture. Figures for compliance with clinical supervision were held in

individual databases, separate SharePoint systems and manually. During our inspections of core

services, we found evidence that staff were accessing regular clinical supervision. The trust had

recently altered the electronic recording system to allow staff to more easily log unplanned clinical

supervision and supervision of staff who they did not line manage.

The trust was asked to comment on their targets for responding to complaints and current

performance against these targets for the last 12 months.

In Days Current Performance

What is your internal target for responding to* complaints? 3 100%

What is your target for completing a complaint? 25 65%

If you have a slightly longer target for complex complaints please indicate what

that is here N/A N/A

* Responding to defined as initial contact made, not necessarily resolving issue but more than a confirmation of

receipt

**Completing defined as closing the complaint, having been resolved or decided no further action can be taken

Total Date range

Number of complaints resolved without formal process*** in the

last 12 months 2313 1 August 2017 – 31 July 2018

Number of complaints referred to the ombudsmen (PHSO) in the

last 12 months 0 1 August 2017 – 31 July 2018

**Without formal process defined as a complaint that has been resolved without a formal complaint being made. For

example, PALS resolved or via mediation/meetings/other actions

We reviewed six complaints investigations. We found that the trust handled complaints effectively.

Complaints investigators worked with external organisations when there was evidence that this

would help to understand and resolve the issue. Each complaints report had clear outcomes and

actions that had been communicated to the complainant in writing. Any delays in resolving

complaints were monitored through the trust performance report. A new patient experience

working group, chaired by a non-executive, reviewed themes of complaints.

The trust received 157 compliments during the last 12 months from 1 August 2017 to 31 July

2018. The ‘CHS Adult Community’ core service had the highest number of compliments with 119

(76%) followed by ‘CHS Sexual Health’ with 10 (6%).


Governance

There were effective structures, roles and systems of accountability to support good governance

and management. These were regularly reviewed and improved. The trust had five committees

that reported directly to the board of directors: the audit committee; the executive committee; the

performance, investment and finance committee; and the remuneration and terms of service

committee. A number of sub-committees, project groups and working groups reported into the

committees and were effective in monitoring performance and risk throughout the trust. Terms of

reference for the board and committees were reviewed at least annually. Each committee also

produced an annual report, which the audit committee reviewed against the terms of reference.

There was evidence that people were held to account for delivery of actions.

Trust governors told us that they had received effective induction, training and support to enable

them to carry out their roles. They described a very positive working relationship with the trust

board, and were well-informed on the trust strategy. They understood their role in holding the

board to account. The lead governor attended board meetings and submitted questions for

discussion. However, governors did not routinely get the opportunity to speak with non-executive

directors without executive directors being present.

All levels of governance and management functioned effectively and interacted with each other

appropriately. There was a visible and consistent approach to risk management and board

assurance. The board assurance framework comprehensively described the risks facing the trust,

the relationship between those risks, and the strategy for dealing with them. It was reviewed

regularly and used to determine the board’s cycle of business. The trust’s committee structure

enabled two-way communication of quality information. We reviewed minutes of each of the five

committees, which showed that meetings were well-attended and that agenda items were

escalated and acted upon as appropriate. We tracked a newly identified risk relating to children in

care and saw that it was escalated through the trust’s governance processes and promptly added

to the board assurance framework.

Progress with integration of community health services with the rest of the trust was reported to

the board through the transitions sub-committee in the form of a bi-monthly community services

improvement programme update. The action plan was comprehensive, including 45 issues rated

red, amber or green. Alignment of policies was one of the issues listed, however during our

inspection of core services we found that some of the community health policies had exceeded

their review date.

The trust provided a document detailing their highest profile risks. Each of these have a current

risk score of four or higher. The risks listed in the table below carry a current risk rating of 12 or

higher.

ID Description Risk level

(initial)

Risk score

(current)

Risk level

(target)

Next review

date

SFG03 IF safeguarding children services are not

delivered by North West Boroughs as contracted,

then the quality of services of the organisation

may be compromised, resulting in reputational

12 16 4 28 Oct 2018


ID Description Risk level

(initial)

Risk score

(current)

Risk level

(target)

Next review

date

and financial implications for Mersey Care

EPRR01 Major outbreak of pandemic flu 20 12 3 1 Nov 2018

EPRR02 (DRAFT) Storms and Gales (Storm force winds

affecting most of region for at least 6 hours)

12 12 6 1 Nov 2018

EPRR09 Flooding in the local community 12 12 3 30 Nov

2018

EPRR10 Loss of Utilities – Gas / Electricity / Water 12 12 4 1 Nov 2018

IT04 If the organisation does not proactively address

by aging IT infrastructure issues. Then it may fail,

resulting in increased downtime, loss of data and

disruption to critical administrative and clinical

systems

12 12 4 17 Sep

2018

IT05 If network, resilience across Trust sites is not

reviewed, then there may be significant network

outages and major disruptions to financial and

clinical systems.

12 12 4 17 Sep

2018

WF09 If the organisational effectiveness plan is not be

implemented effectively, then the quality of care

will be compromised

16 12 8 31 Aug

2018

BI02 If systems do not integrate properly, then

reporting will be inaccurate and confidence in

reporting will be reduced.

15 12 6 31 Jul 2018

All staff at all levels were clear about their roles. They understood what they were accountable for,

and to whom. Responsibilities for oversight of risk mitigation were clearly assigned to board

members and board committees. NHS Improvement told us that the roles of responsibility and

structures for accountability and governance were clearly established, including financial reporting

to the board and budget management throughout the organisation.

The director of patient safety and relevant managerial and clinical staff took ownership of action

plans arising from investigations into deaths and serious incidents. We saw that recommendations

to improve practice had been implemented, both in the service where the incident occurred and

across the wider trust.

Arrangements with partners and third-party providers were governed and managed effectively to

encourage appropriate interaction and promote coordinated, person-centred care.

There were robust arrangements to make sure that hospital managers discharged their specific

powers and duties according to the provisions of the Mental Health Act 1983.


The trust submitted details of seven external reviews commenced or published between 1 August

2017 and 31 August 2018.

Management of risk, issues and performance

There were clear and effective processes for managing risks, issues and performance.

There were comprehensive assurance systems. Performance issues were escalated appropriately

through clear structures and processes. These were regularly reviewed and improved.

Since October 2018, the trust had used a ‘safety huddle’ process to escalate and communicate

risk. This replaced the trust’s previous process, which was an executive ‘stand up’ meeting and

divisional surveillance meeting (as described in our June 2017 inspection report). We observed an

executive ‘safety huddle’, which was attended by executives, chief operating officers and other

relevant staff. The huddle routinely discussed two risks from the risk register, along with all

operational risks that had been escalated through the divisions’ own safety huddles. During the

meeting we observed, risks discussed included waiting lists for low secure services, pressure

ulcers and delayed discharges. Relevant risk and quality data was provided on electronic screens,

allowing the executives to quickly analyse the situation, understand current mitigations, propose

further actions and ultimately gain assurance that risk was being managed effectively.

Staff across the trust knew how to recognise and report safeguarding concerns. The director of

nursing and operations was the executive safeguarding lead, supported by the deputy director of

nursing (who also chaired the safeguarding strategy group). There was a named doctor for

safeguarding, and each service had a dedicated safeguarding lead. The minutes of the

safeguarding strategy group were reviewed by the quality assurance committee, and we saw that

a significant safeguarding concern about delivery of services to children in care had been

escalated effectively to the board. However, the trust did not currently have a non-executive lead

for safeguarding and we could not find evidence of performance on safeguarding being monitored

at board level. Commissioners told us that the trust did not always correctly identify safeguarding

concerns within their serious incidents.

There were processes to manage current and future performance. These were regularly reviewed

and improved. The trust monitored progress on the operational and through the bi-monthly

performance report to divisional leadership teams, the trust board and its committees. The

performance report also included metrics on regulatory targets (CQC’s five domains and NHS

Improvement’s single oversight framework). The trust used performance improvement plans,

reviewed quarterly, to provide assurance around areas of underperformance.

The trust had agreed to undertake a full review of incidents and investigations occurring in

Liverpool Community Health NHS Trust between 2010 and 2014 to comply with the

recommendations of the Kirkup Review. The trust had extended the scope to cover incidents and

investigations up to 2018. The board had made the decision to ensure they were fully aware of the

live risks presented by the acquisition, despite the additional strain on resources and delay in

meeting the Kirkup recommendations that this would entail.

There was a systematic programme of clinical and internal audit to monitor quality, operational and

financial processes, and systems to identify where actions should be taken. We saw evidence of

improvements in practice being made from clinical audit during our inspections of core services.


The trust completed medicines audits on a regular ongoing basis. These included controlled

drugs, antimicrobial utilisation, medicine reconciliation, and safe and secure storage audits. Areas

of concern highlighted in the audits were addressed and re-audits planned to assess changes.

The trust was a member of POMH-UK and participated in their national quality improvement

audits.

However, commissioners told us that they were not fully assured that the trust was conducting

audits to ensure compliance with National institute for Health and Care Excellence guidelines.

There were robust arrangements for identifying, recording and managing risk issues and mitigating

actions. There was alignment between the recorded risks and what staff said was ‘on their worry

list’. Divisional senior managers were able to escalate clinical risks onto the trust risk register

through the safety huddle. Any risk rated 15 or higher went straight up to the board assurance

framework and to the chief executive.

Overall themes from CQC’s Mental Health Act monitoring visits were communicated to the board

through the safety report. Clinical staff within the relevant division monitored and audited actions

from the reports, with oversight from the trust’s mental health law governance group.

Action plans were built in to the risk register and were part of the regular review process.

Potential risks were taken into account when planning services, for example seasonal or other

expected or unexpected fluctuations in demand, or disruption to staffing or facilities.

The trust had a comprehensive business continuity plan, which included considerations of the

impact of the UK’s exit from the European Union. The trust had a dedicated emergency

preparedness, resilience and response team who were in the process of assessing the trust’s

status against the required actions set out in the government’s EU Exit Operational Readiness

guidance for health and care services.

The trust had worked with local acute trusts to develop a plan around increased use of health

services during winter. The trust intended to evaluate the effectiveness of their winter plans at the

end of February 2019. This would inform winter planning for the following year, intended to begin

in April 2019.

The trust assessed and monitored the impact on quality and sustainability when considering

developments to services or efficiency changes.

The trust undertook quality impact assessments for all proposed cost improvements. The trust’s

quality impact assessments effectively identified any potential adverse effects on services and

were underpinned by sound clinical governance systems. They were signed off with the

knowledge and participation of the clinicians who were delivering the services. The trust’s medical

director had responsibility for clinical quality because the director of nursing and operations was

responsible for achieving the cost improvement plans.

There were no examples of financial pressures compromising care. Despite this, NHS

improvement told us that the trust’s that financial performance had been consistently strong. They

said that cash, capital and revenue plans were being delivered in line with plans and national


requirements, and that review meeting discussions with NHS Improvement had demonstrated that

financial risks have been identified and mitigated by the trust.

Providers must report all serious incidents to the Strategic Executive Information System (STEIS)

within two working days of identifying an incident.

Between 1 August 2017 and 31 July 2018, the trust reported 298 STEIS incidents. The most

common type of incident was ‘Apparent/actual/suspected self-inflicted harm’ with 72. Twenty-one

of these incidents occurred in the ‘MH Community-based mental health services for adults of

working age’, 18 in ‘MH Forensic High Secure’ and 16 in MH Mental health crisis services and

health-based places of safety. Other core services accounted for less than 10 each.

Never events are serious incidents that are entirely preventable as guidance, or safety

recommendations providing strong systematic protective barriers, are available at a national level,

and should have been implemented by all healthcare providers. This trust reported zero never

events during this reporting period.

We asked the trust to provide us with the number of serious incidents from the same period on

their incident reporting system. The number of the most severe incidents was not comparable with

the number the trust reported to STEIS. There were 298 serious incidents reported to STEIS (as

the per the CQC download of STEIS) but the trust told us about 305 serious incidents in their

RPIR return.

Type of incident reported

on STEIS

MH

Fo

ren

sic

Hig

h S

ecu

re

CH

S A

du

lts

Co

mm

.

MH

Co

mm

. S

erv

ices f

or

Ad

ult

s o

f W

ork

ing

Ag

e

MH

Secu

re / F

ore

nsic

Inp

ati

en

t

MH

Acu

te w

ard

s f

or

ad

ult

s o

f

wo

rkin

g a

ge a

nd

PIC

U

MH

Ward

s f

or

peo

ple

wit

h

learn

ing

dis

ab

ilit

ies o

r au

tism

MH

Men

tal h

ea

lth

cri

sis

serv

ice

s a

nd

HB

Po

S

MH

Ward

s f

or

old

er

peo

ple

wit

h m

en

tal h

ealt

h p

rob

lem

s

To

tal

Abuse/alleged abuse of adult patient by staff

25 1 2 3 31

Abuse/alleged abuse of adult patient by third party

2 2 4 9

Abuse/alleged abuse of child patient by third party

1 1

Accident e.g. collision/scald (not slip/trip/fall)

13 1 15

Apparent/actual/suspected homicide

1 1

Apparent/actual/suspected self-inflicted

18 2 21 1 8 16 3 72

Confidential information 2 1 1 1 2 1 1 14



on STEIS

MH

Fo

ren

sic

Hig

h S

ecu

re

CH

S A

du

lts

Co

mm

.

MH

Co

mm

. S

erv

ices f

or

Ad

ult

s o

f W

ork

ing

Ag

e

MH

Secu

re / F

ore

nsic

Inp

ati

en

t

MH

Acu

te w

ard

s f

or

ad

ult

s o

f

wo

rkin

g a

ge a

nd

PIC

U

MH

Ward

s f

or

peo

ple

wit

h

learn

ing

dis

ab

ilit

ies o

r au

tism

MH

Men

tal h

ea

lth

cri

sis

serv

ice

s a

nd

HB

Po

S

MH

Ward

s f

or

old

er

peo

ple

wit

h m

en

tal h

ealt

h p

rob

lem

s

To

tal

leak/information governance breach

Disruptive/ aggressive/ violent behaviour

6 4 2 2 7 1 1 24

Environmental incident 3 1 4

Major incident/ emergency preparedness, resilience and response/ suspension of services

8 2 10

Medication incident 1

Pending review 9 5 4 4 2 28

Pressure ulcer 36 1 39

Slips/trips/falls 1 2 8 16

Sub-optimal care of the deteriorating patient

1 1

Substance misuse whilst inpatient

6 2 9

Surgical/invasive procedure incident

2 2

Treatment delay meeting SI criteria

1 1

Unauthorised absence 25 11 7 1 20

Total 84 47 32 26 26 24 19 15 298


on STEIS

Oth

er

MH

Co

mm

. m

en

tal h

ealt

h s

erv

ice

s

for

peo

ple

wit

h a

lea

rnin

g

dis

ab

ilit

y o

r au

tism

N/A

MH

Su

bsta

nce m

isu

se

CH

S C

hil

dre

n,

Yo

un

g P

eo

ple

an

d

Fam

ilie

s

CH

S C

om

mu

nit

y In

pati

en

ts

MH

Co

mm

. b

ased

men

tal

healt

h

serv

ice

s f

or

old

er

peo

ple

CH

S S

exu

al h

ealt

h

To

tal



on STEIS

Oth

er

MH

Co

mm

. m

en

tal h

ealt

h s

erv

ice

s

for

peo

ple

wit

h a

lea

rnin

g

dis

ab

ilit

y o

r au

tism

N/A

MH

Su

bsta

nce m

isu

se

CH

S C

hil

dre

n,

Yo

un

g P

eo

ple

an

d

Fam

ilie

s

CH

S C

om

mu

nit

y In

pati

en

ts

MH

Co

mm

. b

ased

men

tal

healt

h

serv

ice

s f

or

old

er

peo

ple

CH

S S

exu

al h

ealt

h

To

tal


31

Abuse/alleged abuse of adult patient by third party

1 9

Abuse/alleged abuse of child patient by third party

1

Accident e.g. collision/scald (not slip/trip/fall)

1 15

Apparent/actual/suspected homicide

1

Apparent/actual/suspected self-inflicted

1 2 72

Confidential information leak/information governance breach

3 1 1 14

Disruptive/ aggressive/ violent behaviour

1 24

Environmental incident 4

Major incident/ emergency preparedness, resilience and response/ suspension of services

10

Medication incident 1 1

Pending review 2 2 28

Pressure ulcer 2 39

Slips/trips/falls 1 1 2 1 16

Sub-optimal care of the deteriorating patient

1

Substance misuse whilst inpatient

1 9

Surgical/invasive procedure incident

2

Treatment delay meeting SI criteria

1



on STEIS

Oth

er

MH

Co

mm

. m

en

tal h

ealt

h s

erv

ice

s

for

peo

ple

wit

h a

lea

rnin

g

dis

ab

ilit

y o

r au

tism

N/A

MH

Su

bsta

nce m

isu

se

CH

S C

hil

dre

n,

Yo

un

g P

eo

ple

an

d

Fam

ilie

s

CH

S C

om

mu

nit

y In

pati

en

ts

MH

Co

mm

. b

ased

men

tal

healt

h

serv

ice

s f

or

old

er

peo

ple

CH

S S

exu

al h

ealt

h

To

tal

Unauthorised absence 1 20

Total 6 5 4 3 2 2 2 1 298

Providers are encouraged to report patient safety incidents to the National Reporting and Learning

System (NRLS) at least once a month. They do not report staff incidents, health and safety

incidents or security incidents to NRLS.

The highest reporting categories of incidents reported to the NRLS for this trust for the period

August 2017 to July 2018 were ‘self-harming behaviour’, ‘patient accident’, ‘disruptive, aggressive

behaviour’ and ‘implementation of care and ongoing monitoring / review’. These four categories

accounted for 75% of the incidents reported. ‘Self-harming behaviour’ accounted for 24 of the 30

deaths reported.

Ninety percent of the total incidents reported were classed as no harm (62%) or low harm (28%).

Incident type No harm Low harm Moderate Severe Death Total

Self-harming behaviour 1288 915 153 22 24 2402

Patient accident 742 570 148 27 0 1487

Disruptive, aggressive behaviour

(includes patient-to-patient) 856 232 29 3 0 1120

Implementation of care and ongoing

monitoring / review 328 388 267 25 2 1010

Medication 531 34 13 0 0 578

Access, admission, transfer,

discharge (including missing

patient) 512 25 10 1 1 549

Treatment, procedure 212 44 27 3 0 286

Patient abuse (by staff / third party) 167 11 4 0 2 184

Infrastructure (including staffing,

facilities, environment) 149 4 1 0 0 154

Other 73 27 3 0 1 104

Consent, communication,

confidentiality 82 5 0 0 0 87


Incident type No harm Low harm Moderate Severe Death Total

Documentation (including electronic

& paper records, identification and

drug charts) 45 4 1 0 0 50

Total 5026 2269 656 82 30 8063

According to the latest six-monthly National Patient Safety Agency Organisational Report (April

2017 – September 2017) there is no evidence for potential under reporting by this trust.

Organisations that report more incidents usually have a better and more effective safety culture

than trusts that report fewer incidents. A trust performing well would report a greater number of

incidents over time but fewer of them would be higher severity incidents (those involving moderate

or severe harm or death).

Mersey Care NHS Trust reported more incidents from August 2017 to July 2018 compared with

the previous 12 months. While the trust reported more incidents in the most recent 12 months (up

to 8063 from 6890), they reported proportionately more incidents resulting in moderate harm and

severe harm than they did in the previous 12 months. Additionally, the proportion of no harm

incidents reduced from 72.9% to 62.3%.

The rise in moderate and severe harm was due to the acquisition of physical health services,

which record a much higher rate of incidents involving harm (such as pressure ulcers).

Level of harm August 2016 – July 2017 August 2017 – July 2018

No harm 5026 (72.9%) 5026 (62.3%)

Low 1451 (21.1%) 2269 (28.1%)

Moderate 302 (4.4%) 656 (8.1%)

Severe 49 (0.7%) 82 (1.0%)

Death 62 (0.9%) 30 (0.4%)

Total incidents 6890 8063

We reviewed six serious incident cases from the trust. We saw that all relevant details regarding

the incident were recorded, including strategic executive information system numbers, patient

details, and a comprehensive executive summary for each case. Patient and carer involvement

was evident in each case. Where root cause analysis took place we saw evidence of patient,

family and carer involvement in the terms of reference for the investigation. Learning was a key

element of each investigation, with positive practice and learning from negative aspects noted and

considered. Learning was shared using action plans, forums and correspondence. We saw that

investigators took a fair and balanced approach to the investigation. Conclusions were reached


with consideration of all evidence available. We saw that investigators used input from other

organisations, with assistance from social workers and advocates.

We also reviewed nine investigations into deaths. The reports varied in their quality and level of

detail, but each took a systematic approach to understanding potential causes of the death and

identifying lessons learned. When contact details were known, investigators gave families and

carers the opportunity to be involved. In cases where carers had chosen to be involved, there was

clear evidence of their input into terms of reference and/or the investigation and clear evidence

that reports had been shared with them.

Information Management

Appropriate and accurate information was being effectively processed, challenged and acted on.

There was a holistic understanding of performance, which sufficiently covered and integrated

people’s views with information on quality, operations and finances. Information was used to

measure for improvement, not just assurance. The trust’s executive performance report included

regulatory and operational plan key metrics. It was presented at each meeting of the board,

enabling executives and non-executives to quickly understand the challenges facing the trust at

that time.

Quality and sustainability both received sufficient coverage in relevant meetings at all levels. All

staff had sufficient access to information, and challenged it appropriately. Live data on risk and

quality was visible during safety huddles.

There were clear and robust service performance measures, which were reported and monitored.

NHS Improvement told us that the trust had comprehensive financial information stored and

reported from appropriate financial ledger systems. At service level, managers had access to a

range of performance information.

There were effective arrangements to ensure that the information used to monitor, manage and

report on quality and performance was accurate, timely and relevant. Action was taken when

issues were identified. NHS Improvement told us that the Information the trust provided to them

was consistent, reliable and accurately reflected the organisation. The trust used a ‘kitemark’

system to grade the quality of data on which performance reports were based. A green or mostly

green mark meant that the reader could be highly confident in the data; a red or mostly red meant

less confident. Information staff worked to improve the quality of data.

Information technology systems were used effectively to monitor and improve the quality of care.

The trust was a global digital exemplar (an internationally recognised NHS provider delivering

exceptional care through the use of digital technology). Projects included use of the electronic

prescribing and medicines administration system in high secure services, electronic record sharing

between general practitioners and trust services, and ‘dashboard’ views of caseloads for

community mental health staff.

The trust had not had to seek an out-of-area placement for any patient for over one year. The trust

held daily teleconferences for bed management with active monitoring of potential admissions

through accident and emergency or through stepped up care in community mental health teams.


The trust had also implemented NHS Improvement’s ‘Red2Green’ approach to identify and reduce

delays to discharge.

However, the trust held clinical information in 18 different electronic systems (mainly due to the

acquisition of other organisations). This posed a challenge for both staff and analysts in terms of

being able to input, extract and combine data. The trust was working towards better harmonisation

of systems.

There were effective arrangements to ensure that data or notifications were submitted to external

bodies as required. The trust was proactive in working with commissioners and regulators.

However, commissioners told us that when they asked for additional information about operational

teams, there was often a significant delay before the trust was able to provide this information.

There were robust arrangements (including appropriate internal and external validation) to ensure

the availability, integrity and confidentiality of identifiable data, records and data management

systems, in line with data security standards. Lessons were learned when there were data security

breaches. The trust had a separate senior information risk owner and Caldicott guardian, in line

with best practice. The trust reported nine data breaches to the information commissioner’s office

in 2017/2018, none of which resulted in a fine. When serious data breaches occurred the trust

shared lessons learned with staff through the chief executive’s blog and by sending letters out with

payslips.

Engagement

People who used services, the public, staff and external partners were engaged and involved to

support high-quality sustainable services. This included those with a protected equality

characteristic.

The trust had a programme of service user and carer engagement led by the social inclusion and

participation team. The trust was developing a new approach for patients, carers, staff, Foundation

Trust members and wider communities to work ‘side by side’ with each other to improve

engagement, participation and services. The core principles of ‘side by side’ are empowerment

and seeing things from the patient’s perspective. This approach was integrated with the trust’s

quality improvement plan.

The trust actively sought the views of community health patients. The Community Health

Acquisition sub-committee had approved funding for a 12-month programme of intensive patient

and carer engagement, which had started in May 2018. A report to the Liverpool and Sefton

Physical Community Services Programme in December 2018 stated that the project team had

spoken with nearly 200 patients and family members about the care they received across a wide

range of services. The trust also regularly met with Healthwatch Liverpool and Healthwatch

Sefton. However, community health service patients were not yet involved in the running of the

trust. The December 2018 interim report showed how the trust was considering changing their

approach to co-production to reflect the different needs and interests of these patients.

Board of directors’ meeting agendas included a personal story from a patient, carer or member of

staff. Two patient/carer representatives sat on the quality assurance committee. The trust routinely

included patient and carer experience in their reviews of care quality, for example in the evaluation

of the effectiveness of winter plans for community health services.


However, we found that although some governors attended trust engagement events and were

part of service user groups, they did not always have a strong presence in the wider community

and workplace. This meant that they could not be assured that they were representing the views of

the majority of trust members on matters that may impact on the trust’s strategy.

There were positive and collaborative relationships with external partners to build a shared

understanding of challenges within the system and the needs of the relevant population, and to

delivers services to meet those needs.

Commissioners told us that the trust was very engaged in the Health and Care Partnership for

Cheshire and Merseyside. The trust’s strategy for integrated care involved a range of other local

stakeholders. The trust had also worked closely with two other mental health trusts around

perinatal mental health, and partnered with a local college to help develop young people’s careers

in health and social care.

NHS England selected Cheshire and Merseyside mental health providers to become a pilot site for

a new care model, PROSPECT, for low and medium secure mental health services. The trust was

the lead provider in the PROSPECT partnership, which also included two other local trusts and

two independent sector providers. PROSPECT was in its very early planning stages, but was

intended to bring low and medium secure services together as a coherent, recovery-focused

system ‘rooted in communities and place’.

The trust had opened ‘life rooms’ in Walton, Southport and most recently Bootle. Life rooms

offered recovery college courses, employment advice, and support with computer and literacy

skills to members of local communities (including patients and carers). Life rooms provided non-

stigmatising, social opportunities for recovery from mental health problems. They formed part of

the trust’s overall strategy for community-based care.

There was transparency and openness with all stakeholders about performance. Commissioners

gave positive feedback about the accessibility of the trust’s executive team, particularly the chief

executive and the director of nursing and operations.

Learning, continuous improvement and innovation

There were robust systems and processes for learning and continuous improvement. Quality

improvement and innovation were central to the trust’s vision to strive for perfect care.

Leaders and staff strived for continuous learning, improvement and innovation. This included

participating in appropriate research projects and recognised accreditation schemes.

There was a visible and proactive approach to offering and delivering research within the trust.

There was an associate medical director for research, development and innovation, a research

and development manager and an innovation lead for Perfect Care. The medical director was the

board member responsible for research. The Centre for Perfect Care coordinated and facilitated

individual projects. In April 2018 the trust had 54 research studies underway and a further 21 new

studies pending. The trust’s website included information about the trust’s research strategy and

activity. The website also explained how staff, patients and carers could participate in existing

projects or submit an application to the trust.


There were standardised improvement tools and methods. Staff had the skills to use them.

The trust had a dedicated quality improvement team called the Centre for Perfect Care. The

Centre for Perfect Care supported staff to access national evidence to support their clinical

decision-making, form their ideas for improvement into viable proposals reflecting the strategic

priorities of the trust, and involve patients and carers in a meaningful way. The Centre for Perfect

Care used the Model for Improvement to support the planning and implementation of change.

There was an emphasis on exploring ideas and testing them out on a small scale to evaluate the

benefits before introducing them fully into services. The trust’s quality improvement strategy

focused on six main areas: the just and learning culture, reduction in restrictive practice,

improvements in physical health pathways, zero suicide, reduction of community-acquired

pressure ulcers and learning from deaths.

The trust had identified that staff in community health services were not always using the same

criteria to grade pressure ulcers, leading to inconsistent reporting. The trust’s work with staff had

led to a 19% increase in accurate reporting.

Participation in and learning from internal and external reviews, including those related to mortality

or the death of a person using the service, was effective. Learning was shared and used to make

improvements. The trust had a learning from death policy which reflected national guidance. It had

a dedicated mortality review team, who coordinated the process of triaging deaths, ensuring 72-

hour reviews were completed where appropriate and monitoring action plans. Staff learning from

deaths and other serious incidents took place through quality practice alerts, divisional

newsletters, weekly bulletins, Oxford learning events and team debriefs.

All staff regularly took time out to work together to resolve problems and to review individual and

team objectives, processes and performance. This led to improvements and innovation.

During our March 2017 inspection, we saw that the trust had worked closely with patients and

community providers to ensure that people with a learning disability admitted to the trust’s Whalley

site had the best possible chance of a successful discharge. Since that time, the trust had staffed

a new specialist support team across Lancashire, South Cumbria and Greater Manchester. The

specialist support team worked with people with a learning disability and a history of offending

behaviour and/or behaviour that challenged others, as well as people with autism and no learning

disability. The purpose of the team was to support people in community settings either following

discharge from hospital, or proactively to prevent admission in the first place. We spoke with

members of the new teams in our focus groups. They were highly motivated individuals who spoke

with passion about the work they were doing alongside patients, experts by experience, and trust

colleagues (including the chief executive).

There were systems to support improvement and innovation work, including objectives and

rewards for staff, data systems, and processes for evaluating and sharing the results of

improvement work.

The trust’s guide to reducing restrictive practice had been adopted by the World Health

Organisation. Since our last inspection, the trust had continued to refine and roll out ‘no force first’

across all of its mental health and learning disability services. The trust had achieved a further

20% reduction in physical restraint between October 2017 and October 2018, although was still

keen to make further improvements particularly in the area of staff and patient injury.


The trust had been awarded ‘Best Learning and Development Initiative for the Public Sector’ at the

CIPD People Management Awards 2018. The trust had addressed some of its recruitment and

retention problems by offering opportunities to local communities who were experiencing high

levels of unemployment. The trust worked with the Department of Work and Pensions, the Skills

Funding Agency and Health Education England to deliver a six-week pre-employment values-

based training programme. Candidates were able to obtain certificates in health and social care,

information technology and customer service through a mixture of classroom sessions and work

experience at the trust. Seventy-nine per cent of candidates went on to full employment within the

trust.

NHS Improvement told us that the trust had a strong track record of delivering on its financial

plans, managing cash, capital and revenue effectively. The trust finance department was

accredited by Future Focused Finance as level 3 (the highest level), which reflects comprehensive

systems and engagement for staff development and best practice across a range of measures.

The table below provides information on financial metrics. The trust was on target to deliver their

financial control total in 2018/2019. They had managed a number of financial pressures from non-

recurrent resources. The trust had plans in place to reduce its high spend on locum medics by

reducing the non-clinical responsibilities of its substantive consultant workforce. However, the trust

was facing a potential cost improvement plan gap of £7.6 million in 2019/2020.

Historical data Projections

Financial Metrics Previous financial

year (2 years ago)

Last financial year

(April 2017 – March

2018)

This financial year

Next financial year

(April 2019 – March

2020)

Income 247.703 276.581 368.411 356.200

Surplus 4.831 6.958 5.485 4.100

Full costs -242.872 -269.623 -362.926 -352.100

Budget 4.831 5.162 5.485 4.100

NHS trusts can take part in accreditation schemes that recognise services’ compliance with

standards of best practice. Accreditation usually lasts for a fixed time, after which the service must

be reviewed. This trust was not awarded any accreditations.

NHS Improvement told us that the trust had successfully produced a full business case that was

approved by NHS Improvement and the Department of Health and Social Care for the construction

of a £52m new medium secure unit, demonstrating appropriate management of risk and

production of appropriate analysis for major projects.

Mersey Care NHS Foundation Trust evidence appendix: community dental services

Community dental services

Facts and data about this service

The Community Dental Service (CDS) provides dental, clinical and public health services on a

referral basis from a health professional, complementing and supplementing those of the General

Dental Services.

The service covers the geographical areas of Liverpool, Sefton and Knowsley with a number of

fixed dental clinics.

Care is provided in community settings for patients who have difficulty accessing treatment in

high street dental practices and who require treatment on a referral basis which is not available in

a general dental care setting.

The service is strictly by appointment and access to many of the dental services is by referral

from a health professional.

Information about the sites which offer community dental services at this trust is shown below:

Location site name Team/ward/satellite

name Patient group

Number of clinics per month

Geographical area served

Hartington Road Dental Health Education &

Promotion Contract Mixed N/A Liverpool

Hartington Road Dental Health

Promotion Mixed N/A Liverpool

Hartington Road Clinic, Hartington Road, Liverpool,

L8 0SH

Knowsley Orthodontics Dental

Contract Mixed N/A Liverpool

Hartington Road Clinic, Hartington Road, Liverpool,

L8 0SH

River Alt Paediatric Dental Contract

Mixed 128 Liverpool

Vauxhall Health Centre Vauxhall Paediatric

Dental Service Contract

Mixed 117 Liverpool


courses. For example, manual training was completed as both a face to face course which was

supported by on-line learning. Staff told us that the infection prevention and control training was

dental specific and was done on-site. Staff demonstrated to us how they arranged courses

provided by the trust. Staff told us that there was a three day block each month where they could

complete training. This was considered protected time.

Mandatory training was monitored by both management and individual staff. Staff showed us the

electronic system they used to monitor their own training. They told us that they were sent e-mails

to prompt them to complete training as and when it was required. Managers also had oversight of

training levels and prompted staff to complete training at staff meetings.

We were told that the dental service did not hold its own training budget which posed problems

when staff required specific training which was not provided by the trust. External training courses

required authorisation from management outside of the dental service. We were told that on

occasion the payment for these courses had been delayed preventing staff applying for courses

which demand payment at the point of application. In addition, we were told that evidence of

completion of training had been withheld by external organisations until payment for the courses

had been received.

Safeguarding

Safeguarding referrals

A safeguarding referral is a request from a member of the public or a professional to the local

authority or the police to intervene to support or protect a child or vulnerable adult from abuse.

Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and

institutional.

Each authority has its own guidelines as to how to investigate and progress a safeguarding

referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will

work to ensure the safety of the person and an assessment of the concerns will also be conducted

to determine whether an external referral to Children’s Services, Adult Services or the police

should take place.

Community dental services made one safeguarding referral between 1 August 2017 and 31 July

2018. This occurred in May 2018.

The trust had policies and procedures relating to the safeguarding of children and vulnerable

adults. We were shown there were contact details within these polices for the trusts safeguarding

team and the local authority. The dental clinical manager attended bi-monthly trust safeguarding

meetings and had good links with the safeguarding team. Staff told us they felt comfortable to

contact the safeguarding team for advice, guidance or help when required. We were shown an

example of when they sought advice from the safeguarding team relating to concerns identified.

These concerns had been well documented and reported as significant event through the trusts

electronic incident reporting system.

If the dentists had concerns about a child or vulnerable adult, then they could access their medical

records to see if there was any other information recorded about the patient. In addition, we were


told that at Maghull Health Centre there were health visitors and school nurses based there who

they could liaise with if they had concerns about any children.

As part of mandatory training all staff were required to complete safeguarding of children and

adults level one and two. In addition, the specialist paediatric dentist had completed level three

safeguarding children training. As of March 2018, 93% of staff had completed level two

safeguarding children and adult training.

Staff had a good awareness of the signs and symptoms of abuse and neglect. These included

modern day slavery and the prevention of radicalisation. Staff had completed PREVENT training

as part of the mandatory training. They were also aware of the issues of children or vulnerable

adults who were not brought to appointments. All means possible would be made to contact the

parent or carers to arrange another appointment. If multiple appointments were missed, then a

safeguarding referral would be considered on an individual basis.

Cleanliness, infection control and hygiene

The service used a system of local decontamination at each clinic for the reprocessing of used

dental instruments and equipment. They followed guidance issued by the Department of Health -

Health Technical Memorandum 01-05: Decontamination in primary care dental practices (HTM 01-

05).

Used dental instruments and equipment were initially decontaminated using an automated washer

disinfector. If the automated washer disinfector failed, then staff resorted to manual scrubbing of

instruments. We saw evidence of this during the inspection and the process and staff followed the

guidance issued in HTM 01-05. After decontamination, instruments were then inspected under

illuminated magnification to check for any residual debris or damage prior to being placed in an

autoclave for sterilisation. After sterilisation instruments were bagged and stamped with a “use by”

date of one year from the date of processing. At River Alt Resource Centre, we noted that

sterilised instruments were left out for over two hours before being bagged. We highlighted this to

staff on the day of inspection and were told that they would ensure more timely bagging of

sterilised instruments.

Staff described the regular testing of equipment used for decontaminating and sterilising used

dental instruments and equipment. We saw logs of the daily, weekly and three-monthly checks

carried out. These were in line with guidance issued in HTM 01-05.

Hand washing facilities and alcohol hand gel were available throughout the clinic areas. Personal

protective equipment (PPE) such as gloves and masks were readily available throughout the

clinics. However, we noted that staff did not always wear a visor and a disposable apron when

carrying out decontamination duties. We observed staff followed the “arms bare below the elbow”

guidance.

Infection prevention and control audits were carried out every six months. We saw that the results

of the audits were discussed at the six-monthly management review meetings. The results of

these audits ranged from 96% to 99% compliance.

We saw that there were suitable arrangements for the handling, storage and disposal of clinical

waste, including sharps. Safer sharps use was in accordance with the European Directive for the


safer use of sharps. Sharps injury protocols were displayed in surgeries and the decontamination

rooms.

Staff described the process for managing dental unit water lines. This included flushing the water

lines for two minutes at the beginning of the session and end of session. Legionella management

including water temperature testing and flushing of infrequently used outlets was carried out by an

external contractor.

Environment and equipment

Premises and equipment were clean, hygienic and well maintained. There was sufficient

equipment to support safe and effective care. These included dental handpieces and other dental

instruments.

The service was based in premises which were managed by a building management company

who were responsible for the up keep and maintenance at the premises including general

cleaning. We saw daily checklists for the dental nurses to follow to ensure the surgeries and bays

were clean prior to starting a session and after a session had been completed.

The service had a system in place to ensure equipment was maintained appropriately and in line

with regulation or manufacturers guidance. A spreadsheet was kept with dates of when equipment

was last serviced and when it was due to be serviced again. This ensured that all equipment was

correctly maintained.

We found that at each site we inspected equipment was present for dealing with medical

emergencies. This included an automated external defibrillator (AED), emergency medicines and

medical oxygen. Emergency medicines and equipment were in line with guidelines issued by the

British National Formulary (BNF) and the Resuscitation Council UK. We noted that at Maghull

Community Dental centre the bags which some of the oropharyngeal airways were in had been

opened. We raised this issue on the day of inspection and we were told it would be addressed.

We viewed records relating to the safe use of X-ray machines. We saw evidence that these were

maintained according to the Ionising Radiation Regulations 2017. We noted that the routine test of

the X-ray machines at River Alt Resource Centre had recommended that a system was put in

place to ensure that both X-ray machines cannot be operated at the same time. This had not been

done.

A radiation protection advisor (RPA) and radiation protection supervisor (RPS) had been

appointed. We saw local rules for each X-ray machine outlining how each machine should be

operated. These were in line with the Ionising Radiation Regulations 2017.

When X-rays were taken they were justified, reported on and quality assured every time. Dental

care records which we reviewed supported this. This ensured that the service was acting in

accordance with the Ionising Radiation (Medical Exposure) regulations IR(ME)R and protected

staff and patients from receiving unnecessary exposure to radiation.

When domiciliary visits were carried out the premises was risk assessed to ensure they were

suitable to provide treatment. An initial telephone risk assessment was carried out. Then at the

first visit a more detailed risk assessment was completed. Emergency medicines and equipment


were taken on domiciliary visits. An automated external defibrillator was not taken on these visits;

however, this was risk assessed.

Assessing and responding to patient risk

The service took a pro-active approach to reducing the risks associated with the carrying out of the

regulated activities.

We look at examples of dental care records. We were told and saw evidence that the clinicians

recorded patient safety alerts. Medical histories were taken and updated as necessary. Medical

histories included any allergies or conditions which may affect treatment. There was a system in

place for flagging patients with a medical condition.

The clinicians completed a Tooth Extraction Safer Surgery Checklist (TESCC) for any extractions

which were carried out either under local or general anaesthetic. This involved recording the teeth

to be extracted on a sheet and double checking them with another member of staff prior to

extracting them. These were used to reduce the chance of wrong site surgery. The use of TESCC

was actively monitored through audit and discussed at meetings to ensure compliance.

We attended a general anaesthetic session. We saw that a safety huddle was carried out at the

start of the session. This involved a staff introduction, identification of roles and responsibilities

and to discuss the patients who were to be seen and any associated risks or potential

complications. This included patient co-operation or any medical conditions. Checks were

completed on the equipment prior to getting the patient into the surgery. The dentist completed a

TESCC for each patient and recorded the teeth to be extracted on a white board in the surgery.

We witnessed the dentist double checking the teeth which needed to be extracted prior to placing

the forceps on the tooth.

The service used hoists to assist wheelchair users to get into the dental chair. We discussed with

staff about the process for doing this. They had completed both hands on and online training about

the use of hoists. We asked if there was a set protocol or procedure for the use of hoists. Staff told

us that there was not one and felt this would be beneficial as there were some staff who used the

equipment infrequently.

Patients and their parents or carers were provided with written and verbal information about pre

and post-operative instructions about treatments. This minimised the risk of the patient suffering

from post-operative complications such as post extraction haemorrhage or infections. Information

leaflets were given to patients and chaperones with details about what to do after having treatment

under inhalation sedation or general anaesthesia.

Staff were aware of the process to follow in the event of a medical emergency. There were always

adequate numbers of appropriately trained staff at each clinic to deal with a medical emergency. If

a patient became acutely unwell then they would be treated by trained members of staff and an

ambulance would be called if considered necessary. There was a policy in place which provided

staff with guidance about the signs and symptoms of sepsis. This also included what steps to take

in the event of a patient presenting with sepsis.

The dentists used rubber dams in line with guidance from the British Endodontic Society when

providing root canal treatment.


Mercury and blood spillage kits were readily available at all locations which we visited.

The service had a process for receiving national patient safety alerts such as those issued by the

Medicines and Healthcare products Regulatory Agency (MHRA). Where relevant, these alerts

were shared with all members of staff at staff meetings.

Staffing

Total numbers – Planned vs Actual

This data was not provided for community dental services.

Vacancies

Between August 2017 and July 2018, the trust reported an overall vacancy rate of 12% in

community dental services.

Staff group Total number of substantive staff Total % vacancies overall (excluding seconded staff)

Qualified Nurses 0.0 -

Nursing Assistants

0.0 -

Other 16.4 12%

Core service total 16.4 12%

Turnover

Between August 2017 and July 2018, the trust reported an overall turnover rate of 5% in

community dental services.

Staff group Total number of substantive staff

Total number of substantive staff leavers in the last 12 months

Total % of staff leavers in the last 12 months

Qualified Nurses 0.0 0.0 0%

Nursing Assistants

35.7 0.6 5%

Other 36.2 0.5 4%

Core service total 71.8 1.1 5%

Sickness

Between August 2017 and July 2018, the trust reported an average sickness rate of 5% for the

last 12 months for community dental services.

Staff group Total number of substantive staff Average sickness over 12 months

Qualified Nurses 0.0 -

Nursing Assistants 35.7 4%


Other 36.2 6%


Nursing – Bank and Agency Qualified Nurses and Healthcare Assistants

Between August 2017 and July 2018, this core service did not use any bank or agency staff.

Medical locums

The trust did not provide any data for this core service.

Consultant cover

The trust has advised that for community dental services there was no consultant cover.

Suspensions and Supervisions

During the reporting period, this core services reported that there were zero cases where staff

have been either suspended or placed under supervision.

We were told that recently the service was experiencing high levels of sickness. This had

impacted on other staff members especially dental nurses. We were told that it had been tough

recently due to staff shortages and they were often moved around different clinics to provide cover

if there were gaps. Staff told us that they felt “a bit frazzled” as a result of staffing issues.

There was a process in place to ensure clinics such as general anaesthesia were not cancelled as

these were high priority. The dental nurse managers would also work in surgery to cover any staff

shortages. It was clear that the resilience and maturity within the workforce always put patients’

best interests first. Staff were proud to tell us that they do not cancel patients because of staff

shortages. We were told that they were actively recruiting for new dental nurses to help ensure

better staffing levels.

Appropriately trained dental nurses supported the dentists carrying out sedation. All staff had

completed immediate life support training.

Quality of records

Dental care records were mainly computerised. Computers were password protected and backed

up to secure storage to keep patient details safe. There were also paper records held. These were

stored in locked filing cabinets in a secure area. If domiciliary visits were carried out, then either a

lap top computer was taken on the visit or records were recorded on paper and then transferred to

the electronic system when the staff returned to the clinic.

The electronic record keeping system was available at all sites included where general

anaesthesia was carried out.

A record keeping audit had not yet been carried out under the new provider. We saw evidence of

one which had been completed approximately a year ago under the previous provider. We were

shown evidence of a record keeping audit which was planned to be completed soon. This audit


had been amended to ensure it covered the key areas which need to be included in the dental

care records.

We looked at a selection of dental care records and these were clear, concise and well

maintained. They included details of an oral examination, any special tests such as X-rays,

consent and any treatment which had been carried out.

Medicines

Medical gases used for the provision of inhalation sedation were stored securely. They were either

chained to the wall or attached to the machines used in the provision of inhalation sedation. Staff

carried out checks on the medical gas cylinders prior to carrying out inhalation sedation to ensure

there was sufficient amounts of gas to provide the treatment. We saw that a recent incident had

been raised at St Chads Community Dental Clinic regarding the storage of medical gases. They

were stored in a cage outside the building. Staff had identified that the area inside the cage had

become littered with leaves and general waste as it was in a public area. It was also open to

inclement weather conditions. As a result of this, staff had moved these cylinders to inside the

dental service to ensure they were stored safely.

NHS prescription pads were stored securely and there was a process in place to actively monitor

their use. An antibiotic prescribing audit had been carried out by the foundation dentist. The first

audit had identified that not all the clinicians were recording a diagnosis and justification for

prescribing an antibacterial. A follow up audit was completed which showed improvements had

been made.

Safety performance

There had not been any never events at the community dental services in the previous 12 months.

Never events are serious patient safety incidents that should not happen if healthcare providers

follow national guidance on how to prevent them. Each never event type has the potential to cause

serious patient harm or death but neither need have happened for an incident to be a never event.

An example of a never event in dentistry is a wrong tooth extraction.

Staff were familiar with the concept of a never event and described to us the process for reporting

these.

Incident reporting, learning and improvement

Serious Incidents - STEIS

Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).

These include ‘never events’ (serious patient safety incidents that are wholly preventable).

In accordance with the Serious Incident Framework 2015, the trust reported zero incidents (SIs) in

community dental services between August 2017 and July 2018.

Serious Incidents – SIRI (trust data)

Between 1 August 2017 and 31 July 2018, trust staff in this core service reported zero serious

incidents.


Staff described to us how incidents, accidents and near misses were reported. The main pathway

was to record these on the trusts electronic reporting system. Any incidents or accidents which

were reported on the trusts electronic reporting system were sent to the clinical directors, the

operations manager and the dental clinical manager. These were discussed at the weekly

operations meetings. We reviewed incidents which had been recorded and saw that these had

been investigated and where applicable actions put in place to prevent reoccurrence. Incidents

were also discussed at the weekly safety huddle meetings which the operations manager attended

with other services. Staff told us that the trust put pressure on the service to close down incident

reports within three weeks even if the actions identified had not yet been completed.

The community dental service also had a system in place to feedback any learning from incidents.

These were called “Notification Of Clinical Improvement” (NOCI). This system worked hand in

hand with the trusts electronic reporting system. Staff were able to submit concerns, near misses

or incidents through this system. These would be investigated by the assistant clinical director. If

the notification was deemed to require documentation on the trusts electronic reporting system,

then this was done. We saw evidence of when this had been done for an incident. If the incident

was something which was deemed to require further dissemination to staff, then a “Clinical

Improvement Notice” (CIN) was produced and sent by e-mail to all staff. There was also “Golden

Clinical Improvement Notices” which were sent out with read receipts to ensure all staff had read

them. Staff told us that they had confidence in the NOCI system as they knew that anything which

they submitted would be read, considered and discussed where appropriate. We were told that

this system had increased reporting. They told us that this system had provided stability in times of

uncertainty through changes of organisations. We discussed the system in detail with staff and

identified that when a staff member submitted a NOCI then this was only sent to one individual.

This would pose a problem if this member of staff was ever away for a long period of time. In

addition, the policy relating to the use of NOCI had not been updated since 2002.


Is the service effective?

Evidence-based care and treatment

The clinicians provided care, treatment and advice in line with national guidelines to ensure

patients received the most appropriate care. This included the guidance produced by the British

Society for Disability and Oral Health, the National Institute for Health and Care Excellence and

the Royal College of Surgeons. Staff we spoke with were fully aware of these guidelines and the

standards which underpinned them. We looked at a selection of dental care records which

confirmed this.

When providing inhalation sedation, the clinicians followed guidance set out by the Royal Colleges

of Surgeons and the Royal College of Anaesthetists ‘Standards for Conscious Sedation in the

Provision of Dental Care’ 2015.There was a policy in place to support the provision of inhalation

sedation which referenced the guidance. We looked at a selection of dental care records which

evidenced that the clinicians titrated the level of sedation on an individual basis to ensure it was

provided safely.

Nutrition and hydration

Patients undergoing general anaesthesia were given appropriate information by staff of the need

to fast before undergoing their procedure. The patient, parent or carer were given a pre-operative

instruction sheet emphasising the importance of fasting prior to the procedure.

Children having treatment under inhalation sedation were advised to eat and drink normally but

ensure the meal before the appointment should be kept small and at least two hours before the

appointment. This was detailed in the instruction sheet provided to patients.

Pain relief

The dentists told us that they discussed different methods of pain and anxiety management.

These were assessed on an individual basis for patients. They took in to account the patients age,

level of co-operation and complexity of treatment required. For example, where a young, nervous

child attended requiring multiple extractions where local anaesthesia was not possible then a

general anaesthetic was provided.

We saw evidence in dental care records that different methods were discussed such as local

anaesthetic alone, inhalation sedation and general anaesthesia.

We were told that topical anaesthetics were always used prior to any injections. This helps reduce

any pain associated with the injection.

Patient outcomes

Audits – Changes to working practices

The trust have participated in zero clinical audits in relation to this core service as part of their

Clinical Audit Programme.


The service used quality assurance processes to monitor and improve patient outcomes and

ensure quality and safety were not compromised. The service took a proactive approach towards

audit. We saw audits of X-rays, antibiotics prescribing and infection prevention and control. These

audits all had results and action plans associated with this. Staff were aware of the results of these

audits as they were discussed at team meetings. However, we were told that individual results of

the X-ray audits were not provided to the clinicians. The service also audited the proportion of

fluoride varnish applied to patient’s teeth. The results for September 2018 (after exception

reporting) showed that 100% of children and 83% of special care adults received fluoride varnish.

Competent staff

Clinical Supervision

No clinical supervision information was provided for this core service.

Appraisals for permanent non-medical staff

Between April 2018 and July 2018, 86% of permanent non-medical staff within the community

dental core service at the trust had received an appraisal compared to the trust target of 95%. This

is higher than the 80% appraisal rate reported for the previous financial year.

Total number of permanent non-medical staff requiring an appraisal

Total number of permanent non-medical staff who have had an appraisal

% appraisals

71 61 86%

Appraisals for permanent medical staff

Between April 2018 and July 2018, 77% of permanent medical staff within the community dental

core service at the trust had received an appraisal compared to the trust target of 95%. This is

higher than the 67% reported for the previous financial year.

Staff were encouraged to complete additional training relevant to their roles. This was to cater for

the ever-increasing complexity of the patient base.

Many dental nurses told us that they had completed additional qualifications including radiography,

fluoride varnish, oral health education, clinical photography and sedation. They told us that these


Total number of permanent non-medical staff who have had an

appraisal % appraisals

26 20 77%


had been utilised within the service. For example, we were told that the dental hygiene therapist

had been applying fluoride to children’s teeth. After one of the dental nurses had completed the

fluoride application course and started their own clinic then this freed up time for the dental

hygiene therapist and increased access for them.

Staff told us that they had annual appraisals where they discussed training needs. They told us

that as a result of the appraisal they developed a personal development portfolio. Staff told us that

they felt the appraisal process was positive and beneficial.

Some of the dentists were on the specialist register with the General Dental Council for paediatrics

and Special Care Dentistry.

The service used dental hygiene therapists. Dental hygiene therapists are qualified dental

professionals who can carry out treatments such as fillings and extraction of deciduous teeth.

They had also received training in the use of inhalation sedation and often used this. Staff told us

that they played an important role and patients appreciated them.

Multidisciplinary working and coordinated care pathways

The service worked well with other healthcare professionals to understand and meet the range

and complexity of people’s needs.

Multidisciplinary team (MDT) meetings were held for patients who lacked capacity or for those who

had complex medical or clinical needs. Staff provided us with example of when they worked

collaboratively with other healthcare professionals. These included staff from the maxilla-facial

team at the local dental hospital, GPs and other surgical departments. They worked together to

ensure to ensure the best possible outcome for the patient.

Referrals were received into the service through an online referral management service. These

came from dentists, GPs or other healthcare professionals. These referrals were initially triaged in

the referral administration centre and then allocated to the most convenient and appropriate clinic

for the patient. Referrals for special care dentistry were triaged by the specialist. Once a course of

treatment had been completed the patient would be referred back to their own dentist (if

appropriate) for continuing treatment.

Health promotion

Staff were aware of and applied the principals of the Department of Health’s ‘Delivering Better Oral

Health’ toolkit 2013 when providing preventative advice to patients on how to maintain a healthy

mouth. This is an evidence-based tool kit used for the prevention of the common dental diseases

such as dental caries and periodontal disease. Fluoride varnish was applied to patient’s teeth on a

risk-based approach. We saw evidence in dental care records that they discussed oral hygiene

advice, toothbrushing instruction and dietary advice with patients. High fluoride toothpaste would

be prescribed for those at high risk of dental caries. At some of the clinics the dental nurses who

had completed the oral health education training held clinics where they discussed toothbrushing

and diet with patients. They also applied fluoride varnish at these appointments.

We were told that the service had recently done some work about oral cancer awareness. One of

the dental nurses had been to the Mersey Care headquarters where they had a stand raising


awareness of oral cancer and the contributing factors. They spoke to Mersey Care staff and

visitors to raise awareness. This had been featured in the most recent Mersey Care staff bulletin.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Deprivation of Liberty Safeguards

Mersey Care NHS Trust told us that 97 Deprivation of Liberty Safeguard (DoLS) applications were

made to the Local Authority between 1 August 2017 and 31 July 2018. None of which were

pertinent to community dental services.

There was a trust wide consent policy in place to provide guidance to staff. Staff were fully aware

of the need to obtain and record consent when providing treatment to patients. They told us how

they obtained consent. This involved discussing the different treatment options available and any

risks associated with them. This enabled patients to make an informed decision about treatment.

Patients comments confirmed that they were fully involved in the consent process. The service

used NHS consent forms and treatment plans. A copy of the consent form and treatment plan was

provided to the patient and a copy held with the patient’s dental care records. We saw evidence of

completed consent forms

Patients undergoing inhalation sedation had a pre-assessment appointment where consent was

obtained. This is in line with guidance set out by the Royal Colleges of Surgeons and the Royal

College of Anaesthetists ‘Standards for Conscious Sedation in the Provision of Dental Care’ 2015.

Consent was re-confirmed on the day of treatment.

Staff had a good understanding of the legal requirements of the Mental Capacity Act 2005. Staff

were required to complete training about the Mental Capacity Act. They told us that best interest

decision meetings were carried out for patients who lacked the capacity to make decisions for

themselves. We were provided with an example of such a situation and reviewed documentation

relating to it. This had been completed correctly.

Staff were aware of the concept of Gillick competence in respect of the care and treatment of

children under 16. Gillick competence is used to help assess whether a child has the maturity to

make their own decisions and to understand the implications of those decisions.


Is the service caring?

Compassionate care

We observed staff treating patients with dignity and respect. It was clear through discussions with

patients and staff that the service aimed to provide a comfortable and compassionate experience

for all patients. Patient feedback was overwhelmingly positive about the service. Patients told us

that staff were kind, helpful, friendly and caring. Patients also commented that staff were

particularly good at treating children and nervous patients.

Staff provided us with example of how they provided compassionate care. These included going

out to greet and escort patients to and from the car park, bringing them straight into the clinic to

avoid them waiting in a busy and noisy shared waiting area.

Privacy and confidentiality were maintained throughout the service. We saw that no confidential

details were discussed at the reception desk. We were told that if a patient required more privacy

then a spare room would be found to have a confidential conversation. Surgery doors were kept

shut whilst treatment was carried out.

At River Alt Resource Centre, they provided undergraduate training for dental students and dental

therapy students. This was an open clinic arrangement. Patients were made aware of this situation

prior to their appointment. There were privacy curtains on this clinic to improve patient

confidentiality. A separate room was also available if a patient requested this.

Emotional support

Staff were clear on the importance of emotional support needed when delivering care. Patients

told us that staff were sensitive to their needs and made them feel relaxed and at ease prior to and

during treatment.

We were told and saw evidence that when staff were treating children who were nervous and

requiring treatment under inhalation sedation that an acclimatisation visit was carried out. This

simply involved the patient sitting in the dental chair and having the sedation without any

treatment. We were told that this helped improve compliance with treatment at subsequent visits

as the patient was familiar with the sensations they experience whilst having sedation.

We attended a general anaesthetic session and we witnessed positive interactions between staff

and the patient. In addition, we saw that the staff took into account the emotional needs of the

parents. It was clear they took a holistic approach to providing care to patients and their family in

what is a difficult and emotional situation for both patient and parent.

Appointment length and times would be adjusted to individual patient need. For example, for more

nervous patients longer appointments could be booked to ensure staff had time to provide

emotional support to the patient. Staff told us they worked with patient’s carers to determine the

best time when they could be treated most effectively. The clinicians confirmed that they had

adequate time to provide safe, effective and compassionate treatment to their patients.


Understanding and involvement of patients and those close to them

Patients and their families were appropriately involved in and central to making decisions about

care options and the support needed. Patients confirmed that they were fully involved in decisions

and able to ask questions about treatments.

Staff told us, and we saw evidence on dental care records that they involved patients, their parents

or carers about treatment options. They described different treatment options including the risks

and benefits associated with the different treatments. They used models and pictures to assist with

explanations. They also used X-rays which had been taken to assist with understanding. There

were numerous information leaflets about different treatments available at the service.


Is the service responsive?

Planning and delivering services which meet people’s needs

The dental service was commissioned by NHS England. Services were planned to meet the needs

of people who could not access primary dental care services. These included patients with

medical, physical or social issues and patients with dental anxiety.

Reasonable adjustments had been made at all the locations which we visited. These included step

free access, automatic doors, accessible toilets and lowered reception desks. The service used

hoists to assist wheelchair users to get into the dental chair. Staff had received training in their

use. The service did not have facilities to treat bariatric patients. We were told that the local dental

hospital had a bariatric chair where these patients could be treated.

Translation services were available for patients who did not have English as a first language. We

saw notices in the reception areas, written in languages other than English, informing patients

translation service were available. In addition, hearing loops were available for use by people with

hearing aids.

There was generally adequate seating facilities at each location. However, at Everton Road

Community Dental the waiting area was shared with another service. This had restricted the

amount of seating available for patients. This issue had been raised with the estates team.

Meeting the needs of people in vulnerable circumstances

The service was configured to reflect the needs of vulnerable people. It was a referral service

providing either continuing care or a single course of treatment to children or patients with special

needs due to physical, mental, social and medical impairment. Referrals for patients with special

needs were initially triaged by the specialist in special care dentistry. Any reasonable adjustments

could be discussed prior to their first appointment at the clinic.

Domiciliary visits were carried out by the service. These visits were reserved for patients who

could not access the service due to medical, physical or social issues.

Since the merger staff told us that there had been an increased focus on mental health issues.

Staff were keen to gain more access to mental health teams, knowledge and resources already in

the trust to help them to cater better for patients with mental health issues. Staff saw the move to

the current trust as a positive opportunity to be able to provide highly personalised and specialised

care for very vulnerable patients.


Access to the right care at the right time

Accessibility

The largest ethnic minority group within the trust catchment area is ‘White other’ with 1.75% of the

population.

Ethnic minority group Percentage of catchment population (if known)

First largest White Other 1.75%

Second largest Chinese 0.8%

Third largest Other 0.7%

Fourth largest Black African 0.7%

No referrals data was provided for this core service.

General dental practitioners and other health professionals could refer patients for short-term

specialised treatment as well as long term continuing care to the community dental service. Once

a course of treatment had been completed the patient was referred to primary dental care for

ongoing care with their own dentist if appropriate.

Waiting times were actively monitored by the service. The current waiting time for and assessment

for paediatric special care dentistry and paediatric exodontia was approximately six weeks. In

addition, the waiting time from assessment to treatment was six weeks for a dentist and four to six

weeks with a dental therapist.

Waiting times for general anaesthetic had previously been on the risk resister as a result of a high

levels of nitrous oxide being identified at a clinic held in a local hospital in February 2018. This

resulted in the service being suspended. The waiting times had now been reduced and this issue

had been removed from the risk register.

During the inspection we observed that appointments ran smoothly, and patients were not kept

waiting. Staff told us that patients would be kept informed if there were going to be any delays with

their appointment.

Learning from complaints and concerns

Complaints

Community dental services received two complaints between 1 August 2017 and 31 July 2018.

Total Complaints

Fully upheld

Partially upheld

Not upheld Withdrawn Under

investigation Other

Referred to Ombudsman

2 0 0 1 0 1 0 0


Compliments


2018. None of these related to community dental services.

The service took complaints and concerns seriously, and we were told they aimed to address

them in house initially to the patient’s satisfaction. Staff told us that if any patients attended and

wished to make a complaint they would try and resolve the issue at the clinic with the assistance

of the dental operations manager. If the patient was not satisfied with the response, then they

were provided with the trust complaints procedure and the number for the Patient Advice and

Liaison Service (PALS). Staff at the service would liaise with the PALS team to help dealing with

any patient complaints.

There were details of how a patient could make a complaint including the details of PALS

displayed in the main reception area and in the waiting area. There were also details of how to

make a complaint on the trusts internet page.


Is the service well-led?

Leadership

We found leaders had the capacity and skills to deliver high-quality, sustainable care. They were

knowledgeable about issues and priorities relating to the quality and future of services. They

understood the challenges and were addressing them.

Clinical leadership was provided by the clinical directors. They were supported by the assistant

clinical director. They were responsible for overseeing the dentists and dental therapists. The

dental operation manager and dental clinical manager were responsible for the day to day running

of the service. They were supported by dental nurse managers at each location.

Staff felt valued and appreciated in their role. They told us that leaders were visible, supportive

and approachable. They told us that since the move to the current trust the human resources

director had visited the service to speak with staff.

Vision and strategy

The trust had a vision of what it wanted to achieve after the merger. This included, operating with

a ‘One Team’ ethos, uniting primary, social, community physical and mental health services and

creating ways for hospital specialists to provide care in community settings.

The dental service also had a vision. This included succession planning for the service by

engaging with the human resources and workforce team, ensuring commissioning stability by

working with the commissioners and maintaining regular communication with the dental staff to

ensure they are updated with any changes which may occur.

Both the trust and divisional visions were displayed within the service for staff to reference.

The trust values were continuous improvement, accountability, respect, enthusiasm and support. It

was clear through the inspection that staff upheld these values.

Culture

Staff were proud and passionate about their work. Many of the staff had worked for the service for

many years and had seen a great deal of change. There was a strong team spirit and they

supported each other through difficult and uncertain times.

Staff described a more positive culture since the move. They gave us examples of this change.

For example, we were told the trusts approach towards staff sickness was more compassionate

and caring and any correspondence was more sympathetic.

Staff morale was generally good. However, issues with staffing had impacted moral somewhat.

We were told that the service was actively recruiting new members of staff to fill in any gaps.

Staff were aware of their responsibilities to raise concerns if the need arose. They were aware of

the whistleblowing process and could easily access the policy. They were aware of the freedom to

speak up guardian and there were posters in the waiting rooms about this.


Governance

The trust provided policies and procedures to provide guidance for staff. These were generic and

covered all services provided by the trust. These included how to deal with a complaint,

safeguarding and equality and diversity. Because of the specialised nature of the dental service

they had developed their own policies and procedures called “code of practices” (COP). The

dental service was responsible for updating and reviewing these. These were available on the

trusts intranet for staff to reference. These included conscious sedation and infection prevention

and control. We noted that the COP relating to the use of the NOCI had not been updated or

reviewed since 2002. In addition, we were told that the process to send NOCI only involved it

being sent to one individual. We were told that this would be addressed to ensure these were

received by multiple persons. All other COPs were up to date.

Quality assurance processes were used within the service to continually improve the quality and

safety of the service. For example, audits had been carried out on X-rays, infection prevention and

control and antibiotic prescribing. These had associated results and action plans. Staff told us that

the results of the X-ray audit had been discussed at a team level, but individual clinicians had not

been given their own results or feedback.

Matter relating to clinical governance were discussed at monthly locality governance meetings

which the dental operation manager attended. There were effective systems in place to

disseminate information through a system of meetings. These included at a local level and patch

level. In addition, there were bi-monthly dental nurse managers meetings which were chaired by

the dental clinical manager. There were meetings held every four months for all clinical staff.

There were six-monthly management review meetings held which included the clinical directors,

assistant clinical director, band B and C dentists and the dental clinical manager. These were well

attended and minuted with actions identified to improve standards.


The service maintained a risk register which was regularly reviewed. This was used to monitor

known risks associated with the service and put in place actions to reduce the risks. Currently on

the dental service risk register were issues around procurement (including supplies, maintenance

and training) and the lack of service level agreements at certain sites where general anaesthetics

were provided. Where risks had been identified then actions were put in place to mitigate the risk.

We saw that actions were completed in a timely manner to ensure risks were well managed. The

risk register was discussed at the monthly operations meetings and also the six-monthly

management review meetings.

Information management

Staff told us they had access to all the information they needed to provide care to patients. They

had completed training in information governance and were aware of the importance of protecting

patients’ personal information.

Dental care records were a mix of computerised and paper records. We saw computers were

password protected and were told these were backed up to secure storage. Any paper records


were stored in lockable cabinets. We saw staff locked computers when they moved away from

their workstations.

Engagement

One of the dentists was the chair of the local managed clinical network (MCN) for special care

dentistry. In addition, several other of the dentists attended the MCN meetings for special care

dentistry and paediatrics. MCNs are groups of professionals from primary, secondary and tertiary

care who work together to ensure the equitable provision of high quality effective services. These

networks enable the clinicians to engage with general dental practitioners and other providers of

secondary care about how services can be improved.

The service also met with the NHS England commissioners on a quarterly basis. This was to

discuss performance and the contract. We were told they had a good relationship with the

commissioners.

Patients were encouraged to complete the NHS Friends and Family Test (FFT). This is a national

programme to allow patients to provide feedback on NHS services they have used. Results and

feedback from the FFT was disseminated to staff through meetings.


Accreditations

NHS Trusts are able to participate in a number of accreditation schemes whereby the services

they provide are reviewed and a decision is made whether or not to award the service with an

accreditation. A service will be accredited if they are able to demonstrate that they meet a certain

standard of best practice in the given area. An accreditation usually carries an end date (or review

date) whereby the service will need to be re-assessed in order to continue to be accredited.

This core service has not been awarded any accreditations.

All locations had achieved the British Dental Association Good Practice award. This is a quality

assurance scheme that demonstrates a visible commitment to providing quality dental care to

nationally recognised standards.

The service provided training to undergraduate dental students and dental hygiene therapists from

another NHS trust. They also provided educational supervision to a foundation dentist (FD). A FD

is a newly qualified dentist in their first year of qualification. Dentists wanting to work in the NHS

are required to complete a year of foundation training prior to obtaining an NHS performer number.

Many of the dental nurses had completed additional training in order to enhance their skills to

cater for the increasing demand of the local population. These included special care dentistry,

radiography, fluoride varnish application, oral health education and sedation. The service

organised an annual study day. This covered topics such as sedation and how to deal with

complaints. It also offered an opportunity for peer review and to discuss complex cases.


The service was currently working with Public Health England to carry out epidemiology surveys.

The current survey was to assess the dental health of five-year olds in the local area. All data was

due to be collected by June 2019 and the report is due to be published in December 2019.

Mersey Care NHS Foundation Trust evidence appendix: community health services for adults

Community health services for adults


Mersey Care NHS Foundation Trust provides specialist inpatient and community mental health,

learning disability and substance misuse for adults in Liverpool, Sefton and Kirkby. Mersey Care

NHS Trust was established on 1 April 2001 and granted NHS Foundation Trust status on 1 May

2016.

On 1 July 2016, Mersey Care completed the acquisition of Calderstones Partnership NHS

Foundation Trust.

In July 2017, the trust acquired a number of services previously provided by Liverpool Community

Health NHS Trust (LCH) in the South Sefton locality. Mersey Care acquired the remainder of the

former LCH community services on 1 April 2018. These community health services are provided

across Liverpool to a population of approximately 1.2 million. Mersey Care currently delivers

these services across more than 70 locations including health centres, clinics, walk-in centres and

GP practices.

For the provision of community health services, Mersey Care operates a locality based operational

model, with multidisciplinary clinical teams, geographically aligned and focused around GP

practice populations. The previous leadership team from Liverpool Community Health are working

collaboratively with senior management at Mersey Care in leading the Community Health Services

Division.

There are three localities under Mersey Care, these are North Liverpool, Central Liverpool and

South Liverpool. Each locality is led by an associate director and clinical lead. Community

services offered by Mersey Care include, district nursing, physiotherapy, occupational therapy,

dietetics and nutrition, speech and language therapy, podiatry, rehabilitation at home teams and

integrated community reablement and assessment services (ICRAS). ICRAS encompasses

intensive community care teams (ICCT), emergency response teams (ERT) and frailty.

Our inspection was short notice announced which meant that staff and management knew we

were coming. This ensured that staff we needed to speak to were available and clinics were open

for review. We inspected community adult services provided by the Trust over a three-day period

from Tuesday 20 November to Thursday 22 November 2018.

During our inspection we visited nine areas, two of which included clinical areas. We spoke to a

number of staff in various specialities which included, district nurses, physiotherapists,

occupational therapists, community matrons, skin care specialists and senior management.

We spoke to ten patients and carried out five home visits. We also reviewed twenty-two patient

records that were a mixture of paper and electronic documentation

Information about the sites which offer community health services for adults at this trust is shown

below:


Location Site Name Team/ward/satellite name Patient group



Netherton Health Centre, Magdalen Square, Liverpool,

L30 5SP

Adult SALT Mixed N/A Liverpool

Livingstone Drive Adult Speech & Language

Therapy Mixed No Clinics held South Sefton

Bootle Health Centre, Park Street, Liverpool,

L20 3RF Bootle Green District Nurses Mixed No Clinics held South Sefton

Bootle Health Centre, Park Street, Liverpool,

L20 3RF Bootle Yellow District Nurses Mixed

SS Comm Cardiac Total = 9

(Maghull 2; Thornton 2; Bootle 2; Sefton Rd 2;

Netherton 1;)

North Sefton Cardiac Clinics Total = 4

(Ainsdale 1; Churchtown 1; Formby

1; Southport 1)

South Sefton & North Sefton

South Sefton Litherland Town Hall,

Hatton Hill Road, Liverpool, L21 9JN

North Sefton Curzon Road,

Southport PR8 6PL

Community Cardiac (Heart Failure) Teams - South / North

Sefton Mixed No Clinics held South Sefton

Litherland Town Hall, Hatton Hill Road,

Liverpool, L21 9JN

Community Intermediate CareTeam (CICT)

Mixed N/A Liverpool

Goodlass Road Community Matrons Mixed N/A Liverpool

Old Swan Walk In Centre

Community Matrons Mixed N/A Liverpool

Queens Drive Community Matrons Mixed No Clinics Held South Sefton

Thornton Health Centre, Bretland

Road, Liverpool, L23 1TQ

Community matrons No Clinics held South Sefton

Innovation Park Community Occupational

Therapy Mixed No Clinics held South Sefton


L30 5SP

Community Occupational therapy

Mixed N/A Liverpool

Queens Drive Community Occupational

Therapy Mixed N/A Liverpool

Innovation Park Community Physiotherapy Mixed N/A Liverpool

Innovation Park Community Physiotherapy Mixed N/A


L30 5SP

Community Physiotherapy Mixed 60 Liverpool





Goodlass Road Continence (Bladder & Bowel) Mixed South Sefton


Liverpool, L21 9JN Diabetes Mixed 76 plus 68 HCA South Sefton


L30 5SP

Dietetics Mixed 80 Liverpool

Queens Drive Clinic, Moor Lane, Liverpool,

L4 6XG Dietetics & Nutrition Mixed N/A Liverpool

Goodlass Road District Nursing Mixed N/A Liverpool

Old Swan Walk In Centre

District Nursing Mixed N/A Liverpool

Queens Drive District Nursing Mixed N/A Liverpool

Innovation Park District Nursing (Out of Hours

& Evenings) Mixed N/A Liverpool

Innovation Park Emergency Response Team

(ERT) Mixed N/A Liverpool

Innovation Park Intensive Community Care

Team (ICCT) Mixed N/A Liverpool

Innovation Park Intermediate Community Reenablement Access

Services (ICRAS) Mixed N/A Liverpool

Innovation Park IV Therapy Team Mixed 20 Litherland HC / 20

Netherton HC South Sefton


Liverpool, L21 9JN IV Therapy Team Mixed N/A Liverpool

Innovation Park Liverpool Community Frailty

Service Mixed N/A Liverpool

Innovation Park Liverpool Out of Hospital

Service (LOOHS) Therapy Team

Mixed No Clinics held South Sefton

Maghull Health Centre, Westway,

Liverpool, L31 0DJ Maghull District Nurses Mixed N/A Liverpool

Queens Drive Medicines Management: GP

Support Mixed


L30 5SP

Podiatry Team Mixed N/A Liverpool

Queens Drive Podiatry Team Mixed N/A Liverpool

Goodlass Road Practice Nurse Development

Team Mixed


L30 5SP

Rehab at Home - South Sefton

No Clinics held South Sefton






Liverpool, L21 9JN Respiratory Service Mixed No Clinics held South Sefton

Sefton Road Clinic, 20 Sefton Road,

Liverpool, L20 3TA

Seaforth & Litherland District Nurses

Mixed No Clinics held South Sefton

Sefton Road Clinic, 20 Sefton Road,

Liverpool, L20 3TA Sefton OOH District Nurses N/A Liverpool

Innovation Park Single Point of Contact (SPC) Mixed N/A Liverpool

Innovation Park Skin Care Service Mixed N/A Liverpool

Abercromby Health Centre

Social Inclusion Mixed N/A Liverpool

Innovation Park Social Work Team Mixed N/A Liverpool

Innovation Park Telehealth Mixed No Clinics held South Sefton

Thornton Health Centre, Bretland

Road, Liverpool, L23 1TQ

Thornton District Nurses 75 South Sefton

Sefton Road Clinic Treatment rooms Mixed No Clinics held South Sefton


Liverpool, L21 9JN Urgent Care Team Mixed N/A Liverpool

Innovation Park Vaccination & Immunisation

Team Mixed N/A Liverpool



Mandatory training

The trust set a completion target for training courses of 90%90% for some courses and 95% for

other. The overall training compliance for this core service was 90% against this target.

A breakdown of compliance for mandatory courses between April 2017April 2017 and March

2018March 2018 for medical/dental and nursing staff in community health services for adults is

shown below:


830|LOCAL|Complaint & Claims (Once only)| 100%

Role Specific Mandated Training - Deprivation of Liberties - Level 1 (Every 3 Years) 100%

Role Specific Mandated Training - Mental Health Act - Level 1 (Every 3 Years) 100%

830|LOCAL|Safeguarding Adults Level 3 for Senior Managers - 3 years| 100%


830|LOCAL|Safeguarding Adults Level 4 - 3 years| 100%

Continuous Professional Development - Complaints (Every 3 Years) 99%

NHS|MAND|Harassment and Bullying Awareness - No Renewal| 99%

NHS|MAND|Prevent WRAP - 3 Years| 99%

Role Specific Mandated Training - Basic Prevent Awareness (1 Time) 98%

Continuous Professional Development - Adverse Incidents (Every 3 Years) 98%

Continuous Professional Development - Suicide Prevention & Safety Planning (Every 3 Years)

98%

830|LOCAL|Prevent Training for Clinicians| 97%

Continuous Professional Development - Fraud Awareness (Every 3 Years) 97%

Role Specific Mandated Training - Mental Capacity Act - Level 1 (Every 3 Years) 97%

Continuous Professional Development - Smoking Cessation (1 Time) 96%

Mandatory Training (IG) - Information Governance - Refresher (Every Year) 96%


NHS|MAND|Moving & Handling for Inanimate Load Handlers - 3 Years| 95%


NHS|MAND|Fire Safety - 3 Years| 95%

NHS|MAND|Health and Safety - 3 Years| 95%

830|LOCAL|Investigation of Incidents Using RCA (Once )| 95%


NHS|MAND|Conflict Resolution - 3 Years| 94%

NHS|MAND|Equality, Diversity and Human Rights - 3 Years| 94%

NHS|MAND|Infection Control - Level 1 - 3 Years| 94%


830|LOCAL|Health Record Keeping 3 Yearly Compliance| 93%



NHS|MAND|Consent - 3 Years| 93%

NHS|MAND|Mental Capacity Act - 3 Years| 93%


NHS|MAND|Medicines Management Awareness - 3 Years| 92%

Mandatory Training - Infection Control (Every 3 Years) 91%

Mandatory Training (IG) - Information Governance - Introductory (1 Time) 91%

NHS|MAND|Moving and Handling - 1 Year| 90%

830|LOCAL|Infection Control Domestic Staff - 1 Year| 89%

Continuous Professional Development - Dementia Awareness (1 Time) 89%

NHS|MAND|Information Governance - 1 Year| 88%

NHS|MAND|Infection Control - Level 2 - 1 Year| 88%

NHS|MAND|Resuscitation - 1 Year| 88%

Mandatory Training - Safeguarding Adults - Level 1 (Every 3 Years) 86%

Mandatory Training - Safeguarding Children - Level 1 (Every 3 Years) 86%

Mandatory Training - Fire Safety (Every 3 Years) 85%

Mandatory Training - Conflict Resolution (Every 3 Years) 84%

Role Specific Mandated Training - MHA/DoL's Level 2 (Every 3 Years) 84%

Mandatory Training - Health & Safety (Every 3 Years) 83%

Role Specific Mandated Training - Safeguarding Adults Level 2 -Trust Model (Every 3 Years)

82%

Role Specific Mandated Training - Safeguarding Children Level 2 - Trust Model (Every 3 Years)

82%

830|LOCAL|ILS - 1 Year| 80%

Mandatory Training - Equality, Diversity and Human Rights (Every 3 Years) 79%

NHS|MAND|Moving & Handling for People Handlers - 1 Year| 79%

830|LOCAL|IR(ME)R Ionising Radiation Medical Exposure Regulations| 74%

830|LOCAL|Safeguarding Children & Young People L3 Senior Managers - 3 years| 70%


69%

Mandatory Training - Moving & Handling (Every 3 Years) 67%

Role Specific Mandated Training - Safeguarding Adults Level 3 - Trust Model (Every 3 Years)

65%

Role Specific Mandated Training - Basic Life Support (Every Year) 51%

Role Specific Mandated Training - Moving and Handling of People (Every Year) 38%

Role Specific Mandated Training - Safe and Effective Use of Medicines (Every 3 Years) 16%

Role Specific Mandated Training - Controlled Drugs & High Risk Medicines 14%

Role Specific Mandated Training - Medicines Calculations (Every 3 Years) 13%

Role Specific Mandated Training - MUST Adapted Nutritional Screening 0%

Core Service Total 90%


All team leaders within each locality had access to staff training records via an electronic system.

Staff told us that they received reminders electronically to highlight to them that they were due to

complete their mandatory training modules. These reminders were also emailed to the team

leaders so that they could monitor staff compliance and address any training and development

needs as they occurred. In addition to this, data was fed into a monthly governance report which

was monitored by the matrons and the assistant director of nursing. We saw that there was a

Trust induction, statutory and mandatory training policy (Version 2, HR28, review date January

2019) in place at the time of inspection.

During our inspection we observed staff training records for current compliance in all three

localities. We noted that all mandatory training was 100% compliant for North and South localities

in physiotherapy, however in Central compliance was 78%. This was due to the recording of

information governance. Information governance was disbanded and staff had to complete data

security and suicide prevention. We saw evidence that staff were booked onto these courses.

We were told by management in the dietetics department that their mandatory training was input

onto two different systems. One system was before the merger of the Trust and this showed that

all staff were compliant, however the new electronic system for the Trust was showing that staff

were non-compliant. This had been raised to senior management and at present the two systems

could not be linked as they were not compatible.

We were told and shown by management in the district nursing service in the South Sefton area

that the staff were 80% compliant with their mandatory training and the remainder were booked

onto sessions. We were also told that the electronic system was showing that the department was

not compliant. This had been raised with senior management who had told staff it would be

updated.

We saw that mandatory training demonstrated 100% compliance in the speech and language

therapy (SALT) team in South Sefton, however we saw that dementia awareness was not

completed and therefore compliance could not be 100% as stated on the electronic system. The

team manager was not available during inspection and it was highlighted to staff to raise this on

their return.

Safeguarding




institutional.

Each authority has their own guidelines as to how to investigate and progress a safeguarding




should take place.


Community health services for adults made 317 safeguarding referrals between 1 August 2017

and 31 July 2018, of which 315 concerned adults and two children.

Staff understood how to protect patients from abuse and the service worked well with other

agencies to do so. Staff had training on how to recognise and report abuse and they knew how to

apply it. The Trust had a safeguarding team who were available five days per week (Monday to

Friday). We saw that there was a Trust safeguarding adult’s policy and procedure (version 6,

LCH-116, review date April 2016). We noted that the policy had a new Trust cover sheet on the

front of the policy and we raised the review date with senior management and were told that all

policies and protocols were being reviewed at the present time during the transitional process.

Guidance in the policy was up to date at the time of inspection.

All staff in each locality were trained to safeguarding level three. We observed training logs in all

three localities and compliance was 100%.

We reviewed two safeguarding incidents in the district nursing service, both had clear and concise

documented evidence following NHS England guidance (Safeguarding Adults 2017). Relevant

internal and external parties were contacted in line with Trust policy. Discussions were held with

staff on the two incidents and we saw evidence of duty of candour being applied. The duty of

candour is a statutory (legal) duty to be open and honest with patients and their families, when

something goes wrong that appears to have caused or could lead to significant harm in the future.

We were told by staff in all community service areas that if they had any safeguarding concerns

they would contact their line managers and the safeguarding team for advice in the first instance.

In addition to this we were told by the out of hours district nursing service that they would first

contact the on-call duty manager for advice.

All staff would report their safeguarding concerns via the Trust electronic incident reporting

system.


These self-assessments are undertaken by teams of NHS and private/independent health care

providers, and include at least 50 per cent members of the public (known as patient assessors).

They focus on the environment in which care is provided, as well as supporting non-clinical

services such as cleanliness, food, hydration, the extent to which the provision of care with privacy

and dignity is supported and whether the premises are equipped to meet the needs of people with

dementia against a specified range of criteria.

There was no information regarding PLACE assessments for the locations within this core service.

The service controlled infection risk well. Staff kept themselves and equipment clean. They used

control measures to prevent the spread of infection. Infection prevention and control was included

Referrals

Adults Children Total referrals

315 2 317


as part of the Trust mandatory training and all staff we spoke with were compliant with this at the

time of inspection.

The Trust had an infection prevention and control policy (version 2.2, IC01, review date December

2019) that included guidance on hand hygiene, safe handling and disposal of sharp items, person

protective equipment , indwelling medical devices and guidance on infectious diseases. The

current document had a front cover added to the policy to make the reader aware of any changes

following the organisational changes in the Trust. Staff we spoke to in all three localities were

aware of the policy and knew how to access it via the Trust intranet and the Trust website.

We looked at staff competency files in each locality and there was documented evidence that they

had all had training in infection prevention and control.

We saw posters displayed in all treatment rooms and toilet areas promoting hand hygiene. All

staff we spoke to and observed in clinic areas were aware of and carried out good hand hygiene.

There were hand sanitiser gel dispensers in reception and treatment areas in all localities. We

observed both patients and staff using the gel upon entry to the various locations.

We were told by the district nursing team that personal protective equipment was carried in their

bags at all times. In addition to this we saw that there was personal protective equipment

available to staff in the treatment areas.

We observed staff using appropriate personal protective equipment. All staff washed their hands

pre, during and post patient home visits as well as during clinics.

We looked at treatment rooms that the dieticians, podiatrists and district nurses used in each

locality and all were visibly clean. A cleaning checklist for infection prevention and control was

undertaken and had been completed. We saw that the curtains used for privacy and dignity had

been recently changed and were dated.

All store rooms were coded entry. We looked at a random sample of equipment, for example

dressings in the district nursing and skin care service, all were in date and stored in chronological

order. In addition, we looked at single use of equipment as no sterilising of equipment was

undertaken. All were in date.

We observed seven patients having treatment in the district nursing service clinics. We observed

good hand hygiene and personal protective equipment was worn when required. We observed

aseptic non-touch techniques where appropriate. However, on one home visit we observed a

wound dressing and the healthcare professionals non-touch technique could have been better.

This indicated to us that additional training was relevant in this area. This was raised and

addressed at the time of inspection.

Uniforms appeared clean and tidy on all staff within each locality. All staff were bare below the

elbow in treatment areas.

Management told us that patients with suspected methicillin-resistant Staphylococcus aureus

(MRSA), Clostridium difficile (C. diff) or carbapenemase producing Enterobacteriaceae (CPE) that

presented in treatment areas, a deep clean would be carried out as per Trust policy. There were

no incidents of either of these bacteria at the time of inspection.


There were good waste and sharps management in place. We observed sharps bins correctly

labelled and assembled with the temporary closure in place which was fully compliant with

Department of Health (DoH) HTM 07-01. Waste was appropriately separated and disposed of as

per Trust policy.

We looked at a box of syringe drivers in the district nurse’s office in the South Sefton locality which

had an ‘I am clean’ label on the box. However, on inspection the box was evidently not clean

inside and this was raised with staff and resolved at the time of inspection.


Premises used in the provision of care and treatment were visibly clean and tidy.

Clinical areas had hard flooring which was washable and compliant with Department of Health

(DoH) HBN 00-10.

All chairs in the treatment room areas were found to be wipeable, clean and fully compliant with

Department of Health (DoH) HBN 00-09.

Fire exits were clearly signposted in all clinics in each locality. Fire break glass points were

observed at each exit that complied with BS EN 54-11 and review of all fire extinguishers within

reception areas were in date with their annual service.

Management in the dietetics department showed us a professional patient scale that had been

purchased as an additional resource which helped to promote quality of care and treatment. This

had been invaluable for when patients attended clinic.

We were told by staff in all three localities that there was access to specialist equipment for use in

patient’s homes. This equipment was ordered from the community equipment store and for high

risk patients the equipment could be accessed straight away. told by management in the

physiotherapy department that there were delays in the delivery of equipment. This had been

escalated to senior management who told that this was due to capacity issues and was now on

the Trust risk register.

We were told by the out of hours district nursing service that essential equipment could be

accessed up to 10pm every day.

Staff in the occupational therapy department told us that on patient home visits they would

complete a training needs analysis. If there was a risk identified the patient would not be able to

use the equipment until the occupational therapist had fitted it. We did not carry out a patient visit

with the occupational therapists during this inspection.

We were told by management in the rehabilitation at home team that they had a well-stocked

equipment store within the centre. In addition to this they could order equipment from the

community equipment store and have this delivered to all localities.

Equipment in the ICRAS team was checked annually and monitored by the administration team.

This was stored on a spreadsheet electronically. We did not see this at the time of inspection. We

requested information post inspection on effective records for medical devices and were told that

there was no overarching database for medical devices. The Trust had commissioned a database


to be built to ensure that effective records of all medical devices and their maintenance and

service requirements were identified. This was on the Trust risk register and would be

commenced in January 2019 with a plan to be embedded within 12 months.

We spoke to management about the key concerns following the nurse bag audit carried out on 3

October 2017. The key concerns were that items of equipment such as stethoscopes, paper

towels and pen torches were not always available in nurse bags. This had been fed back to staff

via team meetings and on a one-to-one basis. Spot checks had been being carried out following

this audit to ensure staff were accountable for their equipment and a re-audit had been carried out

in October 2018, however the results were not available at the time of inspection.

Fridge temperatures were checked daily in all clinic areas in each locality. All readings were in the

agreed parameters, dated and signed.

We examined a box of syringe drivers based in the district nurse’s office in the South Sefton

locality and found that a number of items were missing. For example, one x SAF T ITIMA 24

gauge and one SAF T INTIMA 22 gauges. This was raised with management at the time of

inspection.

We observed a wound dressing in a district nursing clinic in the South Sefton locality. No sterile

scissors were available for the nurse to complete the task. The nurse explained to the patient that

they had to dress their wound with a different dressing as no sterile scissors were in stock. We

observed that the bandage applied was ill-fitting as unable to cut to size. The nurse apologised to

the patient for this event and explained that there was difficulty in obtaining sterile scissors at the

present time. This was raised with management in the service and senior management at the

Trust at the time of inspection.


The service identified and managed risk well.

Each service in all three localities held morning safety huddles. Discussions took place on

caseloads, staffing, incidents and any safeguarding concerns. In addition to this, lone working

was discussed and joint visits carried out if required.

We were told by management in the dietetics department that regular discussions took place in

the department on patient’s needs and care plans. One session per month was allotted to each

staff member for continuous professional development.

Patient referrals were triaged by senior staff and pathways were in place to help identify the level

of patient risk and clinical need.

Red, Amber and Green (RAG) ratings were utilised throughout the Trust. This ensured that

patients were monitored safely and care provided to the need required.

Risk assessments were carried out as part of the patients first home visit and subsequent follow-

up visits within the physiotherapy, occupational therapy and district nursing teams. These were

completed on the electronic information management system by the physiotherapist and

occupational therapists in the patient’s homes, however the district nurses told us these


assessments are completed on paper in the patient’s homes and then input into the electronic

information management system on their return to the office. This increased the risk of error as

district nurses were duplicating patient records. There were no incidents reported at the time of

inspection in relation to risk assessments.

We looked at twenty-two patient records and saw evidence that initial risk assessments had been

carried out and care plans implemented, for example wound care, visual phlebitis score (VIP) and

malnutrition universal screening tool (MUST). These assessments were all completed correctly,

dated and signed.

Staff were aware of how to recognise a deteriorating patient and all were compliant with the

mandatory basic life support training. We saw that the Trust had a resuscitation and deteriorating

patient policy (LCH-23) but this was overdue for review and documented that it should have been

reviewed in April 2017. This was raised with senior management at the time of inspection and we

were told it would be reviewed that afternoon in their divisional governance meeting.

We reviewed two patient records in the ICRAS team and observed the use of the National Early

Warning Score 2 (NEWS 2). A national early warning score is a guide used by medical services to

quickly determine the degree of illness of a patient based on their vital signs such as pulse rate,

blood pressure and temperature. It also provides guidance for staff to follow if a patient’s vital

signs are outside of normal parameters. The score allows the teams to monitor, detect and

respond to clinical deterioration of patients and this not only improves outcomes it is key in

maintaining patient safety.

We were told by management that the service had not always used the national early warning

score to identify patients who were at risk of deterioration as this had not always been a

requirement for this to be done in most community areas. However, the Trust had plans in place

to roll out the NEWS 2 system across all services by April 2019.

We saw that seventy new pressure sores had been reported in the community area. Senior

management told us that they were concerned that new staff members were not experienced in

pressure ulcer care. A pressure ulcer prevention programme had been implemented with target

dates for band five, six and seven staff to complete training and competencies.

We saw results for November 2018 of the falls risk assessment tool (FRAT) and the malnutrition

universal screening tool (MUST) for the district nursing service. Falls risk assessment scores in

the Central and North locality was 79.3% and 79.1% and the MUST was 82.2% and 79.7%. The

South localities were all above 95%. The Trust target was 95%.


Staffing

Vacancies


community health services for adults.

Staff group Total number of substantive staff Total % vacancies overall (excluding seconded staff)

Qualified Nurses 224.1 9%

Nursing Assistants

52.5 13%

Other 148.5 7%


Turnover

Between August 2017 and July 2018, the trust reported an overall turnover rate of 12% in

community health services for adults.


Total number of substantive staff leavers in the last 12 months


Qualified Nurses 490.5 31.4 13%

Nursing Assistants

119.2 5.6 9%

Other 88.1 6.4 13%


Sickness

Between August 2017 and July 2018, the trust reported an overall average sickness rate of 8% for

this core service.

Staff group Total number of substantive staff Average sickness over 12 months

Qualified Nurses 490.5 7%

Nursing Assistants 119.2 11%

Other 88.1 6%



Nursing – Bank and Agency Qualified nurses

Between August 2017 and July 2018, the core service reported that 5942 registered nursing shifts

were filled by bank staff, 38811 shifts were filled by agency staff and 2242 shifts were unfilled.

Total Number of Shifts available

Total Shifts Filled by Bank Staff

Total shifts Filled by Agency Staff

Total shifts NOT filled by Bank Staff

69494 5942 38811 2242

Nursing - Bank and Agency Healthcare Assistants

Between August 2017 and July 2018, the core service reported that 2247 healthcare assistant

shifts were filled by bank staff, 339 shifts were filled by agency staff and 924 shifts were unfilled.

Total Number of Shifts available

Total Shifts Filled by Bank Staff

Total shifts Filled by Agency Staff

Total shifts NOT filled by Bank Staff

5139 2247 339 924

Medical locums

The trust did not provide any data for this core service.

Consultant cover

The trust has advised that for community health services for adults there was no consultant cover.

Suspensions and supervisions

During the reporting period, this core service reported that there were no cases where staff have

been either suspended or placed under supervision.

The Trust ensured that staff had the right qualifications, skills, training and experience to keep

people safe from avoidable harm and abuse to provide the right care and treatment. However, the

service did not always have enough staff due to sickness and pockets of vacancies in the three

localities. The Trust covered this workforce problem with the use of bank and agency staff and

management told us that they also doubled up on bank and agency staff to support the

recruitment of newly qualified staff.

We were told by senior management that no acuity tool was used for staffing levels. A nominated

band seven nurse had been appointed to co-ordinate staffing on a daily basis. This would be

completed by 9.30am every morning and the band 7 nurse would be empowered to get staff from

other locations if available and if not available escalate it to senior management via the escalation


management system in each of the localities. This would also then be escalated to the Trust

division.

We were told by senior management that a divisional huddle was held daily to look at staffing. A

report would be taken of the Trusts electronic management system and shared with secondary

care and the local clinical commissioning group (CCG). A bronze and silver on call team member

was available twenty-four hours a day, seven days per week and they were empowered to make

decisions around staffing issues. We were told by senior management that teams might pick up

additional workloads instead of moving staff out of their own areas.

Senior management told us that the Trust was offering development posts for band 6 nurses to

ensure good skill mix in teams. In addition to this the Trust was fast-tracking specialist nurses into

district nursing posts, for example a motor-neurone specialist nurse was currently in the process of

joining a district nursing team.

Staffing was on the Trusts risk register and actions and deadlines were in place, for example a

recruitment event for nurses had taken place following an action identified, this had taken place on

a weekend and this had seen a footfall of 70 people, of which 20 had been interviewed for the

community sector. At the time of inspection, we did not see evidence that these interviewees had

been employed.

We were told by management in the rehabilitation at home team that staffing was good at the

present time. The team had the right skill mix to provide a good service. The sickness and

absence rate for the team was 4.5% against the Trust average of 7%. However, we were told that

there had been a band 5 physiotherapy vacancy for the previous two years. Management would

meet with the finance team each month and identify budgets and where availability allowed they

would employ a locum physiotherapist.

Staffing in the speech and language team in South Sefton consisted of one band 7, one band 6

and one band 4 assistant practitioner. There was one vacancy for a band 6 nurse and this was

out for recruitment. Due to the small numbers, staffing was on the Trust risk register. If staff

members were off sick, appointments had to be cancelled and rescheduled. We were told that

since the merger of the new Trust, funding had been granted for another member of staff. Staff

welcomed this and were very positive about the Trust vision and strategy.

Management in the ICRAS team were struggling to recruit physiotherapists. This has been an

ongoing issue for the previous two years. We were told that they had tried to recruit from abroad

and had completed a number of skype interviews, however did not recruit due to sponsorship

problems. Human resources are currently in the process of looking to recruit from Ireland,

however, management are in the process of looking at advertising at the mid-point band six scale

to comply with minimum income requirements set by immigration.

In the ICRAS team we were told by management that they were particularly short of staff on night

shifts and caseloads were difficult to cover, particularly as two of the staff were non-drivers. This

was recorded each shift on the electronic management information system.

Staff in the ICRAS team were regularly transferred out to help with other teams that were short

staffed and this raised concerns as their own workloads were full. Staff told us that they regularly

worked extra hours to complete their own caseloads.


Quality of records

The Trust had a health records policy and procedure (IT06, version 1.6, review date July 2020)

and was accessible for staff via the Trust intranet. All records were electronic in the community

adult services apart from the district nursing service, dietetics and the rehabilitation at home

service.

Records management remained a running agenda item at the quality meetings and we saw

evidence of minutes discussing the current issues and risks associated with the use of hybrid

record keeping. We spoke to senior management who gave us reassurance that the process was

being monitored continuously. Management also provided us with evidence demonstrating the

Trust paper-lite programme which demonstrated services were progressing well against the

Programme plan, with the exception of the district nursing service. This service is the largest of

the community division and a significant amount of work is still to be undertaken to transfer the

current paper based documents to electronic.

District nursing records were predominantly paper. We were told that paper records, for example

care plans and syringe driver checklists were kept in the patient’s homes and the evaluation and

assessment documentation would come back to the office for input to the electronic management

information system . However, staff told us that due to their workloads and no protected time for

administration, notes were not being put onto the electronic management information system in a

timely manner. This raised a risk that notes not entered onto the electronic management

information system would not be accessible to other allied health professionals. We were shown a

spreadsheet by management that demonstrated waiting times of up to 20 days for notes not being

input onto the system. However, staff told us these figures were not a true picture as some staff

had notes for more than 90 days that had not yet been put into the electronic management

information system . We raised this with management and were informed that they would be

auditing these times but at the present time could not provide us with data to corroborate staff

concerns.

We were also told by the district nursing out of hours team that patients’ notes must be entered on

to the electronic management information systems within 24 hours and this was not being

achieved. Staff told us they had raised this with management but nothing had yet been fed back

to them. We did not see documented evidence to corroborate the waiting times at the time of

inspection. We requested this information post-inspection but had not received it at the time of

reporting.

We carried out four home visits with the district nursing teams and reviewed patient records that

were based in the patient’s home. The paper records were clear and legible, however on one

home visit we reviewed a patient record and some pages within the folder were not signed or

dated. All patient records demonstrated full completed assessments, for example, wound

management and wound care plans, pressure ulcer prevention management plans and

malnutrition universal screen tool care plans were in place and filled in correctly. However, one

record had a dementia screen commenced but wasn’t fully completed. We also reviewed a

shared decision tool document which fully explained the risks to the patient by not having pressure

relieving aids in their home.


We carried out a home visit with the community matrons and the electronic information

management system was being used. However, community matrons could not access test results

or GP consultations, they could only access basic entry documentation. The nurse had taken a

written note of the patient’s information that they had gathered from an EMIS printout in the office,

continued to use this paper record to document notes on and then when back at the office would

input the details onto the EMIS system. This added extra administration time to the nurse’s

workload.

We spoke to management in the physiotherapy department in the Central locality who told us they

were taking the lead on the paper-light initiative in their area to ensure that templates were more

robust which would make triaging more effective.

We looked at three electronic patient records in the physiotherapy department in the South Sefton

area and all were completed correctly. We noted on one record that an advanced care directive

had been completed and documented clearly as per Trust policy SD19, advance statement,

advance decision policy.

We were told by management in the occupational therapy department that a summary paper note

was kept in the patient’s home in case the hand held electronic device failed when on a patient

visit. We were also told that a paper copy of a patient’s demographics and triage details was kept

in the office in case the electronic system crashed. These copies were shredded once the patient

was discharged from the service. We raised this with management at the time of inspection and

advised them that keeping copies of patient details did not adhere to the Trust paper-lite

programme and did not follow the Trust health records policy and procedure (IT06, version 1.6)

which stated that creating duplicate records could pose a risk to the service user and should not

be carried out.

We were told by management in the dietetics department that although they had access to the

electronic management system in the office, they were keeping paper records as they were

waiting on the hand held electronic devices to be supplied. In addition to this, management told us

that they were working collaboratively with all dieticians in the localities and that the general

consensus at the time of inspection was that domiciliary patients would remain on paper records

until they were discharged from the service. For patients that had a percutaneous endoscopic

gastrostomy (PEG) tube their records for the previous twelve months would be scanned into the

electronic management information system when the hand-held devices were made available.

We reviewed five patient records in the dietetics department. All were clear, legible, dated, signed

and in chronological order. Three of the records had a comprehensive checklist for assessment of

patients with a percutaneous endoscopic gastrostomy tube and two records had a comprehensive

assessment of patients receiving oral nutrition. Both checklists were clear and completed fully.

Staff told us in the ICRAS team that the local NHS Trust team were relying on paper copies of

discharge summaries as they were unable to access the electronic management information

system. We looked at a paper patient record in this team and it was clear, legible and

chronological in order which demonstrated a good patient history process.

We looked at one patient electronic record in the ICRAS team and it demonstrated a concise,

clear assessment with a clear documentation of the plan of action. A full consent process was


evident which documented that the patient’s own views and preferences had been adhered to. In

addition to this we saw that the referral had met its response time of forty-eight hours.

We were told by the advanced nurse practitioners that records are updated electronically at point

of contact. However, there had been issues with the mobile hand-held devices and staff had been

unable to get access to patient records.

Medicines

The Trust had a handling of medication policy (SD12, version 3.0, review date March 2019). Staff

we spoke to told us that they knew how to access it via the Trust intranet if required.

The service prescribed, administered, recorded, dispensed and stored medicines well. Patients

received the right medication at the right dose and was given at the right time in the right route.

Controlled drugs (CDs) were not prescribed or held by the community service. Community

pharmacists supplied these and the drugs were stored in patients’ homes. We spoke to staff in

the district nursing service on their roles and responsibilities of controlled drugs and noted that

these drugs were not always destroyed and disposed of in line with the Trust policy and

procedures. Staff told us that it was common practice for family members to return their relatives’

controlled drugs to the local pharmacy as the drugs had been prescribed by the community

pharmacy and not the Trust. Records did not always reflect the procedures and processes

outlined in the policy for recording the destruction of controlled drugs. We raised this with senior

management at the time of inspection and we were provided post-inspection of the process of

destroying controlled drugs and a quality practice alert was issued by the medicines safety support

manager to all adult community teams to reiterate the requirement of following all aspects of the

Trust policy and operating procedure.

We saw evidence of Trust wide medicine safety meetings. In these minutes we saw for example,

discussions on incidents and the learning gained from these and bulletin updates. We also saw

actions to be completed and future meetings planned.

We were told by management in the dietetics department that they had no non-medical

prescribers at the time of inspection. However, this was an area they would be looking at in the

future as it would save time on waiting for a GP to prescribe the nutritional drinks.

There were six non-medical prescribers in the ICRAS team. Updates for skills and theoretical

knowledge were regularly undertaken. Staff also kept themselves updated via electronic websites,

for example the British National Formulary (BNF) and the National Institute for Health and Care

Excellence (NICE).

We were told by management in the ICRAS team that a pharmacist and a pharmacist technician

undertook medicine reconciliation with patients. We did not see evidence of this during the

inspection. We saw a pharmacy cupboard on site which held anaphylaxis medications,

intravenous fluids, sub-cutaneous treatments and medications for nebulisers. All were in date and

stored in chronological order. The co-ordinator for the team held the key and this was kept in a

locked drawer.


We spoke to an advanced nurse practitioner (ANP) who told us that prescriptions were completed

electronically and that medications were kept in locked boxes in the patient’s home if they had

concerns. In addition to this we saw that prescription pads were stored in a locked cupboard and

taken out if required. The ANP also told us the process for ordering prescription pads and the

process of reporting lost prescriptions to pharmacy.

We observed podiatry clinics and saw that local anaesthetics were locked in a cupboard in the nail

surgery treatment room. The key was kept in a locked drawer in another room.

We were told by the out of hours district nurses that prescriptions were hand written on FP10’s

and yellow prescription sheets for end of life care patients. GP practices were informed of any

new prescriptions and relatives had to pick the prescriptions up to take to their local pharmacy for

dispensing. FP10’s in the district nursing service were securely locked away in a key cupboard as

per Trust policy.

We spoke to community matrons who told us that there was a non-medical prescribing lead in the

Trust and updates were given on line. Post-inspection we were provided with documentation

confirming attendance to non-medical prescribing forums and refresher training sessions. In

addition, we were also provided with evidence that the Divisional Medicines Management

Pharmacist screened the electronic prescribing data on a monthly basis and presented this to the

Medicines Optimisation Group and Antimicrobial Resistance Group that met on a bi-monthly basis.

Adrenaline was carried by district nursing staff and taken home at night when it was not feasible to

return to their base. This was in line with Trust policy that stated that the drug must be stored

securely either at the individual member of staff’s home or, if feasible, at their base.

Safety performance

Safety Thermometer (September 2017 to September 2018)

The NHS Safety Thermometer allows teams to measure harm and the proportion of patients that

are ‘harm free’ during their working day. For example, at shift handover or during ward rounds.

This is not limited to hospital; patients can experience harm at any point in a care pathway and the

NHS Safety Thermometer helps teams in a wide range of settings, from acute wards to a patient’s

own home, to measure, assess, learn and improve the safety of the care they provide. Safety

Thermometer data should also not be used for attribution of causation as the tool is patient

focussed.

Caveat: the information relates to community services only.

New Pressure Ulcers

The trust reported 70 new pressure ulcers between September 2017 and September 2018.

The most number of new pressure ulcers was reported in August 2018 with 12 (1.44% prevalence

rate). However, the highest prevalence rate occurred in May 2018 with 2.55% (five new pressure

ulcers)


Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18

Prevalence %

1.53 0.40 0.41 0.51 2.55 1.74 1.33 0.68 1.38 0.73 0.81 1.44 1.29

No 3 1 1 1 5 4 4 6 11 6 6 12 10

The service used safety monitoring results well. Staff collected safety information and shared it

with staff, patients and visitors. The service used the information collated to make improvements.

We were told by senior management that they had a clinical strategy to improve the prevention of

pressure ulcers and had implemented a pressure ulcer reduction programme. We were provided

evidence of this plan post inspection which demonstrated interventions, actions and progress

statements of where the Trust was at in a certain timeframe.

We saw a Trust-wide newsletter ‘PURPLE’ (Pressure Ulcer Reduction Programme Learning and

Education) that provided staff of various news items, for example dates for training days,

resources that staff could access, workstream updates and updates on the task and finish group

that would review current guidelines and practice surrounding end of life care and the

management of pressure ulcers.

We saw a pressure ulcer dashboard in each of the localities that demonstrated acquired and

avoidable pressure sores. We were provided copies of these dashboards post inspection which

demonstrated that there was a significant decrease in Grade 4 pressure ulcers from March 2018,

however there had been a sudden increase in the previous three months We saw two cases

reported of grade four pressure ulcers. We requested the root cause analysis post inspection but

had not received the data at time of reporting. A root cause analysis is a method of problem

solving used for identifying the root causes of faults or problems.

In addition to the pressure ulcer dashboards we were told by senior management that in the trust

quality accounts they were now adding grade two pressure sores to monitor themes and trends.

Catheter & UTI


The trust reported three catheter & UTI between September 2017 and September 2018.

The most number of catheter & UTI’s were reported between April and July 2018 with one each.


Prevalence %

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.11 0.00 0.12 0.13 0.00 0.00

No 0 0 0 0 0 0 0 1 0 1 1 0 0

Falls with Harm

The trust reported 62 falls with harm between September 2017 and September 2018.

The most number of falls with harm was reported in June 2018 with 17 (2.07% prevalence rate).

However, the highest prevalence rate occurred in September 2017 with 3.06% (six falls with

harm).



Prevalence %

3.06 1.59 0.00 0.00 1.53 0.43 0.00 1.25 0.88 2.07 1.48 0.12 0.77

No 6 4 0 0 3 1 0 11 7 17 11 1 6

Harm Free Care

The trust reported 6227 cases of harm free care between September 2017 and September 2018.

The most number of harm free care instances was reported in April 2018 with 847 (96.47%

prevalence rate). However, the highest prevalence rate occurred in December 2017 with 98.98%

(184 instances of harm free care).



Prevalence %

94.90 97.62 97.65 98.98 93.88 96.52 97.67 96.47 95.00 95.00 96.24 96.88 95.74

No 186 246 239 194 184 222 294 847 770 779 716 808 742





In accordance with the Serious Incident Framework 2015, the trust reported 4747 serious

incidents (SIs) in Community health services for adults, which met the reporting criteria, set by

NHS England between August 2017 and July 2018. Of these, the most common type of incident

reported was ‘Pressure Ulcer’ with 36 (77%).

Incident Type Number of Incidents

Pressure ulcer 36

Pending review 5

Apparent/actual/suspected self-inflicted harm 2

Surgical/invasive procedure incident 2

Confidential information leak/information governance breach 1

Treatment delay 1

Core Service Total 47

Serious Incidents (SIRI) – Trust data

Between 1 August 2017 and 31 July 2018, trust staff in this core service reported 52 serious incidents.


Of these, zero involved the unexpected death of a patient.

The most common type of serious incidents was ‘pressure ulcer’ with 38.

The number of the most severe incidents recorded by the trust incident reporting system is not

comparable with that reported to Strategic Executive Information System (STEIS). The trust told

us that the reason for the discrepancy was that some STEIS incidents had been removed at the

request of the clinical commissioning groups, which is normal practice.


Pressure ulcer 38

Other 5

Treatment delay 3

Pending review 2

Apparent/actual/suspected self-inflicted harm 1

Confidential information leak/information governance breach 1

Medication incident 1

Accident e.g. collision/scald (not slip/trip/fall) 1


We were told by senior management that safety dashboards were not being used at the present

time to see team profiles. These dashboards would encompass the National Health Service

(NHS) safety thermometer and display topics such as medication safety indicators, early warning

systems of patient safety issues or deteriorating performance, mortality as a patient safety metric

and infection prevention and control measurements. The implementation of these dashboards for

each team in each locality was now part of the Trust trajectory plan.

The service managed patient safety incidents well. Staff recognised incidents and reported them

appropriately. Managers investigated incidents and shared lessons learned with all teams in the

community services.

The Trust used an electronic incident reporting system. There was a positive culture around the

reporting of incidents and staff were encouraged to report incidents regardless of the level of

harm. Staff we spoke to told us that following the unification of Mersey Care there had been a

much better atmosphere around reporting incidents and they felt that things were improving

greatly.

Incidents were reviewed at a local level and discussed at divisional meetings. Incidents that met

the Serious Incidents Framework 2015 underwent a root cause analysis investigation. These

were then presented at a corporate level to the serious incident never event panel (SINE) who met

weekly and discussed a maximum of two serious incidents.

Senior management also told us that they worked closely with the governance leads at the Trust

and that a report from the Trusts electronic incident reporting systems was run off daily. In

addition to this a seventy-two-hour structured review was held twice a week for discussions on

incidents that were reported as moderate harm and above.


Serious incident reviews were undertaken as part of the SINE panel. Staff were involved in

undertaking root cause analysis investigations. Outcomes and lessons learnt were shared with

staff in team meetings and seven-minute briefings.

We spoke to management in each locality and were shown evidence of lessons learnt following

incidents. A seven-minute briefing detailing incidents and lessons learnt was given to staff. We

also saw newsletters sent to staff to keep them informed.

We reviewed six clinical incidents in the district nursing service. All six incidents were categorised

into minor or no harm and we saw evidence that all had been investigated, action plans were in

place, lessons had been shared via the teams seven-minute briefing.

Oxford learning events were held for staff so that reflections on incidents could be discussed. This

gave wider learning to the team in all localities and staff could add a theme that they wanted to

reflect on. Management told us that the current documentation of pressure ulcer care would

continue for a few months due to the number of incidents they were seeing in the teams. We saw

dates set for these training events in December 2018 and January 2019.

Staff told us that incidents would be reported on the Trusts electronic incident reporting system

and that feedback was given via emails and team meetings. Staff also told us that incidents were

discussed in safety huddles every morning and also at the business hub every Tuesday. A staff

member would attend this and then cascade the information back to their team.

There were no incidents within the dietetics department. Management and staff we spoke to told

us that they knew how to report an incident via the Trust electronic incident reporting system and

were aware of the duty of candour. Management also told us that a weekly breakfast meeting was

carried out at the Trust for band seven and band eight staff and incidents would be discussed and

this would be cascaded back to staff via team meetings and emails.

We were shown details of an incident reported in the rehabilitation at home team. Lessons learnt

were identified and fed back to staff from their manager and the governance teams.

We were told by management in the ICRAS team that the pharmacists investigated medicine

incidents which was in line with the Trust policy.

We were shown an incident that had been reported by a staff member as a preventative incident.

The staff member had identified that no plans were made to remove a patient’s clips following an

orthopaedic procedure. This was followed up to ensure the clips were removed.




The service provided care and treatment based on national guidance and evidence of its

effectiveness.

Care was provided in line with national guidance from the National Institute of Health and Care

Excellence (NICE), National Health Service (NHS), Department of Health (DoH) and other

professional bodies that promoted best practice and professional standards.

We saw evidence of standard operating procedures (SOPs) and patient assessments that were in

line with national guidance, for example assessments were carried out utilising Waterlow scores

for pressure care, national early warning scores (NEWS) and malnutrition universal screening

tools (MUST).

Guidance from the national health service for people who drink alcohol and guidance for the

treatment of dysphagia (NHS 2018) had recently changed and we saw evidence that the dieticians

had changed this guidance in their patient information booklets so that evidence based practice

was given. We also saw updates from a National organisation in the dietetics office for patients

with motor neurone disease (MND).

Staff in the rehabilitation at home service provided gold standard care and followed the Chartered

Society of Physiotherapy guidance to keep up-to-date with advances in practice. We saw

evidence of assessment templates used that were in line with Trust policies and guidance.

The community service had a range of care pathways in place to ensure that patients received the

appropriate treatment for their condition.


The service assessed and monitored patient’s nutritional needs effectively. New patient

assessments incorporated patient lifestyles and cultural preferences. These were evident on the

patient records that we reviewed.

Patient nutritional needs were assessed using a malnutrition universal screening tool (MUST).

This is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (or

undernutrition), or obese. It also includes management guidelines which can be used to develop a

care plan. We saw evidence of patients being referred to dieticians and speech and language

therapists (SALT) after being identified as high risk. Nutritional assessments were re-visited if

there were any changes in the patient’s condition.

We were told by the district nursing out of hours service that percutaneous endoscopic

gastrostomy (PEG) feeding regimes varied between each locality and there were concerns raised

to us by staff that this could be a risk to patients as there was no continuity of care in this service.

We were told that as there was only one out of hours service that covered a large geographical

area staff were seeing patients that were not on their own team caseloads and due to the variation

of feeding regimes in different areas they felt under-confident in carrying out these treatments. We

raised this with management and we were told that senior management were looking into putting


out of hours services back to each locality so that continuity of care would be achieved. We did

not see evidence that it was on the Trust risk register.

Pain relief

Staff told us that they would use a pain scoring system of zero to three (Zero = no pain, 1 = mild

pain, 2 = moderate pain and 3 = severe pain) if they had any concerns. However, during our

inspection, out of the twenty-two records reviewed, only two pain scores were evident and these

were documented on the NEWS 2 charts.

Pain was assessed and reviewed during patient interactions and this was evident in the patient

clinics that we attended. We spoke to staff and asked them what they would do with a patient who

was recording a high pain score and was told that they would speak to a doctor or nurse

consultant in the acute sector for advice whilst in the clinic environment but if they were visiting a

patient in the home environment they would speak with the patients GP. Staff also told us that a

follow-up appointment would be undertaken either by telephone or home visit dependent on the

treatment and advice given.

For patients with a cognitive impairment, staff told us that they would us the Abbey pain scale for

the assessment of pain.

Patient outcomes

Audits – changes to working practices

The trust had participated in 11 clinical audits in relation to this core service as part of their Clinical

Audit Programme.

Audit Date completed

Pressure Ulcer Audit Report Q2 (July 2017 to September 2017) 20/10/2017

Cellulitis Audit Report 07/12/2017

Pressure Ulcer Audit Report Q3 (October 2017 to December 2017) 09/03/2018

Sefton Community Respiratory Team -Smoking Cessation 29/03/2018

Pressure Ulcer Audit Report Q4 (January 2018 to March 2018) 27/04/2018

Wound Assessment CQUIN Audit 27/04/2018

South Sefton Community Cardiac Team Patient Survey 16/05/2018

Community Matron Antibiotic Audit 06/06/2018

Diabetes Education Report 21/06/2018

IV Antibiotics for Cellulitis Report 21/06/2018

Venous Leg Ulcer Audit 26/07/2018

The service monitored the effectiveness of care and treatment and their findings to improve

outcomes.


A red, amber and green (RAG) rating tool accredited by the Queens Nursing Institute (QSI 2008)

was used in the community services to monitor outcomes. Patients were categorised into colours,

for example, red (very poorly patients), amber (improving patients), green (social care package),

blue (package of care equipment). Completion of the RAG rating tool was necessary for the

caseload holder to highlight areas of concern and access caseload holder review dates easily. In

addition to this, caseloads were discussed weekly by the senior leadership team on Mondays,

Wednesdays and Fridays to ensure that they were fully informed and any areas of concern

escalated. We attended a MDT meeting in the district nursing service and observed discussions

on packages of care, treatment plans and external party summaries. We were told by

management that an audit was currently being carried out on the implementation of this tool and

data would be available in May 2019. Figures to date are demonstrating that patient home visits

have been reduced and patients are being seen in a timely and efficient manner.

We were shown evidence of the involvement of the dieticians in the National Diabetes Audit and

Diabetes Prevention Programme (NDA-DPP) pilot study. This audit was to identify how non-

diabetic hyperglycaemia information was recorded and to get an understanding of the number of

non-diabetic hyperglycaemia patients were in the localities. Results demonstrated that when a GP

practice enrolled onto the programme and recorded high risk patients under the correct coding, the

prevention programme was able to extract the data and identify the suitability of patients for

referral onto the programme. Management told us that they gave talks three times per week in

their locality and that they were funding this initiative themselves.

We saw evidence of a do not attend (DNA) audit by the dietetics department which demonstrated

a high number of DNA rates. Clinic numbers were small and patients who did not attend

highlighted a high DNA percentage rate. In addition to this, management told us that due to the

small number of patients being seen in clinics, the key performance indicator (KPI) set by the Trust

would need reviewing. Management did not know what the national average KPI was for DNA

targets in dietetic clinics. This had been raised with senior management and no decision had yet

been made in altering the KPI target. However, in an attempt to reduce DNA rates, management

were looking into sending text messages to patient’s mobile phones to remind them of their

appointments.

Management in the frailty team shown us an adapted questionnaire taken from a local government

regulator. This was given to patients on admission to the frailty unit at the local NHS trust and

then given again on discharge. The team were in the process of collating pre and post results

from the questionnaires. At the time of inspection we did not see any outcomes of these results.

We were told by management in the district nursing service that they carried out a large wound

care audit twice a year as part of the CQUIN. This would encompass one hundred and fifty patient

notes. Results were not yet collated at the time of inspection.

We reviewed an audit that was undertaken by the rehabilitation at home service where therapy

assistants had been upskilled because of recruitment issues. The audit was to see if there was an

impact on staff and the patients by upskilling these health care workers. Results demonstrated

that there was no adverse effect on patients and staff felt more confident in visiting patient’s

homes.


We saw evidence that the rehabilitation at home service were collaboratively involved in the

National Hip Sprint audit that captured data on services, pathways, frequency and types of

rehabilitation for hip fracture patients over sixty years of age. This service was being delivered

within the expected parameters of the chartered service of physiotherapy.

We reviewed audits in the physiotherapy department on face to face consultations, joint

consultations, telephone encounters, triages and referrals. These audits were ongoing and results

not yet collated. However, preliminary results demonstrated clinic times were reduced which

allowed more patients to be seen in a timely manner.

We were shown evidence by management in the occupational therapy department of an ongoing

audit by the falls team. Results were not yet available.

We were shown an audit in the occupational therapy team on patients with multiple-sclerosis that

included details of cognitive problems and how staff assess these needs. The results highlighted

that training and confidence in treating these patients was required. This audit would now be used

as a benchmark for further audits in this area.

Staff in the Telehealth team told us they completed monthly and quarterly audits to monitor the

impact of the Telehealth service for patients and carers. They reported positive outcomes from

service users who stated that they had benefited from the service and had developed improved

confidence in managing their health conditions. We did not see evidence of the results to

corroborate this at the time of inspection.

Competent staff

We were told by staff in the district nursing service that competencies were not completed.

However, we were provided post inspection with syringe driver and pressure ulcer care training

competencies. Figures were variable throughout localities, for example the out of hours service

were 100% compliant for their syringe driver training compared to Kensington district nurses

whose compliance was 0%. In addition to this all areas in each locality were not compliant with

their pressure ulcer training and competencies. We saw the pressure ulcer prevention programme

and was told by senior management that pressure ulcer training for band 5, 6 and 7 staff would be

completed by 31 December 2018 and the competencies would be achieved by 31 March 2018.

Management in the district nursing service told us that all new band 5 nurses received a

supernumerary capacity period and would spend time in treatment rooms for pressure ulcer care.

Senior management told us that competencies used to be at team level only but they are now

looked at Trust level so that areas that are not compliant can be identified. We were told that a

new competency framework was being implemented and the Trusts trajectory plan had a deadline

of 31 March 2019 for these to be in place. In addition to this permanent night staff would not have

to fully complete this new competency framework unless they were going to work day shifts. We

raised this with management and were told that wound dressings and clinic treatments were

completed during days shifts and night workers would not need these skills to carry out their roles.

Senior management told us that they had recently developed a competency framework for agency

and bank staff which included an induction pack with a self-assessment framework in place. This

had recently been implemented in the district nursing service on 15 November 2018.


We saw evidence of the Trust trajectory plan for nursing core competencies which was presented

to the divisional safety huddle. A plan was put in place to collate a divisional sign off for all district

nursing day services and we saw actions and timeframes for these competencies to be completed.

Band 6 nurses were now being offered the opportunity to obtain a specialist qualification (SPQ) in

district nursing and that only 24% of the district nursing staff currently held this certification. Senior

management confirmed that they had ten district nurses completing a specialist qualification at the

time of inspection. In addition to this the Trust was offering band 6 nursing staff the opportunity to

obtain a leadership module at Masters level which was being ran by a local university.

The physiotherapy department staff rotated within the service to keep their skills up-to-date. Band

4 staff would rotate annually, band 5 staff would rotate eight monthly and band 6 staff would rotate

six monthly. There was also in-house training provided for staff, for example chair based

exercises.

There was only one band 5 nurse in the IV team who was trained to complete blood transfusions

and the team were struggling to respond to transfusion referrals. This had been escalated to

management and staffing had been put onto the Trusts risk register. In addition to this we were

told that training would become a priority when vacancies were filled.

We were told by administration and reception staff in all localities that protected time was given for

e-learning training.

Staff in the rehabilitation at home team told us that competencies were undertaken prior to

completing any pre-operative assessments in patient homes. We reviewed a competency

checklist that had been fully completed which incorporated the use of equipment and how to use it

correctly. The list was dated, signed and had action plans documented with review dates. We

also spoke to a therapy assistant and was told that they would like to rotate to different teams to

update and learn new skills.

We reviewed a development plan for a new starter in the community assessment team. The plan

was not fully completed and we spoke to their mentor who agreed that the plan was not

adequately completed and would action this straight away. In addition to this we spoke to another

new starter within the team who told us that they did not have one. There was also no evidence of

a skills matrix in place and staff could not articulate what skill sets were required for each band of

staff.

We were told by the community matrons that ‘Advanced Clinical Practice’ was not accessible and

this had been raised as a big concern to senior manager when seeing community patients. In

addition to this community matrons told us that there was no known framework that they had to

work to and that the Trust could not benchmark this to see if the skills they had were adequate.

Staff with non-medical prescribing qualifications kept updated using websites such as BNF.org

and NICE guidance. Staff told us that they also received regular updates from the

communications team at the Trust.

We saw a training needs analysis in the district nursing office, including for example blood

pressure monitoring, blood glucose monitoring, ear syringing and pressure ulcer training.

However, we noted that there was no system in place to ensure safe practice of the Doppler


system. Staff told us that there was no re-assessment for training on this piece of equipment. A

Doppler ultrasound is a test that uses high-frequency sound waves to measure the amount of

blood flow through arteries and veins, usually those that supply blood to arms and legs.

Not all staff we spoke to in the district nursing team felt supported. We spoke with staff who told us

that requests for further training which was documented on their personal development plans had

not been actioned. We raised this with management and was told that due to capacity issues

additional training had not been a priority of the service.

Management in the dietetics department told us there was no supernumerary period for new

starters. However, there was a good buddy system in place and a local induction checklist that we

reviewed. We were also told that band five staff could shadow an acute dietician to gain

confidence and improve their clinical skills in the Trust if required.

Dietitians’ were all registered with the British Dietetic Association (BDA) and regular updates and

forums were attended to ensure evidence based care was given to patients and their families.


Between 1 May 2018 and 31 July 2018, the clinical supervision rate for the core service was 1% -

the trust target was not provided.

Staff Group Clinical Supervision

Target Clinical Supervision

Delivered Clinical supervision rate

(%)

Allied Health Professionals - 3 3%

Other ST&T - 3 2%

Registered Nursing Midwifery and Health visiting staff

- 14 <1%

Core Service Total - 20 1%

We were told by senior management that the Trust had an electronic system to record clinical

supervision and that each team leader submitted an overview of their team. We observed that this

was carried out inconsistently throughout each locality.

We saw evidence of electronic templates, however staff in the district nursing service told us that

their templates were not a true reflection of what staff were receiving. For example, new starters

received clinical supervision but other staff were not receiving it due to capacity issues. The out of

hours district nursing staff who were full time workers would access clinical supervision sessions

during the day when possible. However, we were told by staff who were permanent night workers

that they were unsure how they could access this and had not received any clinical supervision at

the time of inspection.

Community matrons told us that the multidisciplinary meetings were classed as their clinical

supervision. No formal or informal meetings were held or recorded for this. The service managers

stated that clinical supervision was available via a community geriatrician but staff told us that this

did not happen.


We spoke to management in the physiotherapy and occupational therapy departments and were

shown clinical supervision templates. We were told that joint visits, weekly supervision for band 4

and 5 staff, fort-nightly supervision for band 6 staff and monthly supervision for band 7 staff was

carried out. We saw evidence of this in four staff records. In addition to this we were told by staff

that a buddy system was in place and this was welcomed as it ensured all staff were supported at

all times.

Clinical and management supervision was regularly carried out in the ICRAS team. Three sets of

patient notes were audited as part of the supervision process. We saw evidence of the

supervision template being used within the team. In addition to this, every Thursday morning was

protected for one hour for training purposes. Staff told us they felt very supported by their peers

and by management. However, staff in the Telehealth team told us that clinical supervision had

not been carried out for the previous twelve months and with no manager in place for the previous

eighteen months they had felt very unsupported.

We were provided post inspection of the Trusts clinical/managerial safeguarding supervision and

reflective practice policy, number SD33, Version 4 that stated supervision should be monitored

annually through staff appraisals. In addition to this, Trust policy stated that protected time (one

and a half hours, every eight weeks) which is in line with the Nursing and Midwifery Council (NMC)

guidance should be allowed for supervisees to access clinical supervision. Although appraisals

were up to date, the clinical supervision had not been addressed.

We were told by staff in the rehabilitation at home team that although clinical supervision was not

given at the present time, there was reflective practice in the team.


Between April 2018 and July 2018, 82% of permanent non-medical staff within the community

health services for adults core service at the trust had received an appraisal compared to the trust

target of 95%. This is already better than the 66% appraisal rate reported for the previous financial

year.


Total number of permanent non-medical staff who have had an appraisal

% appraisals

1629 1343 82%

Appraisals for permanent medical staff

Between April 2018 and July 2018, 0% of permanent medical staff within the community health

services for adults core service at the trust had received an appraisal compared to the trust target

of 95%. This is the same as the 0% reported for the previous financial year.

Total number of permanent medical staff requiring an appraisal

Total number of permanent medical staff who have had an appraisal

% appraisals

1 0 0%


Appraisal rates for each team were recorded by management and reported monthly to senior

management.

We saw an example of a personal achievement and contribution evaluation that was completed by

a staff member and also by a manager. Results from both parties were then compared when

completing the appraisal together. This demonstrated how each person perceived their

development and was a good starting block to the appraisal process.

Data provided by the Trust up to July 2018 demonstrated that appraisals were 82% compliant.

During our inspection in November appraisals and personal development plans were up to date.

However, two staff members in the district nursing service had not had their appraisals but were

booked in with their team leaders for this process. The physiotherapists in the Central and South

localities were 100% compliant but the North regions appraisal rate was 78%. This was due to

sickness and capacity issues and had been raised to management.


Staff in different specialities worked together as a team to benefit patients and their families.

Doctors, nurses and other healthcare professional supported each other to provide good care.

We saw evidence of multidisciplinary team minutes and forums with external parties.

Community teams were split into localities and neighbourhoods. Teams were based in buildings

that were shared with a range of other services, for example general practitioners (GPs), social

care, walk-in-centres and social care. The patients under their care often used the range of

services within these localities which encouraged collaborative working which enhanced patient

care.

We saw evidence of multidisciplinary team (MDT) meetings that district nurses attended. These

were attended by GP’s, specialist palliative care nurses, allied healthcare professionals and

external charity members.

Joint visits were carried out to patients with palliative care nurses, these were usually carried out

weekly which cemented strong links between the teams.

A tissue viability nurse from the skin care team would rotate to each locality. This not only

supported the district nurses but allowed training to be provided on skin care.

A mental health practitioner would attend safety huddles twice a week in the district nursing

huddles. We saw evidence of this in their safety huddle meeting minutes for the previous three

months prior to inspection. We also saw a shared care tool in the district nursing service which

demonstrated good collaborative working between different specialities.

We were told by management in the physiotherapy department that they used to attend the

palliative care MDT meetings to ensure good links between specialities, however to make for

effective use of time they would now only attend if invited to review a specific patient.


Management in the physiotherapy and occupational therapy departments told us that to avoid

admissions to the acute trust more preventative work was being carried out. For example, a care

home project was being implemented which included asking care homes to complete risk

assessments for their patients. This initiative was welcomed both internally and externally to the

Trust.

The occupational therapy and dietetics departments had established links outside the trust with

other specialities, for example, diabetes specialist groups, neurological specialist groups and local

charities. Staff said these were invaluable resource points and good networking enhanced patient

care as ideas and skills could be shared.

Management in the dietetics department had a task and finish group between the localities which

ensured good communication and continuity of care.

The dietetics department also had support from an external provider for percutaneous endoscopic

gastrostomy (PEG) tube care. The external provider would complete tube changes in the patient’s

home which avoided admissions to hospital.

The ICRAS team provided a service to optimise health and delay the impact of frailty. This service

encompassed numerous teams, for example urgent care, home first, emergency response,

intensive community care, outreach, social work, rehabilitation at home and discharge planning.

This provided a multidisciplinary approach to patient care.

Pharmacists attended the integrated community reablement and assessment team meetings to

enable medications to be discussed, particularly around discharge. A member of the ICRAS team

would attend ward rounds at the local NHS Trust to identify patients requiring their service.

Staff in the rehabilitation at home team during winter pressures would work with the integrated

community reablement and assessment team (ICRAS) to see patients requiring therapy services.

Collaborative working was carried out with dietetics on the International Dysphagia Diet

Standardised Initiative (IDDSI) to reduce referrals to the SALT team. We saw evidence of this in

the dieticians training records.

We were told by the ANPs that multidisciplinary meetings were carried out five days per week and

that the whole team’s caseloads were discussed. We did not see evidence of these meetings

during the inspection.

Community matrons attended multidisciplinary meetings every Thursday and would review

patients and co-ordinate care appropriately. We were told by staff that workloads were shared

over the three localities and that there was great collaborative working between care homes and

nursing homes.

District nursing staff told us they had named link nurses allocated to each nursing home in their

area to ensure a consistent point of contact and good collaborative working with other specialities.

Seven Day Services

The physiotherapy department and the occupational therapy department provided services five

days per week. These ran from Monday to Friday. Physiotherapy, 8am to 4pm and Occupational


Therapy 8am to 5.30pm. There was no out of hours service however, we were told weekend

cover and out of hours cover was available if required.

The ICRAS team provided a seven-day service from 8am to 9pm. Out of hours was covered by

the outreach service.

The speech and language therapy team provided a service which ran from Monday to Friday, 9am

to 5pm. This was not an urgent service and care was not provided out of hours.

The out of hours district nursing service provided cover seven days a week, 4.30pm to 8.30pm for

the twilight shift and 8.30pm to 8pm for the night service.

Health promotion

Staff across the community service encouraged patients to make healthy lifestyle changes and

promoted ways for patients to manage their own health. This included referrals to smoking

cessation services and wellbeing services.

We were told by management in the dietetics departments that there was a wellbeing healthy

eating event every Wednesday at the local library. The department ran this event with help from

public health to promote healthier lifestyles and this was open to staff and the public.


Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental

Capacity Act 2005. The Trust had a mental capacity act and deprivation of liberty safeguards

policy (version 3, LCH-119, review date May 2019) in place which was available on the Trust

intranet and internet.

We spoke to staff and they knew how to support patients experiencing mental ill health and those

who lacked the capacity to make decisions about their care.

We were told by staff that if they had concerns of a patient suffering fluctuating capacity they

would speak with their line manager for advice and they would also analyse the situation with their

colleagues. Staff would also direct patients to GP’s, mental health services and local and national

voluntary charities for support.

We saw a mental health capacity assessment completed in a patient record within the dietetics

department. The form was fully completed with a clear and concise assessment and a summary

was input onto the electronic management information system. However, we were told that the

mental health team could not access the electronic system and therefore would not see the full

assessment unless it was emailed to their department. This had been raised to senior

management and staff were told to continue with this process as the electronic systems between

the departments were not yet unified.

Staff were aware of their responsibilities in relation to consent. We observed staff obtaining verbal

consent during patient home visits and documenting this both on paper and on EMIS.


Consent to record sharing with other internal and external parties was taken at each patient visit

and this was evident on the electronic patient records that we reviewed. However, it was not

always clear from the paper records that consent was gained on each subsequent visit.


Mersey Care NHS Foundation Trust told us that 97 Deprivation of Liberty Safeguard (DoLS)

applications were made to the Local Authority between 1 August 2017 and 31 July 2018. None of

which were pertinent to community health services for adults.



Compassionate care

We observed patients being supported in a caring, compassionate and kind manner by staff in

clinic and treatment room areas as well as in patient home environments. Staff took time to

interact effectively with people using the service and treated patients and their families in a

dignified and respectful way. For example, we observed excellent care given to a patient in the

podiatry clinic. Full explanations were given to the patient throughout their treatment and time was

given for the patient to relay any concerns that they had regarding their current issues.

We observed staff introducing themselves to patients and relatives in a friendly and engaging

manner and clear explanations being given for their visit or appointment. We also observed staff

being encouraging, sensitive and supportive towards patients and their families.

Staff listened attentively to patient concerns and responded appropriately with clear and concise

explanations. For example, one patient was concerned about experiencing side effects from a

prescribed medication; the nurse explained in a way that the patient could understand on how the

treatment may affect them and gave reassurance on when to seek medical attention.

Staff demonstrated empathy and compassion towards patients and their families and showed

concern and sensitivity when discussing difficult or personal issues.

Staff gave us examples where teams had gone above and beyond normal duties. For example,

staff in the IV therapy team had downloaded music for a patient who had dementia so that it could

be played during visits, this helped to put the patient at ease during treatment. Staff had collected

prescriptions on route to housebound patients who did not live within a delivery radius of a

pharmacy and staff had self-funded supplies of tea and biscuits so all patients visiting the

department were offered refreshments.

Patients we spoke to confirmed that staff treated them respectfully and with kindness. They also

told us that they felt supported and were happy with the care they had received. In addition to this,

patients told us that not only did they feel listened to but they were offered support so that they

could fully understand their condition. One long standing patient told us “I know I am going to get

good treatment here, they are like my family and have really good understanding of my condition”.

We saw evidence that staff had great knowledge about their patients and their medical histories

and this ensured great communication between all parties.

We carried out two home visits with the rehabilitation at home team. We observed full holistic

assessments of patients prior to being admitted to the acute site for surgery. Both patients were

fully informed of what would happen following surgery and what equipment would be available for

them. We spoke to both patients and were told that they found the visits invaluable and it had

alleviated some of their concerns regarding their recovery process.

We observed five treatment clinics within the district nursing service. Each patient visit was clear

and informative. Patients details were checked at the beginning of the appointment and consent

for the treatment obtained. Full explanations were given to the patients throughout the

appointment.


Emotional support

Staff provided emotional support to patients and their families to minimise their distress.

Staff demonstrated that they understood the importance of providing patients and their families

with emotional support. Staff showed an awareness of the emotional impact of conditions and

treatment on patients and provided support to minimise their distress.

We observed staff providing reassurance and comfort to patients and their relatives during home

visits and clinic appointments. We also saw clinic staff meeting patients in clinic waiting areas and

engaging with patients in a welcoming and approachable manner to put them at ease.

Patients were encouraged to get comfortable before treatments commenced and we observed

staff responding in a compassionate, timely and appropriate way when people experienced

physical pain, discomfort or emotional distress. We heard staff asking patients about their support

networks and observed patients being offered reassurance and encouragement was given on

when to seek further medical advice and support if they had concerns about their condition.

We observed staff ensuring that privacy and dignity of patients was maintained. Staff

demonstrated they had developed trusting relationships with some long-standing patients. One

patient said “I know I can always come here. I feel totally supported here and people fall over

themselves to be nice”.


Staff had an excellent knowledge and understanding of their caseloads. We saw staff supporting

patients and their families and encouraging them to manage their own health and care so that they

could maintain independence. For example, we saw a district nurse explaining the patients

planned treatment and care pathway so that the patient would feel confident in undertaking

appropriate self-care procedures.

We observed staff delivering pressure ulcer awareness to patients and their families.

We observed staff actively encouraging patients to be involved in making decisions on their care

and treatment. For example, on a home visit with the rehabilitation at home team we observed

discussions on post-surgery care which helped to develop a better understanding of the potential

impact on their independence post-discharge. We spoke to a patient during a home visit and was

told that they found the pre-admission visit extremely useful as it helped them understand what

would happen following surgery and what equipment they were likely to need during the recovery

process.

We observed staff taking into account the health and well-being of a carer, for example, a patient’s

carer appeared unwell and was shown compassion and empathy from the staff member. The

carer was also encouraged to access their GP.

We saw treatment room staff explaining to patients why particular approaches were beneficial and

patients were consulted on their preferred choices of treatment. Staff also involved family

members in the patient’s treatment discussions with the patient’s consent. Patient feedback was

positive. One patient stated “I feel very supported and I know I am going to get great care. They


discuss my treatment options with me and I’m a lot more confident in making decisions about my

future treatment”. Another patient said, “the treatment room nurses are good”.

We saw evidence of shared care plans in place for some patients receiving support from district

nursing teams. Staff told us that plans were offered to patients where complex issues existed to

develop a shared agreement of the level of care the patient was happy to accept. We saw

examples of plans that had been developed for patients who had rejected health advice from the

district nursing team and risked a deterioration in their health condition. We also saw evidence of

patients who were deemed as having capacity, but whose carer had rejected district nursing

advice. The plans documented the specific decision that had been made; the patients view and

goals; the level of information given to the patient including treatment options, risks, benefits and

alternatives to treatment. Staff told us that the shared care plan approach enabled patients (and

carers) to feel listened to and enabled appropriate support to be made available to help the patient

understand all the risks associated with the decision. Staff stated the final decision was always

made by the patient and situations where a shared plan could not be agreed would be escalated

via the incident report system.

Language line was used for patients whose first language was not English. An interpreter could

also be booked in advance if required. However, we were told by the out of hours district nursing

service that they had no access to the language line during the night and this had been a

challenge on occasions.




The Trust planned and provided the majority of services in a way that met the needs of local

people. Management were aware of local priorities and service priorities were aligned to these.

We were told by the dietetics department that they did not provide weekend or out of hour

services. If there was a problem with the patient’s percutaneous endoscopic gastrostomy (PEG)

tube then the patient would have to attend accident and emergency.

The community assessment team provided a five-day service, from Monday to Friday, 8.30am to

4.30pm. This team only covered patients who had a Liverpool GP and had a Liverpool address.

Pathways that they worked to were, twenty-eight-day pathway, one to one care pathway and a

fast-track pathway. We were told that due to operational hours any fast track referrals outside

these hours would have to wait, for example referrals received on a Friday evening would have to

wait until a Monday morning.

We inspected a health technology service (Telehealth) that was run by the Trust. This was a

nurse led service that worked together with GP practices to support adults with long term

conditions to live at home and be self-caring. Referrals would be received from GP’s, community

matrons, specialist nurses or allied health professionals. A nurse assessment would then be

completed at the patient’s home. Telehealth empowered patients to monitor their own health, for

example a patient could measure their own blood pressure, pulse, body weight or oxygen levels at

home, input them onto their hand-held tablet and the information was then received and looked at

by a healthcare professional which gave patients the peace of mind that their condition was being

monitored. Education videos were available on the devices and we were told by management that

they were currently in the process of looking into providing this service in other languages.

We were told by staff in the ICRAS team that if they took blood from a patient then they would

deliver this to the local health centre or local NHS trust. This service was invaluable to patients

and reduced waiting times on blood test results.

Information leaflets were available to patients on various conditions. We only observed leaflets in

English but were told by staff that they could obtain leaflets in other languages. We were also told

by the administration staff that the friends and family test cards could be supplied in other

languages if required.

We saw a display board in one of the clinic areas highlighting what the speech and language

therapy team do. This was very informative and a great resource for patients and their families.


The service took account of patient’s individual needs. We saw good examples of personalised

care.

Staff in the community care team told us they were having difficulties in obtaining mental health

input during the continuing health care (CHC) process. We were told by staff that inpatients may

have had a mental health assessment but there was a gap in service for follow up of mental health


care. In addition to this staff told us that they had difficulty in accessing mental health services if a

patient on the twenty-eight-day pathway deteriorated

For patients who had complex needs, learning disabilities or a cognitive impairment, staff would

work collaboratively with patients and their families to develop a relevant package of care. They

would also use a care navigator from mental health services.

Patients who were unable to leave their homes were provided with home visits where possible.

We were told that podiatry would only carry out home visits if patients were housebound. The

team would work closely with district nurses around pressure ulcer care.

We observed ramps for wheelchairs and pushchairs in all service areas as well as lifts to other

floors for patients who required them. Disabled facilities were available in all areas.

For patients whose first language was not English, translation services were available if required.

The translation telephone number was in all staff mobile phones so that it was accessible to them

whilst in patient homes.

We saw advertisements in clinical areas for memory cafes ran by a National charity.


We were told by management in the physiotherapy department that if a patient with complex care

needs was deteriorating in health they would either ring a more experienced team member for

advice, escalate to a consultant geriatrician or arrange a joint consultation with them.

Accessibility

The largest ethnic minority group within the trust catchment area is ‘White other’ with 1.75% of the

population.


First largest White Other 1.75%

Second largest Chinese 0.8%

Third largest Other 0.7%

Fourth largest Black African 0.7%

Referrals

No referrals data was provided for this core service.

Service referrals in each locality were received from numerous sources, for example, care homes,

district nurses, community matrons, GP’s and virtual wards (health centres).

We were told by staff in the district nursing service that there were no criteria in place for referrals

and that management were not supportive in enforcing this. Staff told us that they were seeing

patients that did not have district nursing needs. We spoke to senior management and were told

that this was being addressed at the time of inspection and that referral criteria were being looked

at.


Staff in the district nursing service told us that the continuing health care (CHC) process was

behind target by approximately two months. In addition to this staff were being asked to undertake

the CHC process assessment for patients that were inappropriate to their service, for example

mental health needs. We were not shown data to corroborate this at the time of inspection.

We were told by staff in the district nursing service that when patients were deferred in order to

manage caseloads there was no systematic way of monitoring the deferment and no agreed limit

of how many times a patient could be deferred. We were told that this had been raised to

management but we saw no evidence documented at the time of inspection.

Staff in the district nursing service felt that the RAG rating system used on the electronic

management information system was not working as efficiently as it could be. For example, Amber

patients were deemed the normal rating for the whole service and was accepted practice for the

day to day running of the service. Staff in the service were also struggling to refer patients to the

emergency response type services to prevent admission as these teams were always operating

on a RAG rating of red and so unable to respond in a timely manner.

The out of hours district nursing service had to cover a large geographical area and a lot of their

time was spent travelling which not only affected timely visits to patients but reduced patient

contact time as there was a rush to see patients in the timeframe given. In addition, there was no

continuity of care in this service as it did not belong to one locality. Management told us that

senior management are looking into putting this service back to individual localities.

There were times when clinics had to be cancelled by the district nursing service due to staff

capacity. During the week of 12 November 2018 five clinics had to be cancelled. Patients were

offered clinics in other areas but found this difficult due to the distance that had to be travelled on

occasions. We asked senior managers how this was going to be addressed as staff had raised

these concerns but had not received any information at the time of writing the report. We also

requested information on clinic closures but this had not been received at the time or writing the

report. Therefore, we were not assured that this was being monitored effectively.

We observed staff offering patients choice of appointment times and venue and facilitated this as

much as possible

Community matrons no longer undertook phlebotomy procedures and this sometimes caused a

delay as the patient had to be referred to other teams to undertake this procedure.

Referrals in the physiotherapy service were triaged from the Central management office and

differentiated into care homes, neuro-rehabilitation and community. The referrals sat in an

inbound box on the electronic management system. This would show when they were booked

and how long they had been waiting. The referrals would then be triaged by the band 7 team

leader. We

were told by the team leaders that they were in the process of training the band 6 staff to triage.

Each month capacity and acuity was looked at so they could monitor waiting times. At the time of

inspection, the department was reaching their waiting times target of eight weeks.

Staff in the intravenous therapy team told us that they had reduced the number of referrals

accepted due to capacity and training issues. Referrals for antibiotic regimes were currently being


deferred to the district nursing teams. Blood transfusion and cellulitis referrals were considered as

urgent referrals and if received before 1.30pm then a same day visit was required. All GP referrals

were prioritised to reduce risk of hospital admissions. A band 6 nurse would triage and make the

decision if a patient could be visited.

Referrals to the dieticians were input onto the electronic management information system by the

administration staff. A band 6 nurse would triage the referrals. The timeframe for patients to be

seen was eighteen weeks from referral and we saw evidence that these timeframes were being

met.

Referrals to podiatry were from a universal referral system. Patients would complete a referral

form, submit it and then it was triaged by the team leader. Each referral was placed in a category,

either urgent, high, moderate or low. For example, diabetics with ulcers would be high and nail

cutting would be low. In addition to this, referrals were risk rated and appropriate action taken

dependent on the score.

Patients referred to the frailty team were only accepted from accident and emergency and had a

seventy-two-hour discharge target using the Bournemouth criteria. We were told that this target

was not always met due to capacity and demand.

We spoke to staff in the ICRAS team regarding medical practitioner access and was told that

during the hours of 9am to 5pm a medical practitioner could be accessed quickly, however out of

hours it was difficult at times.


Complaints

Community adult services received 21 complaints between 1 August 2017 and 31 July 2018. The

main complaints themes were patient care which accounted for 13 (62%) of the complaints.

patient care which accounted for 13 (62%) of the complaints.

Total Complaints

Fully upheld

Partially upheld

Not upheld Withdrawn Under

investigation Other

Referred to Ombudsman

21 3 0 9 1 6 2 0

Compliments


2018. Two hundred and thirty-eight of these related to community health services for adults, which

accounted for 76% of all compliments received by the trust as a whole.

The service treated concerns and complaints seriously, investigated them and lessons learnt were

shared with all staff. Complaints and compliments were reported as part of the divisional monthly

meetings and discussed daily in local team safety huddles.

Staff and management told us that they would try to deal with complaints at a local level. We were

given an example of how the service learnt from a complaint and took appropriate action to

prevent similar concerns. The action included further training and support for staff.


If a patient or family member raised a complaint, staff would direct them to the community patient

advice and liaison service. In addition to this, they would inform their line manager so that an

attempt could be made to resolve the issues locally and promptly.

We saw thank you cards in all service areas and in the occupational therapy department in the

Central locality we were shown a letter from a patient to an individual staff member stating that she

was amazing at their job. Staff in all areas told us that compliments were shared monthly in their

team meetings. However, verbal compliments were not being monitored.

We were told by staff in the district nursing team that they had received numerous verbal

complaints regarding clinic closures but these were dealt with at the time and not recorded.

We saw leaflets and information on notice boards in service and clinic areas for patients and staff

on how to make a complaint.



Leadership

The service had managers at all levels with the right skills and abilities to run a service providing

high-quality sustainable care.

Management were aware of the challenges to maintaining high quality services and developing

services to meet the changing needs of the population. Articulated plans and actions identified

were in place for the future development of services.

The divisional and service leads had a range of experience and came from a variety of

backgrounds. Staff told us that senior management were visible and approachable. This was

particularly beneficial to staff during the transformation of the Trust community services.

Vision and strategy

We were shown documented plans of the service strategy. The service had a clear vision and set

of values of continuous improvement, accountability, respect and enthusiasm. These values also

followed the National Health Service England (NHSE) 6C’s of care, compassion, competence,

communication, courage and commitment. The Trust knew what it wanted to achieve and

workable plans to turn it into action, developed with involvement from staff, patients, families and

key groups representing the local community.

We saw the Trusts operational plan for 2018-2019 which highlighted key priorities of reducing

community acquired pressure ulcers and reducing staff sickness.

Staff were aware of the Trust strategy and were fully informed of the transformation of the

community services.

Posters were in place in all service and clinical areas demonstrating the Trusts values.

The service had appointed a transformation lead for community services who had consulted staff

in all localities so that they could contribute their ideas or add any concerns to the plans of the

service. Staff we spoke to said they were encouraged by the new management structure and

were looking forward to working in the new Trust.

We saw an update in November 2018 of the service transformational plan for district nursing and

community matrons. This demonstrated plans to align ICRAS with community nursing to ensure

patients remained at the centre of care. We were shown step up and step-down pathways that

would be the key in delivering consistent integrated evidence based care.

We were told by senior management that they were looking at a weighting tool for caseload

management. This would assist managers to distribute caseloads equitably which would help

teams manage their workloads.

We were told by management that there were plans to bring in a practice development mentor for

district nursing staff. This would aid clinical skills training and competencies.


We were also told by staff that the patient experience team was to visit patients receiving support

at home and to attend staff meetings. We did not see plans in place for this initiative at the time of

inspection.

Culture

Although managers across the service were promoting a positive culture that supported and

valued staff to create a sense of common purpose based on shared values. There were variances

to this when speaking to staff.

Most staff told us that they felt supported by their managers and were listened to when raising any

issues or concerns. We were told by management in the physiotherapy department that there had

been concerns in the past of discriminatory and abusive behaviour by staff. However, since

moving to the Trust this has not happened and staff felt more at ease. We were told that if these

behaviours did occur an informal get together would happen to try and resolve the situation. If not,

it would be escalated as per Trust policy.

There was a freedom to speak up guardian at the Trust for staff to approach and raise concerns to

if required. However, we were told by some staff in one locality that they were frightened of

speaking up due to the fear of reprisals. We were told that managers take it personally if issues

are raised. In addition to this some staff stated they were reluctant to speak up to ‘freedom to

speak up champions’ due previous experiences.

Although most staff we spoke to felt supported we were told by staff in the district nursing service

in all three localities that there was a lack of visibility by senior and middle management and they

felt there was a lack of recognition and acknowledgement for the work they were doing. We were

also told by staff in the ICRAS team that they were not being involved in the decision-making

process for the future. They felt that they were being told what was happening with no views

being taken from the team. This was very disconcerting for staff as they there was no clear

direction from management.

We were told by community matrons that they felt communication from senior management was

poor, for example they felt there was a lack of communication on the potential changes to the

service and their roles.

Staff in the district nursing service felt that the Trust was using their goodwill to see patients that

were not suitable for their service.

However, there were examples of where management had supported staff. For example when

concerns had been raised about B12 injections and getting blood results as some GPs were not

updating prescriptions and the injections continued without evidence of a review. The

management worked collaboratively and supported staff to resolve these issues.

Staff told us about the ‘Tell Joe and Ask Joe’ initiative that had been implemented so that anyone

could speak up about any concern or idea they may have. This process was also highlighted on

Trust welcome boards so that it was accessible to service users, carers and visitors.

We were told by the dietetics team that the freedom to speak up guardian had visited their

department and left a contact number for staff.


We saw a positive attitude within all teams in each locality and staff told us that now all services

were under the new Trust, staff morale had improved dramatically.

Governance

There was a clear reporting and governance structure in place. There were monthly divisional

meetings in which performance, risk, incidents and complaints were reviewed. However, there

were areas that required improvement.

We observed that a range of policies were overdue for review. For example, Liverpool Community

Health (LCH) 6 – Clinical Handover of Care (March 2017), LCH 18 Bed Rail Policy (December

2017), LCH 23 Resuscitation (April 2017). These policies did have a Trust front cover with the

new Trust logo on but the forms were not all completed. We also saw that the responsible owner

of these documents was no longer employed by the Trust. We spoke to senior management

regarding the policies and were told that a policy group had been established to look at policies

and protocols during the transition process to the trust. We were also told on the day of inspection

that an operations meeting was taking place that afternoon and policies would be discussed but

they could not give a timeline as to when these would be resolved. Senior management told us

that this was not on the Trust risk register at the time of inspection.

We were told by senior management that policies and protocols were discussed in breakfast

meetings. We did not see evidence of these meetings at the time of inspection.

We looked at five policies in the district nursing service, for example Falls, Blood Glucose

Monitoring, Syringe Driver, Pressure Ulcer and Wound Guidance. All these were dated, version

controlled and easy to access on the intranet for staff.

We saw evidence of a variety of standard operating procedures, for example pre-op assessment,

trauma patient referrals, first visits to patient homes and caseload management. All were dated

and version controlled.

We were told by management that the lone working policy was being removed as it would now be

included in the security policy of the Trust. We saw that lone working devices were on the Trust

risk register due to the ongoing management and monitoring of devices. Staff had been told to

check their devices prior to leaving the office and ensure that their colleagues and managers knew

where they were going at all times.

We saw minutes of the monthly governance meetings. We saw for example that team leaders,

care managers and allied health professionals attended. Discussions took place on performance,

outcomes, risks, incidents and complaints.

We saw evidence of team meetings in all specialities. The values of the Trust were evident in all

minutes and action plans and timelines were documented. Monthly team meetings were carried

out in the district nursing clinics for the Sefton area, however August 2018 had to be cancelled due

to lack of capacity within the team.

Staff told us that patient experience reports were discussed at team meetings and patient

comments were shared. This was evidenced in the team meeting minutes we observed.


We were told by management in the district nursing service in Sefton that they had put a service

review together and had a project team to take this forward. In addition to this staff were

encouraged to put their views forward into the vision of the service. We did not see evidence of

this service review at the time of inspection.

We reviewed a guideline for treatment by the dieticians to patients who required nutritional

support. However, although the guideline was informative and in date with the National Institute of

Health and Care Excellence (NICE), it was not dated, not version controlled and not available on

the intranet or internet. We queried this at the time of inspection and management told us they

were not sure whose responsibility it was to update it. Therefore we were not assured that staff

would be following the correct version to provide care in line with up to date guidance.

We saw evidence of the local division workshop ‘Green Light Toolkit’ which gave participants an

overview of gaps in assurance and agreed actions put in place following the audit in 2017. The

Green Light Toolkit is a guide to auditing and improving mental health services so that it is

effective in supporting people with autism and learning disabilities.

The Trust was disbanding the module of information governance and replacing it with data

protection and suicide prevention modules. This would help to prioritise safe care across all the

divisions.


The Trust had systems in place for identifying risks, planning to eliminate or reduce them and

coping with both the expected and unexpected.

The Trust used an electronic reporting system to record the risk register. We saw departmental

and divisional risks recorded on the register. We were told by management that having the risks

on an electronic register allowed incidents to be linked to the risks recorded. This was invaluable

when looking at themes and trends.

Senior management told us that they were currently in the process of implementing a dashboard

to demonstrate, staffing, management, incidents. This was currently being piloted in the Central

region. At the time of inspection, we did not see evidence of this.

Senior management told us that a community matrons implementation plan was in the process of

being actioned to look at staffing and flexible working. This would be profiled for the next five

years. We saw evidence of this in the Trust trajectory plan.

Staff in all the community adult services had a lone working device that was used when out on

patient visits. This was welcomed by staff as they felt safer knowing that their peers and

management knew where they were at all times when out of the office environment. We were told

by management in the dietetics department that in addition to this, staff would write on a white

board where they were going for that day.

We were told by management in the dietetics department that the Trusts key performance

indicator (KPI) of 8% for the do not attend (DNA) rates was unachievable. This had been

escalated to senior management and the team were waiting on a decision.


Dieticians did not offer a weekend or out of hours service and if a patient had a problem with their

percutaneous endoscopic gastrostomy (PEG) tube they would have to attended accident and

emergency. We did not see evidence during the inspection that this was on the Trusts risk

register.

At the time of inspection, the service had reviewed all unexpected deaths and minutes of meetings

we observed demonstrated that these had been discussed. However, senior management told us

that this was an area for improvement as expected deaths were not routinely reviewed and this

was not in line with National guidance on learning from deaths. We were told that every expected

and unexpected death would now be reported via the electronic incident reporting system and this

had been cascaded to staff via team meetings and emails. Going forward regular meetings would

be held to discuss morbidity and mortality reviews.

We were told by management in the rehabilitation at home team that there was no risk register for

their service. They told us that risks are placed on to the risk and governance template monthly

and that it only contained what the risk is and no detail on mitigating actions or risk scores

identified.

Data was provided from the Trust on their serious incidents. However we observed that the

number of most severe incidents recorded by the Trust incident reporting system is not

comparable with that reported to Strategic Executive Information System (STEIS). The trust told

us that the reason for the discrepancy was that some STEIS incidents had been removed at the

request of the clinical commissioning groups, which is normal practice.

We saw local and divisional dashboards identifying the divisions financial performances and

recommendations.


The trust collected, analysed, managed and used information to support all its activities, using

secure electronic systems with security safeguards.

The service used paper records and an electronic management information system for patient

records. There was a sharing agreement in place for access to patient information from external

healthcare providers such as GP’ who used the system for patient records and information. Staff

had access via login details and passwords.

We saw confirmation of scheme cover for the Trusts employer’s liability, public liability, products

liability and professional indemnity for the period 01 April 2018 to 31 March 2019.

We saw a standard operating procedure for caseload management which was in place to ensure

staff prioritised time to cleanse their caseload and update the red, amber and green (RAG) rating

tool on a weekly basis. However, we were told by staff in the district nursing service that due to

the weighting of caseloads and capacity this was not being achieved. We were told that the

average weightings were twenty-four plus. We did not see evidence of weightings during our

inspection. We requested evidence of this post inspection but had not received data at the time of

reporting.

Engagement


The trust engaged with patients, staff, the public and local organisations to plan and manage

appropriate services and collaborated with partner organisations.

The service provided patients with a friends and family survey which identified if patients would

recommend the service to friends and family. Results collated were positive. However, staff told

us that the response rate was not good. This had been raised with senior management, but no

feedback had been received.

The physiotherapy department undertook a patient satisfaction survey in addition to the friends

and family survey. Patient feedback collated demonstrated positive results.

A rehabilitation at home survey had recently been completed and the results demonstrated were

very positive.

Staff had regular team meetings and were encouraged to contribute ideas for development and

improvement of the service. In addition to this we observed a web-based question and answer

page that offered staff the opportunity to ask the chief executive questions on any subject matter.


Lessons learnt and shared were embedded into practice throughout the localities. For example,

Oxford learning events, seven-minute briefings and seventy-two-hour structured reviews.

Complaints and compliments were discussed in team meetings to aid continual improvement of

the services offered.

The Trust had employed a transformation lead to help support the delivery of the new service.

The lead was working across all localities and was supporting staff through the new structure.

Accreditations






This core service has not been awarded any accreditations

Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families

Community health services for children, young people and families


Mersey Care NHS Foundation Trust provides specialist inpatient and community mental health,

learning disability and substance misuse services for adults in Liverpool, Sefton and Knowsley.

Mersey Care NHS Trust was established on 1 April 2001 and granted NHS Foundation Trust

status on 1 May 2016.

In July 2017, the trust acquired a number of services previously provided by Liverpool Community

Health NHS Trust in the South Sefton locality. Mersey Care NHS Foundation Trust acquired the

remainder of the former Liverpool Community Health NHS Trust services on 1 April 2018. These

community physical health services are provided across Liverpool to a population of approximately

11 million people. Mersey Care NHS Foundation Trust currently delivers these services across

more than 70 locations including health centres, clinics, walk-in centres and GP practices.

Mersey Care NHS Foundation Trust delivers a range of community based health services to

children, young people and families across Liverpool in a variety of community settings including

home visits, at schools and health centres. Mersey Care NHS Foundation Trust operates a locality

based operational model, with multidisciplinary clinical teams, geographically aligned and focused

around GP practice populations and schools. The localities the services operate from are, North

Liverpool, Central Liverpool and South Liverpool. Each locality is led by an associate director and

clinical lead. Community services offered include; health visiting, school nursing, healthy families

programme, child health inclusion and family nurse partnership.

Our inspection was short notice-announced which meant that staff knew we were coming a short

time before visiting to ensure everyone we needed to speak with was available. We inspected

community health services for children, young people and families provided by the trust over a

three-day period from 20 November 2018 to 22 November 2018.

During our inspection, we visited four office bases and two clinic sites. We spoke with 53 members

of staff including; school nurses, health visitors, nursery nurses, assistant practitioners, support

workers, team leaders, administration staff, clinical leads, care managers and a safeguarding

nurse specialist.

We spoke with three patients, attended one home visit and observed care at two school

questionnaire sessions, involving over 52 children. We reviewed 15 patient records and three

safeguarding referral records. We attended one team safety meeting and conducted a focus group

which was attended by over 44 staff members from across the community division.

Information about the sites, which offer services for children, young people and families at this

trust, is shown below:


Location site

name

Team/ward/satellite name Patient

group

Number of

clinics per

month

Geograp

hical

area

served

Hartington Road

Clinic,

Adult & Paediatric Special Care

Community Dental Contract (Liverpool,

Sefton & Knowsley)

Mixed - Liverpool

Burlington House Child Health Information System (CHIS) Mixed N/A Liverpool

Goodlass Road Children's 0-5 years Health Visiting Mixed N/A Liverpool

Innovation Park Children's 0-5 years Health Visiting Mixed N/A Liverpool

Queens Drive Children's 0-5 years Health Visiting Mixed N/A Liverpool

Vauxhall Health

Centre Childrens Health Inclusion Team Mixed N/A Liverpool

Based in the

hospital Children's Health Visiting Liaison Team Mixed N/A Liverpool

Goodlass Road Education Health Care Plans Mixed N/A Liverpool

Old Swan Walk

In Centre Education Health Care Plans Mixed N/A Liverpool

Queens Drive Education Health Care Plans Mixed N/A Liverpool

Dovecot Health

Centre Family Nurse Partnership (FNP) Mixed N/A Liverpool

Innovation Park Healthy Families Mixed N/A Liverpool

Bayliss at LIP School Nursing Team Mixed N/A Liverpool

Goodlass Road School Nursing Team Mixed N/A Liverpool

Queens Drive School Nursing Team Mixed N/A Liverpool

Goodlass Road Special Schools Mixed N/A Liverpool



Mandatory training

Mandatory training was facilitated by a combination of face to face and e-learning. All base leads

had access to each member of the team’s training record via the electronic staff records. This

meant that base leads could monitor staff compliance and address any training or development

needs or issues with compliance.

Mandatory training compliance was discussed at monthly team meetings across all teams and

monthly divisional performance meetings to cover the three localities. An integrated quality and

performance operational report was produced each month for each locality which detailed the

compliance level for mandatory training.

During our inspection, all staff we spoke with across a variety of teams were up to date with

mandatory training and staff told us they were reminded when the training was due and were

given time to complete it.

Following our inspection, we reviewed the integrated quality and performance reports which

covered the period September 2017 to September 2018 which showed that mandatory training

compliance was 95% across the three localities.

The trust set a target of 95%95% for completion of mandatory training and their overall training

compliance was 79% against this target. This was because continuous professional development

training (non-mandatory) and role specific mandated training had been included within the overall

compliance figures despite many role specific training modules being completed as NHS

mandatory training modules. Therefore, the service was achieving the target of 95% for mandatory

training across the three localities.

A breakdown of compliance for mandatory courses between August 2017 and July 2018 for all

staff in community services for children, young people and families is shown below:

Training courses Grand Total %

Role Specific Mandated Training - Mental Capacity Act - Level 1 (Every 3 Years) 100%

830 Local Complaint & Claims (Once only) 100%

NHS Mandatory Harassment and Bullying Awareness - No Renewal 100%

830 Local Investigation of Incidents Using RCA (Once) 100%

Continuous Professional Development - Complaints (Every 3 Years) 98%

830 Local Prevent Training for Clinicians 96%

NHS Mandatory Health and Safety - 3 Years 94%

NHS Mandatory Prevent WRAP - 3 Years 94%

NHS Mandatory Resuscitation - 1 Year 94%

NHS Mandatory Fire Safety - 3 Years 93%

NHS Mandatory Safeguarding Adults Level 2 - 3 Years 93%



NHS Mandatory Safeguarding Children Level 3 - 3 Years 93%

Mandatory Training - Infection Control (Every 3 Years) 92%

830 Local Health Record Keeping 3 Yearly Compliance 92%

NHS Mandatory Consent - 3 Years 92%

NHS Mandatory Mental Capacity Act - 3 Years 92%

NHS Mandatory Conflict Resolution - 3 Years 91%

Mandatory Training - Conflict Resolution (Every 3 Years) 90%

Mandatory Training - Fire Safety (Every 3 Years) 90%


NHS Mandatory Equality, Diversity and Human Rights - 3 Years 90%

Mandatory Training - Moving & Handling (Every 3 Years) 88%

Mandatory Training - Safeguarding Adults - Level 1 (Every 3 Years) 88%

NHS Mandatory Infection Control - Level 2 - 1 Year 88%

NHS Mandatory Medicines Management Awareness - 3 Years 88%

NHS Mandatory Information Governance - 1 Year 86%

Mandatory Training - Equality, Diversity and Human Rights (Every 3 Years) 85%

Mandatory Training - Health & Safety (Every 3 Years) 83%

NHS Mandatory Moving and Handling - 1 Year 83%

Continuous Professional Development - Adverse Incidents (Every 3 Years) 76%

Role Specific Mandated Training - Basic Prevent Awareness (1 Time) 76%

830 Local ILS - 1 Year 75%

Continuous Professional Development - Smoking Cessation (1 Time) 71%

Continuous Professional Development - Fraud Awareness (Every 3 Years) 70%

Continuous Professional Development - Suicide Prevention & Safety Planning (Every 3 Years) 70%

Role Specific Mandated Training - Basic Life Support (Every Year) 56%

Role Specific Mandated Training - Safeguarding Adults Level 2 -Trust Model (Every 3 Years) 47%

Role Specific Mandated Training - Safeguarding Children Level 2 - Trust Model (Every 3

Years) 47%

Mandatory Training (IG) - Data Security Awareness - Level 1 (Every Year) 40%

Role Specific Mandated Training - Safeguarding Adults Level 3 - Trust Model (Every 3 Years) 38%

Role Specific Mandated Training - Safeguarding Children Level 3 - Trust Model (Every 3

Years) 38%

Role Specific Mandated Training - Moving and Handling of People (Every Year) 36%

Continuous Professional Development - Dementia Awareness (1 Time) 21%

Role Specific Mandated Training - MHA/DoL's Level 2 (Every 3 Years) 21%

Role Specific Mandated Training - Safe and Effective Use of Medicines (Every 3 Years) 21%

Role Specific Mandated Training - Controlled Drugs & High Risk Medicines 20%

Role Specific Mandated Training - Medicines Calculations (Every 3 Years) 18%



Role Specific Mandated Training - Mental Health Act - Level 1 (Every 3 Years) 0%

Role Specific Mandated Training - MUST Adapted Nutritional Screening 0%

Role Specific Mandated Training - Witness to Medication (Every 3 Years) 0%

NHS Mandatory Safeguarding Children Level 2 - 3 Years 0%

NHS Mandatory Moving & Handling for People Handlers - 1 Year 0%

Core Service Average 79%

Safeguarding




Commonly recognised forms of abuse include physical, emotional, financial, sexual, neglect and

institutional.

Each authority has its own guidelines as to how to investigate and progress a safeguarding




should take place.

Community health services for children, young people and families made 11 safeguarding referrals

between 1 August 2017 and 31 July 2018, of which none concerned adults and 11 children.

There were three peaks identified in child referrals across the period in April (three), June (three)

and July (three).

There were clearly defined and embedded systems in place to manage safeguarding. Staff

understood how to protect patients from abuse and the service worked well with other agencies to

do so.

The safeguarding policy was current and accessible to staff electronically. Procedural pathways

were clear for referral to the local authority. The electronic patient administration system had a

flagging system to identify and alert staff to children on child protection plans, looked after children

and high-risk families. Procedures were in place to identify and manage female genital mutilation

and child sexual exploitation.

Safeguarding training compliance was monitored, facilitated and overseen by the trusts

safeguarding team. All staff at the services we visited had completed safeguarding training level

Referrals


0 11 11


three which was mandatory for staff delivering services for children, young people and families.

Both female genital mutilation and child sexual exploitation awareness were included within the

safeguarding training. The trust had a specialist domestic violence and female genital mutilation

safeguarding nurse who could be contacted for specialist advice.

Safeguarding supervision was carried out by the safeguarding team, each locality had a specialist

safeguarding nurse who facilitated and monitored safeguarding supervision and compliance

levels. Safeguarding supervision consisted of both formal and informal supervision and was

carried out every six to eight weeks. All staff we spoke with during our inspection had received

safeguarding supervision within the previous six weeks.

During our inspection staff told us that they were able to contact their safeguarding specialist

nurse for advice at any time. This was encouraged by the teams and meant the appropriate

referral pathway was followed. Any contact made with the safeguarding team about an individual

was logged on the electronic patient record. There was a duty rota for cover when the locality

nurse was on annual leave or unavailable due to sickness.

All services received safeguarding information from external agencies through a secure electronic

email system. During our inspection we observed that services facilitated this in different ways for

example the health visiting teams had administration staff who monitored the email account whilst

the child health inclusion team had a rota to facilitate monitoring the incoming information to

ensure safeguarding information was not missed.

During our inspection we reviewed three safeguarding referral records and found that information

within them was legible, dated and timed. Risk assessments were included within the

safeguarding records and information was clearly documented including action plans and

priorities.


The trust had a standard (Universal) infection prevention and control policy which informed staff of

the safe management of sharps, procedure for dealing with bodily fluids, personal protective

equipment and decontamination of the environment. The policy was in date and accessible to staff

electronically. Infection prevention and control formed part of the trust mandatory training and was

undertaken annually. All staff we spoke with were compliant at the time of the inspection. Staff had

access to personal protective equipment such as gloves, alcohol hand gels and aprons.

The trust did not have a separate hand decontamination policy however, hand hygiene was

detailed within the main infection prevention and control policy and followed the World Health

Organisation ‘5 Moments’ guidance. During our inspection we found that hand hygiene audits

were not completed by any of the community teams, this meant that the service could not highlight

that hand hygiene procedures carried out by staff were effective in the prevention and control of

the spread of infection. The trusts infection prevention and control policy stated that hand hygiene

audits should be undertaken monthly

The service operated clinics and appointments from a variety of sites for which cleanliness was

overseen and maintained by the building leaseholder (not the trust), as such cleaning schedules

and audits were not available to view during our inspection. Both clinic sites visited during our

inspection were visibly clean and tidy. Information requested following our inspection showed the


trust regularly carried out self-assessment cleanliness audits on buildings not solely leased by

them to assure themselves of compliance with infection prevention and control. Following our

inspection, we reviewed a cleaning audit from a building which was maintained solely by the trust

and found that cleaning was carried out regularly in line with the infection prevention and control

policy, the compliance rate was 90%.

The trust had an infection prevention and control team however, the team only routinely audited

(monthly) for the special schools nursing team who operated from permanent base rooms within

six schools across the area. This was a concern because all other teams within the service were

not receiving advice or input from specialist infection prevention and control nurses highlighting

best practice and there were no champions within any of the teams across the service.


Premises used in the provision of care and treatment which were visited during our inspection

were tidy and well maintained. Clinic rooms had hard flooring in line with infection prevention and

control guidance for effective decontamination and wipeable patient seating. Staff told us that each

member of staff utilising the clinic room was responsible for ensuring the equipment and

environment were clean and fit for purpose however, this was not recorded.

Cleaning wipes were available for the decontamination and cleaning of equipment at all sites we

visited however, cleaning after the use of equipment was not currently being recorded or

documented. This meant that the service could not highlight that equipment was being

decontaminated and cleaned in line with the trusts policy for the management and

decontamination of medical devices. We were told by the clinical lead that one team within the

service was currently trialling the recording of the cleaning equipment after each use, however

staff told us during our inspection that this had been in place for two months but had not been

audited or feedback sought from staff with a view to rolling this out across the service.

We observed six sets of weighing scales at various sites and saw all were calibrated within the last

few months and fit for purpose. Staff told us that the calibration of equipment such as weighing

scales and audiometer headphones was recorded centrally and arrangements for re-calibration

arranged through the administration staff/clerks.

During our inspection we observed stock used by the service was in date, stored and labelled

correctly. Clinical waste was labelled and stored correctly within clinical settings and sharps were

managed in line with trust policy.

All offices we visited were securely locked with either a keypad or swipe card for access.

Cupboards containing personal documents and information were locked and keys kept in a

separate area.


The majority of teams within the service managed areas of assessing and responding to risk

effectively. A proactive approach to anticipating and managing risks to patients was embedded

and recognised as the responsibility of all staff.


Each team we visited held a weekly safety meeting to discuss caseloads, staffing and address any

concerns such as safeguarding alerts. During our inspection we attended a team safety meeting

and observed there was good identification of current issues and evident forward planning in

relation to those issues.

All patient electronic records had an alert system which informed staff of concerns such as

children on child protection plans, female genital mutilation alerts and language barrier alerts. Staff

were able to show us the alerts and how to access the information from them. The system could

also be accessed by various community healthcare services such as GP’s and walk in centres.

Information between external agencies was received and managed through a protected shared

email account.

There were robust plans in place when immunisation and vaccination sessions took place, and

this was carried out by a designated immunisation and vaccination team. The team had been set

up in September 2018 and staff told us this was due to increasing caseloads within the school

nursing service. The immunisation and vaccination team leader was able to give an example of a

recent immunisation session which had not gone particularly well due to a lack of cooperation from

the school. Following the session, the team discussed the incident and sought ways in which to

improve going forward. The team leader spoke with the school and arranged for two immunisation

champions to be selected for future immunisation sessions to aid the process.

A further example of assessing and responding to patient risk was obtained from the child health

inclusion team. This team assesses the health and wellbeing of asylum seekers within the first

three weeks of arrival into the U.K. Although the team were not commissioned to provide

immunisations and vaccinations they had sought governance approval from the trust to do so for

prioritised patients such as new born babies and children who have never received any

vaccinations, having identified a risk to these patients.

Health visiting teams used a variety of questionnaires to identify various themes throughout

contact stages such as assessing mums for possible signs of depression within the postnatal

period, identifying social interaction for children such as emotion, activity and social conduct. This

meant that the patient or mum could be referred to other services when appropriate.

School nursing had an effective system in place for triaging referrals using a standard operating

procedure which enabled them to classify referrals as “non-urgent, urgent and immediate”. This

meant that children with the most urgent needs were referred on or assessed in a timely manner.

There were however, areas of school nursing in which assessing and responding to patient risk

was not managed effectively. Part of the school nursing role was to deliver health and wellbeing

questionnaires to look for health needs in children. During our inspection staff told us that there

was no set time frame as to how quickly questionnaires should be triaged. Information supplied by

the trust following our inspection detailed a standard operating procedure which stated that initial

triage of questionnaires should be completed two weeks following the closure of the information

being uploaded onto the electronic system. This was a significant risk because children who are

potentially vulnerable who may need direct intervention and support for example due to mental

health or safeguarding could be left waiting for this. During our inspection we also found that there

were no clinical pathways to support school nurses for specific identified conditions such as self-


harm or mental health. The clinical leads told us that they were in the process of developing a

series of pathways to support school nursing.

Staffing


community services for children, young people and families.

Staff group Total number of substantive staff Total % vacancies overall (excluding

seconded staff)

Clerical & Adm Clinical Suppr 1.4 -1%

Clerical & Admin Central Serv 0.9 6%

Nurse Health Visitor Community

Services 8.8 34%


Turnover

Between August 2017 and July 2018, the trust reported an overall turnover rate of 11.3% in


Staff group Total number of

substantive staff

Total number of

substantive staff

leavers in the last 12

months

Total % of staff leavers

in the last 12 months

Allied health professionals 55.7 5.9 10.5%

Health care assistants 61.8 1.0 1.6%

Nursing & midwifery registered 137.9 20.9 15.2%

Other (including admin & clerical) 35.3 5.1 14.3%

Core service total 290.7 32.8 11.3%

Sickness

Between August 2017 and July 2018, the trust reported an overall sickness rate of 6% in



substantive staff

Total % permanent staff

sickness overall

Allied health professionals 55.7 3%

Health care assistants 61.8 8%

Nursing & midwifery registered 137.9 7%



substantive staff


sickness overall

Other (including admin & clerical) 55.7 6%


Nursing – Bank and Agency Qualified nurses

Between August 2017 and July 2018, Mersey Care NHS Foundation Trust reported an overall

bank and agency usage of 2472 hours for qualified nursing staff.

Total Number of Hours

available

Total Hours Filled by

Bank Staff

Total hours Filled by

Agency Staff

Total hours NOT filled

by Bank Staff

4526 216 2256 49

**Some of the data provided by the trust showed that more hours were filled than available, hence percentages are

not shown, just number of hours.

Nursing - Bank and Agency Healthcare Assistants

Between August 2017 and July 2018, Mersey Care NHS Foundation Trust reported no usage of

bank and agency staff for health care assistants.

Suspensions and supervisions

During the reporting period, this core service reported that there were no cases where staff have

been either suspended or placed under supervision.

Capacity and demand was assessed in all teams throughout each locality and caseloads were

monitored by team leaders to ensure even distribution of work throughout each service. A planning

tool was used to plan and manage demand, workload and resources. The service was in the

process of implementing a new electronic system to monitor caseloads which would allow for

easier monitoring of staff workload. Staffing and workload were discussed at monthly team

meetings and weekly staffing huddles for all teams, across all areas.

We spoke with a team lead for the health visiting South locality who reported good staffing

numbers within the team. This team had a member of staff who had previously left returning in

December which meant that there were no vacancies within the team. Staffing levels were an

issue within the North locality due to sickness however, the South team were able to cover

caseloads and appointments comfortably for this due to having full staffing levels.

The service was engaged with a national improvement programme through NHS Improvement to

support a reduction in sickness absence and undertake research into factors affecting sickness

and to monitor the impact of health and well-being interventions.

There were staffing issues across all school nursing teams and staff told us that there was a

national shortages of school nurses. The service was addressing this issue by developing staff by

them completing a public health training programme which meant that when qualified these staff

would be able to practice as school nurses which showed succession planning.


There was a good skill mix in all teams we visited. There was a wide variety of both clinical and

non-clinical staff who supported the service including; health visitors, nursery nurses, community

nurses, public health school nurses, school nurses, support workers, school health practitioners,

assistant practitioners, healthcare assistants, specialist paediatric liaison nurses, specialist family

nurses and administration clerks.

All staffing issues including current vacancy rates and turnover across the three localities were in

the process of being implemented into the monthly integrated performance and quality report. As

such, we were unable to assess these figures across the three localities following our inspection

as this was still under development. Sickness levels across teams were detailed within the

integrated performance and quality report, we observed that sickness within health visiting in the

north was the highest at 9% which mirrored information given to us during our inspection. Action

plans had been put into place to support this.

Quality of records

The service used an electronic system for patient records. Staff could access the information they

needed to assess, plan and deliver care, this included agency and bank staff. The electronic

patient recording system could also be accessed by various external healthcare providers such as

GP’s, walk in centres and other community services.

Staff told us that the trust was going ”paper light” which involved the scanning of pre-electronic

records onto the system. Existing paper records were held securely in locked filing cabinets within

all office sites we visited during our inspection. Nursing notes which were completed on home

visits and during clinics were typed into the electronic system on the staff’s return to the office and

paper copies confidentially destroyed. Questionnaires were scanned onto the system and

attached to patient records by administration staff or team clerks and then confidentially destroyed.

The quality of documentation was consistently good across the service. We reviewed 15 sets of

records during our inspection, entries were legible, dated, timed and the system logged

electronically the name of the person inputting the information. Care plans, safeguarding and

various health assessments and/or questionnaires were clearly documented for health visiting,

special schools and school nursing. We did however observe two school nursing records were

advice had been given regarding specific conditions but not actually documented.

Staff told us that patient records were audited annually however, the clinical leads were unable to

access the results of the 2017/2018 audit and this information was requested following the

inspection. The results showed that there was good compliance in relation to areas such as

recording of patient NHS numbers and health promotion advice being discussed however,

compliance was poor in other areas for example the patients first language and if an interpreter

would be required.

There was clear evidence within the information of actions to improve the audit results and how

this was disseminated to staff. During our inspection, the clinical leads told us the audit was

currently being retaken to compare to the results from the previous year to measure improvement.


Medicines

Medicines were appropriately stored and access was restricted to authorised staff. There were

appropriate arrangements in place for the destruction of unwanted or expired medicines. We saw

that medicines in cold storage were kept in a fridge however the fridge was unlocked at the time of

our inspection which meant that medicines may be accessed by unauthorised people. A daily

record of fridge temperatures was maintained to ensure that medicines were kept at the correct

temperature. The temperature record had been completed each day for the fridge which was used

by the immunisation and vaccination team. Staff were able to describe the process of reporting a

problem with either the fridge or the temperature measures.

There was a medicines management policy for both cold chain medicines and the reporting of

medicines related incidents. Both were in date and accessible to staff electronically. Staff were

able to describe the process for ordering medicines and reporting medicine related incidents.

Two teams within the service were able to administer medications by the use of Patient Group

Directives; the child health inclusion team and the immunisation and vaccination team. Patient

Group Directives are written instructions which allow specified healthcare professionals to supply

or administer a particular medicine in the absence of a written prescription from a doctor.

During our inspection we reviewed all Patient Group Directives for both teams and found them to

be signed, in date and easily accessible to staff both electronically and in paper format. The team

leader for the immunisation and vaccination team told us that staff were encouraged to take paper

copies of the Patient Group Directives out with them when attending immunisation and vaccination

sessions. When not in use we observed that the Patient Group Directives were stored in a locked

cabinet within each respective office.

The immunisation and vaccination team had access to advice and assistance from the trust’s

medicine management team. The medicine management team had responsibility for the ordering

and auditing of medicine stock for the team and completing audits of fridge temperatures which

were carried out quarterly. Staff told us that a medicines management audit had been undertaken

recently but the team leader had not received the results of this. We requested this information

following our inspection however, the trust did not provide this.

During our inspection we reviewed the medicines log for vaccinations being held in the fridge and

found that there was a discrepancy with one vaccine for which the count was incorrect by one vial.

There was a further discrepancy with the number of adrenaline grab bags which were used for

allergic reactions during immunisation sessions. Staff advised they would record both

discrepancies as incidents on the electronic system for review and investigation by the medicine

management team. All medicines held were in date with the batch numbers were clearly recorded.






In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents

(SIs) in community services for children, young people and families, which met the reporting

criteria, set by NHS England between August 2017 and July 2018. They were both categorised as

‘Other’.


Other 2


Serious Incidents (SIRI) – Trust data

Between 1 August 2017 and 31 July 2018, trust staff in this core service reported two serious

incidents. Of these, none involved the unexpected death of a patient. The most common types of

serious incidents were ‘other’ (two).

The number of the most severe incidents recorded by the trust incident reporting system is

comparable with that reported to Strategic Executive Information System (STEIS). This gives us

more confidence in the validity of the data.


Other 2


The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which

all contain a summary of Schedule 5 recommendations, which had been made, by the local

coroners with the intention of learning lessons from the cause of death and preventing deaths.

In the last two years, there have been two ‘prevention of future death’ reports sent to the trust for a

response. A third report involved a patient who died whilst in the trust’s care, but the trust was not

directly asked for a response.. None of these related to this core service.

All staff had access to the trust-wide electronic incident reporting system. Staff were able to tell us

and demonstrate how they would report an incident using this system. Staff had a good

understanding of what would constitute a reportable incident and gave specific examples of when

they had completed an incident report.

All staff we spoke with were aware of duty of candour which is a regulatory duty that relates to

openness and transparency and requires providers of health and social care services to notify

patients (or other relevant persons) of certain notifiable safety incidents and provide reasonable

support to that person. Most staff were able to tell us the who the duty of candour lead was for the

trust and we saw posters detailing what duty of candour was and the name of the lead in all office

bases we visited.

Managers reviewed all low-level incidents and we saw evidence that appropriate responsive

actions were taken as a result of incidents. Managers were able to give specific examples of


incidents reported and subsequent actions as a result of them. One example of this was the

reporting of a lack of car parking facilities which was resulting in staff being late for work due to

driving around to locate a suitable space. As a direct result of this the service had supplied staff

with laptops and introduced “agile working” which meant that staff were able to work from home or

alternative locations.

We saw evidence that the service investigated serious incidents thoroughly and monitored the

impact of recommendations for improvement through audit. Lessons were learned and

communicated through weekly and monthly staff meetings and email. Leaders were able to tell us

when duty of candour would be applied and robust arrangements were in place by way of twice

weekly “being open” meetings to review any moderate incidents within 72 hours and agree actions

which met with national guidance. Community health services for children, young people and

families had no incidents up to our inspection for which a formal duty of candour notice would be

applied.

The trust had developed its own programme ”just and learning” which was designed to promote

openness and willingness to report incidents without fear of retribution or victimisation. Information

supplied prior to our inspection informed us that there were 40 “just and learning” ambassadors

within the trust however, there were no ambassadors within the community children, young people

and families service and some staff had not heard of the programme.




Staff at each service followed the Department of Health and Social Care Healthy Child

Programme. The Healthy Child Programme is an early intervention and prevention public health

programme of screening tests, immunisations, developmental reviews, information and guidance

to support parenting and healthy choices. The teams offered immunisation, vaccination, health

and development reviews, new birth screening and advice around health and wellbeing.

During our inspection we saw evidence that the service used questionnaires and pathways which

followed best practice and national guidance. An example of this was the family nurse partnership

who used an observational tool called DANCE (Dyadic Assessment of Naturalistic Caregiver

Experience) which enabled staff to assess parent and child interaction. Health visiting had an

infant feeding policy in place which was based on national guidance and staff were able to give us

detailed information about breastfeeding and the benefits to both mother and baby and how this

was used in practice for patients.

National Institute for Health and Care Excellence (NICE) guidance was used in the development of

questionnaires for both school nursing and health visiting. All patient group directives followed the

National Institute for Health and Care Excellence (NICE) guidance and staff were updated in any

changes to guidance for all teams by email or during team meetings.

Following our inspection, we requested the minutes from a selection of team meetings across the

service and were able to see evidence of the discussion of changes in practice as a result of

amendments to national guidance and best practice.

Patient outcomes

Audits – changes to working practices

The trust have participated in no clinical audits in relation to this core service as part of their

Clinical Audit Programme.

The service monitored the effectiveness of care and treatment and used the findings to improve

patient outcomes. We were given examples of how services supported the delivery of the healthy

child programme. Staff across the health visiting teams had trialled using a text message service

to remind families the night before an appointment was due in an attempt to increase the key

performance indicator target for one-year assessments which was noted to be low. As a direct

result of this health visiting teams had seen a slight increase in the number of attendances.

The immunisation and vaccination team was set up as a direct result of the monitoring of key

performance indicators which showed targets were not being met and thus the team was created

separately from school nursing in a bid to increase target performance. Although the team was

new staff told us they felt patient outcomes would improve as a direct result of the team being able

to monitor uptake rates and performance separately from the school nursing service.

The patient uptake rate for flu vaccinations was monitored by Public Health England with a

national target of 65%. The team were currently underperforming at 55%, we saw evidence of an


action plan and staff told us they had been actively engaged in providing ideas in how the target

could be improved.

School nursing were able to give an example of submitting data in relation to the national child

measurement programme which showed a high percentage of patients who had opted out of the

programme. As a result of this the service had changed the application forms to an electronic

format which aligned with national NHS priorities of becoming paperless, the resulting audit to

assess for improvement had not been undertaken at the time of our inspection, however, staff

were optimistic for improvement.

Competent staff


Between 1 August 2017 and 31 July 2018, the average clinical supervision rate for the core

service was 5%, the trust did not have a target for clinical supervision.

Team

Clinical

Supervision

Target


Delivered

Clinical

supervision rate

(%)

831 Z 3007 LCH Practice Nurse Development

(L7)

169 135 80%

830 Z 2047 LCH Vaccination and Immunisation

Team (L7)

134 2 1%

830 Z 3541 LCH AHP's North - Rehab at Home

(L7)

12 0 0%

830 Z 2599 LCH Specialist Students - North (L7) 20 0 0%

830 Z 2536 LCH Physiotherapy Adults - South

Liverpool (L7)

11 0 0%

350 L9 Podiatry - Sefton CS (Z4CH27) 39 0 0%

830 Z 3029 LCH LOOHS - Social Workers (L7) 18 0 0%

350 L9 Respiratory/Actrite (Sefton) (Z4CH44) 69 0 0%

830 Z 2531 LCH Adults Occupational Therapy -

North (L7)

27 0 0%

350 L9 Sefton Bank Staff Control (Z4CH80) 3 0 0%

830 Z 2541 LCH Podiatry - Team Leaders (L7) 6 0 0%

350 L9 Treatment Room South - Sefton CS

(Z4CH30)

26 0 0%

830 Z 3020 LCH Health Visitor Team Leaders -

South (L7)

6 0 0%

351 L9 Treatment Room South - Sefton CS

(Z4CH30)

36 0 0%

830 Z 3039 LCH Health Technology Managers

(L7)

6 0 0%

830 Z 0109 LCH Operational Senior 8 0 0%


Team

Clinical

Supervision

Target


Delivered

Clinical

supervision rate

(%)

Management - Nurse-Led (L7)

350 L9 Dietetics - Sefton CS (Z4CH14) 19 0 0%

830 Z 0144 LCH Children in Care (L7) 9 0 0%

830 Z 2534 LCH Physiotherapy Adults - Central

(L7)

10 0 0%

830 Z 0145 LCH Safeguarding Adult's (L7) 15 0 0%

830 Z 2539 LCH Podiatry - North (L7) 28 0 0%

830 Z 0146 LCH Safeguarding Children (L7) 32 0 0%

830 Z 2545 LCH AHP's North Dietetics Team

Leaders (L7)

18 0 0%

830 Z 0147 LCH Targeted Services for Young

People (L7)

6 0 0%

830 Z 3016 LCH Social Inclusion - Children's

(L7)

12 0 0%

830 Z 2019 LCH Health Visitors Central Team 5

(L7)

37 0 0%

830 Z 3027 LCH LOOHS - ERT (L7) 61 0 0%


Central (L7)

15 0 0%

830 Z 3033 LCH Skin Team (L7) 36 0 0%


(L7)

36 0 0%

830 Z 3042 LCH Health Visitors South Team 2

(L7)

243 0 0%


(L7)

41 0 0%

831 Z 2524 LCH School Nurses North Liverpool

Team 1 (L7)

31 0 0%


(L7)

28 0 0%

831 Z 3027 LCH LOOHS - ERT (L7) 16 0 0%


(L7)

22 0 0%


South Liverpool (L7)

6 0 0%

830 Z 2025 LCH School Nurses Team Leaders -

Central (L7)

6 0 0%

830 Z 2535 LCH Physiotherapy Adults - North

Liverpool (L7)

46 0 0%

830 Z 2026 LCH School Nursing Central Team

1 (L7)

42 0 0%


Team

Clinical

Supervision

Target


Delivered

Clinical

supervision rate

(%)

830 Z 2538 LCH Podiatry - Central (L7) 29 0 0%

830 Z 2027 LCH School Nursing Central Team

2 (L7)

30 0 0%

830 Z 2540 LCH Podiatry - South Liverpool (L7) 29 0 0%

830 Z 2030 LCH Family Nurse Partnership -

Liverpool (L7)

21 0 0%

830 Z 2544 LCH AHP's North - Dietetics (L7) 35 0 0%

830 Z 2037 LCH Treatment Rooms - Central

(L7)

51 0 0%

830 Z 2559 LCH MM Distribution/Stores (L7) 3 0 0%

830 Z 2038 LCH Treatment Rooms - North (L7) 12 0 0%

830 Z 3007 LCH Practice Nurse Development

(L7)

18 0 0%

830 Z 2039 LCH Treatment Rooms - South

Liverpool (L7)

51 0 0%

830 Z 3019 LCH Educational Healthcare Plan

Liverpool (L7)

5 0 0%

830 Z 3021 LCH Health Visitors South Team 1

(L7)

42 0 0%

350 L9 Pharmacy Community - Sefton CS

(Z4CH25)

3 0 0%

830 Z 3023 LCH School Nurses South Liverpool

Team 1 (L7)

40 0 0%

830 Z 3026 LCH LOOHS - Community

Assessment Team (L7)

40 0 0%

830 Z 2099 LCH Specialist Students - Central

(L7)

4 0 0%

830 Z 3028 LCH LOOHS - Therapy Service (L7) 29 0 0%

830 Z 2503 LCH Operational Management -

North Liverpool (L7)

3 0 0%

830 Z 3030 LCH Bladder & Bowel Team (L7) 138 0 0%


North (L7)

17 0 0%

830 Z 3038 LCH Telehealth (L7) 24 0 0%

830 Z 2521 LCH Health Visitors North Team 1

(L7)

48 0 0%

830 Z 3040 LCH Single Point of Contact (L7) 331 0 0%

830 Z 2522 LCH Health Visitors North Team 3

(L7)

78 0 0%

830 Z 3530 LCH Children's Liaison Team (L7) 16 0 0%

830 Z 2523 LCH School Nurses Team Leaders - 3 0 0%


Team

Clinical

Supervision

Target


Delivered

Clinical

supervision rate

(%)

North (L7)

831 Z 2523 LCH School Nurses Team Leaders -

North (L7)

25 0 0%

830 Z 2524 LCH School Nurses North Liverpool

Team 1 (L7)

46 0 0%


North (L7)

18 0 0%

830 Z 2525 LCH Special Schools Liverpool (L7) 33 0 0%

831 Z 3016 LCH Social Inclusion - Children's

(L7)

9 0 0%

830 Z 2527 LCH AHP's North - Speech &

Language Therapy SALT (L7)

32 0 0%

350 L9 Diabetes - Sefton CS (Z4CH13) 13 0 0%


Central (L7)

7 0 0%

Core Service Total 2688 137 5%

Clinical supervision was regular and took place both formally and informally during handovers,

team discussions, peer reviews and appraisals. Sessions focussed on information sharing and

learning. Staff told us that they received clinical supervision on average every six weeks. Clinical

supervision is important because it enables staff to reflect upon their practice with skilled

supervisors and practitioners with a view to increasing knowledge, skills and highlighting

development needs to improve patient care, going forwards.

Clinical supervision rates were collated and were due to be reported within the monthly integrated

performance and quality report for each locality. The compliance with clinical supervision was

discussed at weekly divisional safety meetings. Following our inspection, we saw evidence from

the weekly divisional safety meetings minutes that clinical supervision was discussed and ways to

improve rates discussed, going forward.

Leaders told us during our inspection that whilst clinical supervision was not new, the reporting of

clinical supervision had not been formalised which had resulted in rates appearing low. A

standard form was now being used to record the information and this was being collated by the

performance and intelligence team. Clinical leaders were confident that rates would increase

because of this, going forward. We saw evidence of improvement in clinical supervision rates from

those stated above within the October monthly integrated performance and quality report for all

three localities.


Between August 2017 and July 2018, 83% of permanent non-medical staff within the community

services for children, young people and families core service had received an appraisal compared

to the trust target of 95%.


Total number of permanent non-medical

staff requiring an appraisal

Total number of permanent non-

medical staff who have had an

appraisal

% appraisals

210 175 83%

Managers appraised staff’s work performance and supported professional development. During

our inspection, all staff we spoke with said they had received an appraisal within the past 12

months.

We saw written evidence of appraisal meetings for staff in school nursing, which included areas for

development and action plans for achieving goals which had been identified. In health visiting we

saw the schedule for staff appraisals for the coming year.

The clinical leads told us that the service was moving onto a new electronic system in April 2019

which would enable both clinical supervision and staff appraisals to be recorded and monitored

more efficiently than it was at present. The system would also enable staff to access their own

records and therefore monitor their own performance. Appraisal rate data was reported monthly as

part of the integrated performance and quality report for each locality.

All staff within the service were qualified to carry out their roles effectively. Each team had a good

mix of staff covering a range of services. Staff told us how their roles were being developed to

provide holistic care across the children’s, young people and families service. For example, the

special schools team had recruited a qualified public health nurse to enable the delivery of aspects

of the Healthy Child Programme alongside the medical care model which was already being

delivered.

The majority of staff told us they were supported in developing new skills and were excited about

the opportunities this offered. An example of this was a school nurse who told us she had attended

training offered by the National Prevention of Cruelty to Children (NPCC) in looking at identifying

neglect within health and social care. Health visiting staff told us they were encouraged to attend

training offered by the Institute of Health Visiting which incorporates ‘train the trainer’ training

within its programmes. This meant that once staff were trained they would then become trainers

themselves and were able to return and train other staff members. However, we were told that not

all staff felt supported and had raised concerns about training not being offered across all teams

and the cessation of staff development days.

All teams across the service had robust preceptorship programmes which aided new starters in

becoming familiar with their area of work and allowed for issues or concerns to be highlighted. All

preceptorship programmes across school nursing, special schools and health visiting spanned six

months and were overseen by a senior nurse or team leader. The family nurse partnership had a

specific proficiency programme which was overseen by the family nurse partnership supervisor.

Each new staff member received an appraisal after three months on the preceptorship programme

in which staff were encouraged to discuss worries or concerns. During our inspection we spoke

with three new staff members from across various teams who told us they felt supported in their

preceptorship.



Staff of different kinds worked together as a team to benefit service users. Health visitors, nurses

and other healthcare professionals supported each other to provide good care. We saw many

examples of excellent multidisciplinary working across teams during our inspection.

The service had a team of paediatric liaison nurses who worked from four acute hospital sites. The

team supervisor told us that the aim of the team was to bridge the gap between maternity and

health visiting and also accident and emergency departments and school nursing. Information was

shared and this ensured safeguarding concerns and opportunities were not missed. Health visiting

staff told us of the benefit of receiving information from the liaison nurses in planning assessments

and appointments to meet key performance indicator targets.

Both school nursing and health visiting teams were co-located and staff told us of the benefit of

this and how this had impacted positively on the quality and overall delivery of the service. For

example, health visitors could discuss the children on their caseload who were due to transfer to

school nursing.

Health visiting teams had begun working from the early help assessment hub which was operated

and run by the local safeguarding children board. The early help assessment is a service which

specifically looks at early identification of families who may require additional help and support.

Each month a different health visitor would work from within the hub which incorporated; a police

officer, social worker and support workers. Staff told us they felt this was a really positive

experience and had greatly aided in understanding how other services worked and in gaining face

to face advice. Team leaders told us an amendment was being made so that health visitors would

rotate on a three-month basis as feedback although positive for the project had stated that monthly

rotation was not allowing for development of professional relationships.

During our inspection we observed excellent working relationships between school nursing and

teachers. A multidisciplinary approach to the completion of school questionnaires was observed

and both professions had evident respect and appreciation for each other.

The child health inclusion team worked across disciplines and had established good working

relationships with local schools, dentists, doctors and social workers. This team had extended its

multidisciplinary working as it was one of eight regional centres for first contact asylum seekers.

The team lead attended national meetings for Public Health England and national network

meetings to discuss best practice and programme improvement.

There was an abundance of multidisciplinary meetings across teams within the service and it was

evident that the service had great enthusiasm for working across services both externally and

internally to improve the quality and delivery of the service.

Health promotion

Health promotion was deeply embedded within all teams and staff told us this was a fundamental

part of all areas of work within community services for children, young people and families.

Healthy eating and diet, exercise programmes during pregnancy, smoking cessation and sexual

health were some health promotion activities addressed. Staff were aware of services available in


the community across teams and localities where they could refer patients and their families when

necessary.

We saw evidence of information leaflets pertaining to dental hygiene, emotional health and

wellbeing and smoking cessation. School nursing teams had products for helping in giving talks

relating to menstruation and sexual health. Health visiting teams were able to give advice on

breastfeeding and had access to a breastfeeding advice service. We observed the child health

inclusion team had access to toothbrushes and toothpastes which had been supplied by a charity

to give out to first contact asylum seekers. This service had also put an internal case forward to

secure funding for vitamin drops which had been given out previously but had since been

withdrawn.

The service had a healthy families team which was a service offered to any child identified as

being overweight. The whole family were invited to attend a six-week programme providing

education and advice regarding healthy eating and lifestyle. However, many staff we spoke with

during our inspection were unaware of the team or how to refer a patient onto them.



Mersey Care NHS Foundation Trust told us that 97 Deprivation of Liberty Safeguard (DoLS)

applications were made to the Local Authority between 1 August 2017 and 31 July 2018 of which

none were pertinent to community health services for children, young people and families.

Staff we spoke with said they had not had to apply for any Deprivation of Liberty Safeguards. All

staff said they would discuss any capacity issues with the trust safeguarding team who are easily

accessible via telephone and email.

Staff we spoke with were aware of the importance of mental capacity when carrying out

assessments and could explain their decision making when considering this. Both mental capacity

and deprivation of liberty training were included within the trusts mandatory training and the

compliance rate was 92%. Both the family nurse partnership and health visiting staff we spoke

with were able to tell us that if there were concerns in relation to maternal mental capacity they

could access an enhanced midwifery team for advice.

The service had a consent policy which was in date and accessible to staff electronically. All staff

we spoke with during our inspection had a good understanding of consent and Gillick

competencies and how these were applied. Staff were able to verbalise when a decline of consent

would be overridden if there was an issue in relation to a safeguarding concern.

As the services were pre-planned often consent had already been sought and recorded within the

electronic patient record. The immunisation and vaccinations team sent out consent letters to

parents before an immunisation session. We saw evidence that consent was documented clearly

and legibly during our inspection.



Compassionate care

During our inspection we observed two school questionnaire completion sessions involving over

52 interactions between school nursing staff and children. There was an exceptional, therapeutic

approach to care delivery. We observed staff were highly skilled at adjusting their tone, language

and terminology to adapt to the child they were speaking with. We observed that staff knelt down

so that they were at the same level as the child and spoke reassuringly and compassionately

during all interactions.

We saw evidence of a family and friends test from a baby weigh-in clinic in which patients

described receiving an “excellent service” and that the “staff are incredibly caring and friendly and

put me at ease”.

During our inspection, we spoke with 53 members of staff across a variety of professional groups.

All those we spoke with showed compassion in their work and were clearly dedicated in their

profession.

Emotional support

Staff provided emotional support to patients to minimise their distress and we were given many

examples where this was evident.

One team member told us of a situation where a patient’s house had burnt down. The team had

worked with a local charity to provide vouchers for the family to buy clothing for both mum and her

children. The team also linked in with local food banks to ensure both mum and her children had

food. The team had since held fundraising events for the charity.

During one of the school questionnaire sessions, a child became upset and had started to ask a

lot of questions to the school nursing team. We observed the school nurse reassuringly ask the

child if he would like to speak in private, following this the child returned to the classroom happy.

There was an occasion when a child had disclosed to the service during the completion of a

questionnaire about concerns they had. The service worked with the child and their family together

with the school to ensure the family were safe.

We attended a home visit during our inspection and found the interaction and emotional support

given to the mum exceptional. The health visitor was reassuring and allowed the mum plenty of

time to discuss her worries and concerns. The mum was given advice on the changing dynamics

of family life after the birth of a baby. The trusted interaction between the health visitor and the

new mum was evident.


Staff involved the children, young people and families and those close to them in decisions about

their care and treatment.


All staff we observed had an excellent rapport with the children, young people, families and carers.

There were examples of complex issues the teams had to deal with and long term professional

relationships built with parents and families.

We observed staff during the school questionnaire sessions explaining to the children the reason

for the questionnaire and how the information would be used to plan sessions in their school and a

timeframe for this. We observed staff explaining in simple terminology what confidentiality and

ethnicity meant and why this was being asked. Children were clearly advised that they did not

have to take part if they didn’t want to. At the end of the explanation clarification was sought as to

if the children understood what was being said to them and they were offered an explanation

again, if they did not understand.

The health visitor during the home visit clearly explained to the patient the reason for the visit and

provided reassurance that whilst she may not be seen by the same health visitor for clinic

appointments, the health visitor would endeavour to attend all home visits herself.

It was evident from the school visit, home visit and from speaking with staff that the understanding

and involvement of patients and their families in their care was of paramount importance to them.




The trust planned and provided service in a way which met the needs of the local people.

Changing needs of the community were monitored using a variety of sources including local

intelligence, GP information and schools.

Health visiting planned its visits and tailored the work according to the local population using

intelligence on areas of social deprivation and previous poor attendance to clinics. School nursing

used the questionnaires to plan its programme of work and develop services as needs were

collated and understood. The immunisation and vaccination team were in the process of

developing drop in clinics based on local intelligence to suggest where these would be most

beneficial and see the greatest uptake rate.

Prior to the acquisition of some of the children’s services from Liverpool Community Health NHS

Trust, the trust had not previously held any physical health services. As such, there was an

ongoing transformation programme for which there was a transformational clinical lead and

improvement plans were based on planning and delivering services based on local needs. At the

time of our inspection, the trust was gathering information relevant to each locality and in the

process of planning services going forward. There were clear plans in place.


The service took account of patient’s individual needs and we were given many examples of

support given to vulnerable children, young people and families.

Health visiting, school nursing and the family nurse partnership all held weekly safety meetings

were caseload allocation including vulnerable patients were discussed. The electronic patient

record was used to alert staff to anything which may be deemed as a vulnerable situation such as

safeguarding or looked after children alerts.

The child health inclusion team specifically dealt with vulnerable children, young people and their

families as the first contact for asylum seekers. As such this service had access to crisis

counselling, midwifery services and a GP on site at the clinic where the patients and their families

were seen.

The special schools team had access to a specialist complex needs nurse for advice and support

in relation to caring for children with complex needs including learning disabilities and physical

health disabilities.

The immunisation and vaccinations team had met with a local Imam to offer educational sessions

for local Muslim communities regarding immunisations. Further work was planned for educational

sessions for both the polish and travelling communities.

All services we spoke with were able to tell us about referral processes for mental health (both

child and maternal), speech and language therapists, early help intervention, counselling and

bereavement services.


Each service had access to language line for people with English as a second language. They

were easily accessible by telephone and leaflets informing people of the service were available.

Staff told us that face to face interpreter bookings could also be made.


Accessibility

The largest ethnic minority group within the trust catchment area is white other with 1.75% of the

population.


First largest White Other 1.75

Second largest Chinese 0.8

Third largest Other 0.7

Fourth largest Black African 0.7

During our inspection, we observed a variation in the way referrals were managed across the

teams and services. There were however, no reported incidents specifically related to the way in

which referrals were managed.

Staff told us during our inspection that referrals for health visiting were managed through one

central team electronically. Referrals were received from GP’s and from information shared by the

paediatric liaison nurses located within the acute hospitals. Each health visitor was attached to a

local GP practice, this meant that they saw patients who were within specific GP catchment

populations.

School nursing referrals were received electronically through a protected shared email account.

Each team had a staff member to cover the incoming referrals throughout the day. A triaging

process was in place which allowed referrals to be allocated and seen based on immediacy of

need.

The child health inclusion team received referrals in a set format each day from the home office.

Staff told us that it was incredibly difficult to meet the targets for the key performance indicators as

due to the nature of the patients the service was seeing. For example, a target to have an

antenatal contact at 28 weeks of pregnancy was often impossible for the team as often they were

seeing patients already in late stages of pregnancy.

The family partnership nurses received referrals from the GP, hospital and patients. All referrals

into the team were taken to the weekly meeting for discussion and allocation. The service had a

number of national targets set out by the Department of Health, data was inputted into a national

database monthly. The service had a dashboard from which information regarding current

compliance against national targets was monitored. Following our inspection, information supplied

by the trust showed that the service was performing in line with the national standards.

Both the family nurse partnership and all health visiting teams offered set clinic appointments or

home visits. The child health inclusion team offered clinic appointments on set days however, due

to the nature of the patients using the services they would often see patients who “turned up” at

the clinic without an appointment wherever possible. Health visiting offered baby weigh-in drop-in


clinics which were run by nursery nurses and staff told us these were well attended. The health

visiting service did not offer any additional drop-in clinics and staff told us that these had been

removed in order to ensure compliance with ante-natal contact appointments.

The immunisation and vaccination team offered three drop-in clinics across the area at the time of

our inspection. They also facilitated mop-up sessions for any children who had been unable to

attend the school immunisation session which were run from the clinic where the team were

based.

All services and teams we visited told us of issues with patients not attending for clinic

appointments. This was addressed within each team during the safety meeting and monitored

regularly. Where a patient accessed other services or there were concerns around the family, the

relevant services were informed.


Complaints

Community services for children, young people and families received seven complaints between 1

August 2017 and 31 July 2018. The main complaints themes were privacy, dignity and wellbeing.

Total

Complaints Fully upheld Partially upheld Not upheld

Referred to

Ombudsman

Upheld by

Ombudsman

7 2 2 2 0 0

The service took complaints and concerns seriously, investigated them and learned lessons from

the results and shared these with staff at weekly safety and monthly team meetings, if appropriate.

Specific feedback from complaints, relating to the staff member involved was discussed on a one

to one basis. We were given a specific example of learning as a result of a complaint which

resulted in additional training for staff around managing challenging situations. Families we spoke

with were aware of how to submit a compliant

The team leaders told us that they invited complainants to discuss the complaint in the first

instance, to identify and resolve issues in a timely manner. There was a standard template for

completion of informal complaints and this was completed by the relevant team leader. The formal

complaint rate was low within the service and staff told us that they referred patients to the patient

advice and liaison service if they were unable to resolve concerns at the time they were raised.

Information relating to complaints was published in the monthly integrated performance and quality

report.

We reviewed two complaints which related to children, young people and families. There was

evidence that these complaints had been thoroughly investigated and the responses to the

complainant contained sufficient detail. The responses to these complaints were provided to the

complainants in a timely way in both cases both with details of how to refer the complaint to the

Parliamentary Health Service Ombudsman if the complainant remained unsatisfied.


Compliments

The trust received 157 compliments during the last 12 months from 1 August 2017 and 31 July

2018. Three of these related to community services for children, young people and families, which

accounted for 2% of all compliments received by the trust as a whole.

The service encouraged staff to log compliments on the electronic system as well as complaints or

incidents. Staff told us that most compliments were received verbally and often they did not record

these as they felt they were “just doing their job”.



Leadership

The service had managers at all levels with the right skills and abilities to run a service providing

high-quality sustainable care.

The locality care managers and clinical leads had a range of experience and came from a variety

of professional backgrounds. This provided a diverse knowledge base which was utilised across

the three localities and gave the benefit of understanding the challenges and priorities for

sustaining the community children, young people and families service.

The team leaders had the experience and capability to understand their teams and staff we spoke

with across services and teams held their team leaders in the highest possible regard. They

described their immediate managers as approachable and supportive. Leadership beyond the

immediate level was not always apparent to staff and some staff members did not know who their

locality care manager or clinical lead was.

All staff we spoke with were aware of the chief executive but were not aware of any other

members of the senior management team or board.

Vision and strategy

The trust had a clear vision and set of values which were continuous improvement, accountability,

respect and enthusiasm. The service had a strategy for community children, young people and

families in the form of an improvement plan. The service had a transformation lead to support the

delivery of the improvement plan. The lead was working across the three localities to support both

care managers and clinical leads.

During our inspection clinical leads and care managers were able to tell us both the trusts strategy

and the improvement plans and strategy for the service. They were able to tell us the trusts vision

and how the community children, young people and families service was striving to achieve this.

Staff within the teams across the services we spoke with were able to quote the trusts vision of

“perfect care”. However, staff were unaware of either the trust or service strategy or how this was

going to be achieved for community children, young people and families.

Culture

All levels of management promoted a positive inclusive culture that supported and valued staff.

Staff told us they enjoyed working in within their respective teams and felt well-supported by their

colleagues and immediate line managers. All staff we spoke to had a positive attitude about

working for the service and were hopeful for improvements and improved stability that working for

a new trust would bring. All staff stated they had seen a marked improvement in both

communication and engagement following the acquisition of services by the trust.

We spoke to a variety of staff at the teams and services we visited. Those who had been in post

for some time had seen improved staff morale. We saw good working relationships between all

grades of nursing, team leads and ancillary staff within each service. However, staff within some


ancillary services told us they often felt left out and gave specific examples of when they had not

been included within team planning and events.

Staff told us that professional development within the service was actively encouraged and

promoted. Staff were able to provide specific examples of requesting development and how this

had been facilitated.

The trust was working hard to promote a positive culture of openness, transparency and honesty

and staff told us they were encouraged to speak up and raise concerns. The majority of staff we

spoke with were able to tell us who the trust’s freedom to speak up guardian was and there were

posters which detailed the initiative and named the trust guardian which were visible within all

offices we visited.

Governance

Governance structures, processes and systems of accountability were clearly set out within the

service. Each team within the community services for children, young people and families held

weekly team huddles, actions from these meetings were recorded and we saw evidence of this

following our inspection. Actions from the team meetings fed into the weekly locality meeting for

which actions were also recorded and evidence of this was provided by the trust following our

inspection. Actions from the weekly locality meetings fed into the monthly quality assurance

committee meeting, at board level, for which evidence was provided prior to our inspection.

Community services for children, young people and families were delivered across three localities;

North Liverpool, Central Liverpool and South Liverpool. Each locality encompassed different

teams based on geographical location, teams included; health visiting, school nursing, special

schools, child health inclusion team, immunisation and vaccination team, healthy families team,

child health information services, family nurse partnership and paediatric liaison service.

Each team had a supervisor or team lead who were responsible for the daily management of each

team and reported directly to the locality care manager however, operational vacancies existed in

all localities for a manager in between the team leader level and care manager level which the

trust told us they had recruited for and were in the process of putting into place. The care

managers reported directly to the operational associate directors alongside the locality clinical

leads. The associate directors reported to the chief operating officer who then reported to the

board.

Clinical leads and care managers were able to tell us how information was fed up and down into

the operational team however, staff were not and some were unaware of who or what constituted

for the senior operational management team or what the governance structure looked like beyond

their immediate line managers.


There were effective processes in place to identify, monitor and address current and future risks.

The monthly integrated performance and quality reported highlighted current key risks within each

locality and detailed what measures were in place to control the risk and the action plan going

forward. All risks where held on an electronic divisional risk register and we discussed key risks

with the management team, risks were managed well and both locality care managers and clinical


leads were able to explain which risks were pertinent to their particular area and describe where

they were up to in terms of progress. We saw that risks were being continuously monitored and

updated, an example of this was the risk to the special schools’ team in which they were unable to

provide the healthy child programme due to not having any nurses with a specialist community

public health nursing qualification. This risk had been eliminated by the recruitment of a specialist

community public health nurse who had commenced in post in October. This was part of a series

of risks associated with the special schools’ team and evidence provided by the trust following our

inspection showed there were clearly defined timescales and actions to eliminate all risks

highlighted and that plans were in place to do this.

The service had begun undertaking individual team self-assessment inspections which followed

the Care Quality Commissions five key questions methodology. Each team was in the process of

receiving the self-assessment inspection and this was being conducted by the quality assurance

team. The reports highlighted areas of achievement, areas of concern, areas for improvement,

risks and actions required for each team. During our inspection we were told by the clinical leads

that these reports would be carried out annually and any team with actions to be completed would

be reviewed after three months. This process enabled the service to monitor compliance with the

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The clinical leads for

each respective locality had oversight of the reports and told us that they would be able to monitor

trends, themes and also share best practice across localities going forwards. These reports were

discussed at monthly divisional meetings.

The service had appointed a children’s transformational lead to oversee the redesign of the

service and support staff during the process. A Liverpool community services sub-committee had

been established to help improve and gain assurances on the quality of the care provided for all of

the community services during the redesign. We reviewed the minutes from the sub-committee

meeting minutes and found risks, action plans and the improvement plan were scrutinised in great

detail with clear timeframes for completion of tasks and risks going forwards. There was evidence

that tasks were completed within specified timeframes for example the ongoing rebranding of

patient leaflets to show the Mersey Care Foundation Trust logo was almost completed and this

had a timeframe of December 2018.

The service had effective systems for monitoring and managing performance. Team performance

was overseen by individual team leaders. Each team was required to submit data and report

against key performance indicators on a monthly basis. Staff told us they received updates on

where their team was in terms of performance via their monthly team meetings. Following our

inspection, we saw evidence within the meeting minutes of the discussion of performance against

the key performance indicators.

Staff were informed of the teams’ performance at monthly team meetings. We reviewed team

meeting minutes following our inspection and saw evidence of this. Locality performance was

reported within the monthly integrated performance and quality report and discussed at monthly

divisional meetings. We reviewed divisional meeting minutes following our inspection and saw

evidence of this. Directorate management reviewed quality, safety and operational performance

data at the monthly operational management board, this fed directly into the quality assurance

committee, which was at board level. All staff we spoke with during our inspection were able to tell

us in detail where their team/division were up to in terms of performance. The service performed

consistently well across all three localities in relation to all aspects of the healthy child programme


with the exception of breastfeeding prevalence for the North locality. The breastfeeding prevalence

for the North locality was consistently below the target of 30% with an average over a twelve-

month period of 19.9%. Staff told were able to verbalise why the rate was consistently low for this

locality and what measures were in place to try to improve the figures such as being able to

access specialist advice on breastfeeding for patients through partner organisations.

The service collated information such as the number of children accessing the service and

developmental checks at different ages. Monthly performance data was published within the

integrated performance and quality report, measured against the previous month for comparison

and an overall level for the year to date given. This meant the service could see where targets

were not being met and identify areas for improvement.


The service collected, analysed, managed and used information well to support all its activities,

using secure electronic systems with security safeguards. There were systems in place to ensure

the confidentiality of identifiable data, records and data management systems in line with data

security standards. Both staff and management told us that privacy audits were carried out

monthly for each team by the team leader, this ensured only staff who should be accessing

information, were accessing information.

The online records system was effective for use in information gathering for audit and reporting

purposes. For example, the immunisation and vaccination team were able to pull uptake rates for

the influenza vaccination straight from the electronic system which could then be fed into the

Public Health England database. The different information systems used within the service were

used to collate and inform reports and intelligence for the team leaders and the locality leads, such

as the monthly integrated performance and quality report.

Staff within the department told us that they had access to the information that was needed for

them to undertake their roles effectively, this included bank staff and staff assisting from other

teams or localities. We observed that connectivity within office settings was good and staff told us

that when there was a problem with electronic systems these were rectified quickly and efficiently.

However, staff told us that often there were connectivity issues when working from patient’s

homes or site visits. Three out of four of the acute sites where the paediatric liaison nurses worked

from, did not have access to input information onto the electronic patient record. These nurses

could only access the system in the ‘read only’ function. We observed that this issue was on the

divisional risk register and an action plan was in place with specified time scales in which to

resolve this issue.

Engagement

The trust engaged well with staff and local organisations to plan and manage appropriate services

and collaborated with partner organisations effectively. However, public and patient engagement

was lacking.

As the service did not operate from permanent sites which were solely owned or leased by the

trust, staff told us the only method of receiving feedback from patients or the public was by

physically giving patients family and friends feedback forms. Staff had been unable to do this as


the logo on the family and friends test information had not been amended to show name of the

new trust.

School nursing staff told us they engaged with children by holding focus groups within schools

which helped in the development of questionnaires. Direct feedback as a result of this had helped

school nursing staff to change one of the questions within the questionnaire which they felt was

more appropriate and would yield more detailed results.

The child health inclusion team had taken part in a feedback consultation review carried out by the

engagement team for the trust. Nine families were interviewed to gauge how they felt they were

treated by the team during their clinic appointments and reviews. We reviewed the consultation

and found all responses to the team were positive and there were many examples of the

commitment and care this team provided.

The trust were working hard to engage with staff and staff told us about communications received

weekly from the Chief Executive, a scheme in which staff could send questions or comments to

the Chief Executive and requests could be made for ‘birthday breakfasts’. The trust held bi-annual

roadshows for all staff which team leaders told us they actively encouraged staff to attend.

There were many good examples of how both the trust and team leaders were striving to promote

health and wellbeing for staff. The service was carrying out monthly ‘pulse checks’ at all team

meetings to assess staff morale and look for any improvements which could be made. A ‘buddy’

system for those returning from long term sick was being trialled by one health visiting teams to

support staff with workload and pressures on their return to work.

The child health inclusion team told us they had received a full day of resilience training in

collaboration with an external counselling and wellbeing organisation. In health visiting one staff

member told us during the summer they had taken part in power walks and rounders during lunch

to promote wellbeing and boost staff morale.


There was a clear focus on continuous learning and improvement. The service was committed to

improving services by learning from when things go well and when they go wrong. We were given

many examples of when areas of work had been scrutinised and improvements suggested. For

example, school nursing were in the process of developing an electronic questionnaire and the

immunisation and vaccination team were developing an electronic consent form. Both these areas

of work were time consuming and difficult when information needed to be shared. It was proposed

that electronic versions would aid in the management of each respective area.

Improvement and innovation within the service was driven by leaders and senior management.

We were given many examples of ideas for improvement, some of which were underway and

some which were yet to be agreed. For example, the deployment of a health visitor within the early

help assessment hubs to assist in multidisciplinary working and increase staff knowledge. A forum

had been arranged for December 2018 to discuss the implementation of the 0-19 service model

which forms part of the Department of Health’s Five Year Forward View to co-ordinate the delivery

of public health for children aged 0-19 by integrating health visiting and school nursing teams.


Staff were encouraged to think about ways in which the service could improve the quality of the

care given and were keen to learn from other services at other trusts. For example, health visiting

were working with commissioners and team leaders from health visiting services across the North

West in the development of a peri-natal mental health pathway. School nursing were working

collaboratively with sexual health teams to increase staff knowledge base and develop additional

training for staff.

Mersey Care NHS Foundation Trust evidence appendix: end of life care

End of life care


Information about the sites, which offer end of life care services at this trust, is shown below:

Location site name Team/ward/satellite name Patient group



Innovation Park, Edge Lane,

Liverpool, L7 9NJ Palliative care team Mixed N/A Liverpool

Litherland Town Hall, Hatton Hill Road, Liverpool,

L21 9JN

Palliative care team Mixed N/A South Sefton

End of life services are provided by two palliative care teams which are based in Liverpool and

South Sefton. Mersey Care NHS Foundation Trust acquired the services that are provided in

South Sefton in June 2017. The trust subsequently acquired services that are provided in

Liverpool in April 2018. This meant that at the time of inspection, both palliative care teams were in

the process of making sure that a standardized service was provided across both areas.

End of life services in the community are led by GPs, and are supported by the palliative care

teams, community district nursing teams as well as allied health professionals such as

occupational therapists. Referrals to the palliative care teams are made when advice or support is

required to deliver safe and effective care.

Between November 2017 and October 2018, community services reported 4,648 deaths. Records

indicated that during the same period, the palliative care teams in both Liverpool and South Sefton

had received a total of 2,081 referrals (45% of occasions).

During the inspection, we spoke to staff of different grades, including district nurses, members of

the palliative care team and senior managers. We attended a multidisciplinary team meeting that

was held at a local hospice. We attended six visits to patient’s home addresses with district

nursing staff as well as members of the palliative care team, and spoke to ten patients and

relatives on the telephone, discussing the care that they had received.

We took time to review six patient records during home visits that we attended, as well as

reviewing retrospective patient records of patients who had passed away. Additionally, we

reviewed information that was provided by the trust both before and after the inspection.



Mandatory and Statutory Training

The trust had an induction, statutory and mandatory training policy that was available to all staff on

the intranet. Mandatory training had been delivered through both face to face sessions and e-

learning. Staff who we spoke with were aware of their responsibilities to complete this in a timely

manner.

Training was monitored by the learning and development department at a trust wide level. In

addition, local records had been kept for the Liverpool palliative care team. This was because they

had employed an educator who had maintained oversight of this. However, the South Sefton team

did not have an educator to undertake this role.

Mandatory training modules differed between the Liverpool and South Sefton palliative are teams.

This was because both services had been acquired at different times, meaning that South Sefton

completed modules that had been developed by Mersey Care NHS Foundation Trust, while the

Liverpool team completed modules that had been developed by the organisation that they were

previously managed by.

The trust set a target of 90%90% for completion of mandatory training and their overall training

compliance was 88% against this target.

A breakdown of compliance for mandatory courses as of July 2018July 2018 for all staff in end of

life care services is shown below.

South Sefton palliative care team:


Mandatory training - Conflict resolution (every 3 years) 83%

Mandatory training - Equality, diversity and human rights (every 3 years)

100%

Mandatory training - Fire safety (every 3 years) 100%

Mandatory training - Health and safety (every 3 years) 100%

Mandatory training - Infection Control (every 3 years) 83%

Mandatory training - Moving and handling (every 3 years) 67%

Mandatory training - Data security awareness – Level 1 (every year)

50%

Mandatory training - Information governance 0%

Role specific mandatory training – Basic life support (every year)

83%

Role specific mandatory training – Basic PREVENT awareness (once only)

100%

Role specific mandatory training – Mental Capacity Act / Mental Health Act and Deprivation of Liberty safeguards (every 3

33%



years)

Role specific mandatory training – Safe and effective use of medicines (every 3 years)

33%

Role specific mandatory training – Controlled drugs and high risk medicines (every 3 years)

50%

Role specific mandatory training – Medicines calculations (once only)

33%

Role specific mandatory training – Moving and handling people (every year)

83%

Role specific mandatory training – MUST adapted nutritional screening (once only)

0%

Grand Total 62%

Liverpool palliative care team:


Equality, diversity and human rights (every 3 years) 100%

Fire safety (every 3 years) 100%

Harassment and bullying awareness (once only) 100%

Health and safety (every 3 years) 100%

Information governance (every year) 91%

PREVENT (every 3 years) 100%

Health record keeping (every 3 years) 100%

PREVENT training for clinicians (once only) 100%

Conflict resolution (every 3 years) 100%

Consent (every 3 years) 100%

Infection control – level 2 (every year) 100%

Mental Capacity Act (every 3 years) 100%

Moving and handling for people handlers (every 3 years) 91%

Resuscitation (every year) 100%

Investigation of incidents using an RCA (once only) 90%

Medicines management awareness (every 3 years) 100%

Grand Total 98%


Safeguarding

There was a safeguarding policy for adults and children that was available on the intranet. Staff

who we spoke with knew how to access this. However, we found that this was out of date and

should have been last reviewed in 2016.

The trust had a safeguarding team who were available between Monday and Friday, during

normal working hours. Referrals to external safeguarding services were made out of hours. Staff

who we spoke with informed us that they knew how to contact them for advice if needed.

Staff who we spoke with gave us examples of what constituted a safeguarding concern. Examples

given included neglect, physical abuse and emotional abuse. One member of staff gave us an

example of a recent scenario when they had made a safeguarding referral for a patient.

Most staff had an awareness of female genital mutilation. This was important as since October

2015 it is mandatory for regulated health and social care professionals to report known cases of

female genital mutilation in persons under the age of 18 to the police.

In addition, staff also had an awareness of child sexual exploitation as well as PREVENT (a

counter terrorism strategy that is aimed to stop people becoming terrorists or supporting

terrorism).

Staff understood their responsibilities to report safeguarding concerns and knew how to do this.

Contact numbers were available on the intranet for different safeguarding teams across Liverpool

and South Sefton.

Safeguarding concerns were recorded on the electronic records system when needed. This was

important as it reduced the risk of safeguarding concerns not being communicated between

members of staff. In addition, safeguarding concerns had been included in the daily safety huddle

that all staff attended at the start of every shift.

Liverpool Palliative Care Team:


Safeguarding Adults Level 2 – (Every 3 years) 100%

Safeguarding Children Level 2 – (Every 3 years) 100%

South Sefton Palliative Care Team:


Mandatory Training - Safeguarding Adults - Level 1 (Every 3 Years)

100%

Mandatory Training - Safeguarding Children - Level 1 (Every 3 Years)

100%

Role Specific Mandated Training - Safeguarding Adults Level 2 -Trust Model (Every 3 Years)

100%




100%

Role Specific Mandated Training - Safeguarding Adults Level 3 - Trust Model (Every 3 Years)

100%


100%





institutional.





should take place.

End of life care services made four safeguarding referrals between 1 August 2017 and 31 July

2018, of which four concerned adults and none concerned children.


The trust had an infection and prevention control policy which was available for staff to access on

the intranet.

Between April and November 2018, the service had not reported any incidents of patients

developing meticillin-resistant staphylococcus aureus, methicillin-sensitive staphylococcus aureus

or colostrum difficile while being cared for in the community.

We found that patients who were at risk of infection had been identified during daily safety huddles

that took place at each district nursing base. This was important as it allowed information to be

communicated between all staff and made staff aware of potential risks that were faced prior to

undertaking a home visit.

All district nurses and members of the palliative care team carried hand gel. We observed that

staff decontaminated their hands using this after each patient contact. This reduced the potential

risk of infection being spread.

Referrals


4 0 4


Staff also had access to personal protective equipment, including clinical gloves and aprons. Staff

were aware of their responsibilities to use these when needed.


All equipment used by the palliative care team was maintained by an external provider. The trust

had recently introduced a system to monitor the location of equipment as well as compliance with

servicing and portable appliance testing when needed. However, records indicated that this was in

the process of being updated. This meant that the service did not yet have a full oversight of all

equipment that was being used.

We reviewed compliance with the servicing of syringe drivers that were used on a regular basis.

Although records indicated that 93% of these that were in the Liverpool area had been serviced in

the last 12 months, only 67% had been serviced in line with the manufacturers guidance in the

South Sefton area. This was important as it meant that there was an increased risk that equipment

would become faulty during use.

The trust had a policy for the use for syringe drivers. This was important as they were used on a

regular basis. However, the service had not planned to monitor compliance with the policy. This

meant that there was an increased risk that improvements would not always be made when

needed.

The palliative care and district nursing teams informed us that they could request equipment when

required and were aware of the process to do this. Equipment could be accessed straight away if

needed. Staff who we spoke with told us that there was sufficient equipment available to manage

patients at the end of life.

The service had planned for sharps to be disposed of after use. All members of the district nursing

teams carried boxes to dispose of sharps when they had been used. District nurses who we spoke

with were aware of the procedure to dispose of these safely.


A team of palliative care nurses were available during normal working hours, between Monday

and Friday in both the Liverpool and South Sefton areas. During these times, members of the

palliative care team attended home visits with the district nurses. District nurses were available to

provide care and treatment to patients 24 hours a day, seven days a week.

There was no formal arrangement in place to support out of hours district nurses if they required

advice about topics such as the management of a patient who was at the end of life. However,

staff informed that if they had concerns, they would contact a GP to seek further advice.

The service did not have a formal agreement to access a specialist consultant in palliative care for

advice. However, members of the palliative care team informed us that they would speak to a

consultant who was based at a local hospice if needed.

The palliative care team regularly reviewed all patients who were known to them. This was

important as it meant that patients were prioritised and management plans were put in place in a


timely manner, which was particularly important at weekends as there was only one member of

the palliative care team on duty.

Safety huddles were held at each district nurse team base at the start of every shift. This allowed

staff to prioritise patients within their caseload and for the management team to ensure that staff

knew about priority patients. The safety huddle covered topics such as infection control, do not

attempt cardiopulmonary resuscitation as well as if a patient was on an end of life pathway.

There was also access to an emergency response team. Staff knew how to contact them if

immediate support was required. Referrals were made for several different reasons, including to

prevent an inappropriate hospital admission while a patient was waiting for a social services

referral to be made or for community health care funding for a support package to be agreed.

The trust had a deteriorating patient policy which was available to all staff on the intranet. Staff

who we spoke with were aware of this and knew how to access it. However, we found that this

should have been last reviewed in April 2017.

The service had not always used a system to identify patients who were at risk of deterioration.

This was because there had not always been a requirement for the national early warning score

system to be used in all areas. A national early warning score is based on a patient’s vital signs

such as pulse rate, blood pressure and temperature. It also provides guidance for staff to follow if

a patient’s vital signs are outside of normal parameters.

However, despite no standardised system staff were required to monitor patient’s vital signs as

part of a home visit. We attended six home visits during the inspection, finding that these had been

completed thoroughly on all but one occasion.

In addition, we found that documentation from previous visits had been removed from patient’s

records and placed in patient files which were located at the district nurse bases. Staff informed us

that they checked the patient’s files before they attended a home visit so that they could compare

vital signs from previous visits.

The management team had recognised the need for a standardised approach across all areas,

and were in the process of implementing a service wide system to support staff in monitoring

deteriorating patients.

Staff were also required to complete a variety of risk assessments for all patients. This included

risk assessments for falls and pressure ulcers. We found that these had been completed on five

out of six occasions when required.

However, on one occasion, we reviewed the records of a patient who had been deemed at high

risk of falls, finding that there was no documented evidence of what action had been taken to keep

the patient safe. In addition, the falls risk assessment that was used for all patients did not reflect

current practice. This was because the risk assessment stated that a referral had to be made to a

team that no longer existed.

Staffing


The Liverpool palliative care team employed six band seven nurses and five band six nurses. The

South Sefton palliative care team employed four band seven nurses as well as two band six

nurses. Both the Liverpool and South Sefton palliative care teams had been established to have a

team leader. Members of the management team informed us that while South Sefton had a

substantive team leader, two members of part time staff were currently undertaking this position in

Liverpool on an interim basis.

There were sufficient numbers of staff available during weekdays. However, staff informed us that

they had sometimes struggled to provide an effective service at weekends. This was because the

service had planned to only have one member of staff on duty, meaning that staff had not been

able to undertake home visits with members of the district nursing team and had to provide

support over the phone.

Rotas for Liverpool and South Sefton between June 2018 and November 2018 indicated that the

planned number of palliative care nurses had been achieved on all occasions, Members of the

management team informed us that there were plans to review staffing levels to ensure that there

were sufficient numbers of palliative care nurses to match the needs of the number of patients who

had been referred to the service, particularly at the weekends.

Records indicated that staffing caseloads for both Liverpool and South Sefton had been

manageable between August 2017 and July 2018. Caseloads in Liverpool had ranged between

seven and nine patients per member of staff and caseloads in South Sefton had ranged between

eight and 14 patients per member of staff during the same period.

The service employed a part time GP who led end of life services across both the Liverpool and

South Sefton areas. There were no other members of medical staff employed by the service to

provide end of life care.

Members of the management team informed us that there were several staffing vacancies across

the district nursing teams in both the Liverpool and South Sefton areas. There had been a small

number of occasions when this had impacted on patients receiving end of life care.

For example, on one occasion, a patient who had been discharged from hospital during the night

had not been seen due to staffing shortages in the night team. In addition, relatives had raised

concerns that a member of staff had not been available to discontinue a syringe driver after their

relative had passed away.

Vacancies

Between August 2017 and July 2018, the trust reported an overall vacancy rate of -10% (over

establishment) in end of life care services.

Staff group Total number of substantive staff Total % vacancies overall (excluding

seconded staff)

Clerical & Admin 1.5 -23%

Nurse Other Community Services 18.9 -8%


Core service total 20.4 -10%

Turnover

Between August 2017 and July 2018, the trust reported an overall turnover rate of 16% in end of

life care services.


Total number of substantive staff

leavers in the last 12 months


Nursing & midwifery registered 8.8 10 11%

Other (including admin & clerical) 0.4 0.4 100%


Sickness

Between August 2017 and July 2018, the trust reported an overall sickness rate of 10% for end of

life care services.


substantive staff


sickness overall

Nursing & midwifery registered 8.8 8%

Other (including admin & clerical) 0.4 30%


Suspensions and Supervisions

There was no data pertinent to end of life care services.

Quality of records

The service used a paper based and an electronic records system. All district nursing records

were paper based and were completed following each patient visit. We found that paper based

records were removed regularly from records at a patient’s home address and placed in a folder

which were secured securely at each district nursing base. This meant that district nurses had to

review patient records before attending a patient visit who required end of life care.

Patient records were also kept electronically which included records made by members of the

palliative care team. All staff had access to the electronic system and could review the records

from patient visits.

GP consultations and visits had also been recorded on the electronic system. Providing that a

patient had given permission for their electronic records to be shared, all staff were able to access


these when needed. This system allowed care between different teams to be shared so that care

for patients at the end of life was co-ordinated effectively.

We reviewed six sets of patient records during patient visits, finding that patient records were

legible, dated and signed. In addition, any examination or advice given had been clearly

documented.

The palliative care teams in both the Liverpool and South Sefton areas had introduced a paper

based individualised care plan for staff to use when patients were in the last days of their life. This

covered a range of topics such as the administration of anticipatory medicines as well as care after

death and verification of death.

We found that this document had not always been completed fully when needed. We reviewed 15

sets of records for patients who had passed away, finding that eight had not been fully completed.

This included if medical devices had been removed, if controlled drugs had been destroyed in line

with policy or who a death had been verified by.

We had concerns that members of the management team did not always have oversight of areas

that required improvements to be made. This was because members of the management team

informed us that this information may have been sometimes been included in other parts of the

patient records and as a result, had not always been captured in either clinical or patient record

audits.

Medicines

The trust had a medicines management policy which was available to staff on the intranet. Staff

we spoke with were aware of this and knew how to locate it. This was supported by a small

number of standard operating procedures, including a procedure for the destruction of controlled

drugs.

However, we had concerns that controlled drugs had not always been destroyed after a patient

had passed away. This was because on sampling eight retrospective records for patients who had

passed away, we found that there was no evidence that controlled drugs had been destroyed on

two occasions. This meant there was an increased risk to safety as the controlled drugs had not

been accounted for and there was a risk that they could be reused by people who they were not

intended for.

The trust had undertaken a care of the dying audit in June 2018. Records indicated that

compliance with destroying controlled drugs in line with trust policy was only 62%.

In addition, the trust did not have a process to support staff on occasions when controlled drugs

had been removed by a third party, such as the coroner or the police. This meant that there was

no documented evidence of what had happened to the controlled drugs.

We raised these concerns with the trust following the inspection who informed us that a safety

alert had been issued to remind staff about destroying controlled drugs. In addition, the trust

informed us that staff had been asked to incident report occasions when a third party had taken

the controlled drugs so that there was a clear audit trail of how they had been managed. However,


there was no evidence provided after the inspection and at the time of writing the report that the

trust’s policies and procedures had been amended to reflect this.

We attended six visits to patient’s homes, finding that staff had clearly checked and documented

administration of patient’s controlled drugs correctly on all occasions. This had been done in line

with trust policy. However, we found that on two occasions, patient’s own medicines had not been

clearly documented.

Anticipatory medicines were prescribed by a patient’s GP. Alternatively, there were several

members of the palliative care team who were nurse prescribers. This meant that they could

prescribe anticipatory medicines in a timelier manner. The end of life care strategy that was

published by the Department of Health in 2008 states that it is important to prescribe anticipatory

medicines as early as possible. This is important so that staff can treat common symptoms, such

as nausea and vomiting as well as pain.

The service had introduced a pre-populated anticipatory medicines prescription chart which listed

several different medicines along with the maximum dose. Staff were required to record the

administration of anticipatory medicines on this chart. In addition, staff were required to review

anticipatory medicines every 28 days, which was in line with national guidance.

We sampled six retrospective records for patients who had required anticipatory medicines, finding

that there was documented evidence that they had been prescribed and administered in a timely

manner on all but one occasion. Staff who we spoke with were aware that patient’s own medicines

should be discontinued where possible, which was in line with national guidance and was done in

association with a GP.

Staff were supported to administer anticipatory medicines by documentation which was included in

each patient’s individualised care plan. This provided a step by step process of how to manage

several different conditions. In addition, the anticipatory medicines prescription charts indicated

maximum doses of each drug, indicating when a further medical review should be sought.

The service used syringe drivers to administer medicines such as pain relief. However, we had

concerns that the service was not always able to provide a member of staff who had been trained

to use a syringe driver safely when needed. This was because training compliance varied between

the Liverpool and South Sefton localities as well as different district nursing teams.

Records indicated that overall compliance was only 57% in South Sefton, ranging between 0%

(BGT district nursing base) and 89% (Crosby district nursing base). In addition, records also

indicated that overall compliance in the Liverpool area was 70%, with compliance ranging from 0%

(City Centre district nursing base) and 100% (Croxteth district nursing base).

However, we did note that there was 100% compliance with syringe driver training in the out of

hours district nursing team. This was important as they were responsible for covering both the

South Sefton and Liverpool areas between 5.30pm and 8.30am, seven days a week.

Following the inspection, the trust informed us that they aimed to improve overall compliance to

95% by March 2019.


An advice leaflet was given to patients and relatives about the use of strong opioids, such as

morphine (a controlled drug used for pain relief). This provided advice about topics such as side

effects, when to get in touch with a doctor as well as providing information about the different

types of opioids that were available and what they were used for.

Safety performance

Safety Thermometer (September 2017 to September 2018)

The NHS Safety Thermometer allows teams to measure harm and the proportion of patients that

are ‘harm free’ during their working day. For example, at shift handover or during ward rounds.

This is not limited to hospital; patients can experience harm at any point in a care pathway and the

NHS Safety Thermometer helps teams in a wide range of settings, from acute wards to a patient’s

own home, to measure, assess, learn and improve the safety of the care they provide. Safety

Thermometer data should also not be used for attribution of causation as the tool is patient

focussed.

Caveat: the information relates to community services overall.

New Pressure Ulcers

The trust reported 70 new pressure ulcers between September 2017 and September 2018.

The most number of new pressure ulcers was reported in August 2018 with 12 (1.44% prevalence

rate). However, the highest prevalence rate occurred in May 2018 with 2.55% (five new pressure

ulcers).

Many pressure ulcers are acquired by patients who were at the end of life. This is due to several

reasons, including reduced mobility as well as difficulties with nutrition and hydration.

However, it was unclear how many pressure ulcers had been acquired by patients at the end of

life. This was because information provided by the service following the inspection was unclear. In

addition, safety dashboards were not used for end of life services to highlight the total number of

patient harms that had occurred.

Members of the palliative care and the district nursing team had recognised this as an issue. As a

result, several awareness and training events had been organised for staff from both the Liverpool

and South Sefton areas.



Prevalence %

1.53 0.40 0.41 0.51 2.55 1.74 1.33 0.68 1.38 0.73 0.81 1.44 1.29

No 3 1 1 1 5 4 4 6 11 6 6 12 10

Catheter & UTI

The trust reported three catheter & UTI between September 2017 and September 2018.

The most number of catheter & UTI’s were reported between April and July 2018 with one each.



Prevalence %

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.11 0.00 0.12 0.13 0.00 0.00

No 0 0 0 0 0 0 0 1 0 1 1 0 0

Falls with Harm

The trust reported 67 falls with harm between September 2017 and September 2018.

The most number of falls with harm was reported in June 2018 with 17 (2.07% prevalence rate).

However, the highest prevalence rate occurred in September 2017 with 3.06% (six falls with

harm).


Prevalence %

3.06 1.59 0.00 0.00 1.53 0.43 0.00 1.25 0.88 2.07 1.48 0.12 0.77

No 6 4 0 0 3 1 0 11 7 17 11 1 6

Harm Free Care

The trust reported 6227 cases of harm free care between September 2017 and September 2018.

The most number of harm free care instances was reported in April 2018 with 847 (96.47%

prevalence rate). However, the highest prevalence rate occurred in December 2017 with 98.98%

(184 instances of harm free care).



Prevalence %

94.90 97.62 97.65 98.98 93.88 96.52 97.67 96.47 95.00 95.00 96.24 96.88 95.74

No 186 246 239 194 184 222 294 847 770 779 716 808 742


The trust had an incident reporting policy which was available to staff on the intranet. All clinical

and non-clinical incidents were recorded using an electronic incident reporting system. Staff who

we spoke with were aware of this policy and knew how to access the reporting system.

Staff who we spoke with could give us examples of types of incidents that they would report. This

included pressure ulcers, medication errors or anything that resulted in patient harm.

During the last 12 months, a total of 229 (Liverpool) and 120 (South Sefton) clinical and non-

clinical incidents had been reported concerning patients who were at the end of life, including

patients who were both known and not known to the palliative care team.

There was documented evidence that incidents that had been reported had been investigated and

that actions had been implemented to minimise the risk of a similar incident reoccurring as much

as practicably possible.

Members of the palliative care team informed us that they attended weekly ‘being open’ meetings

which were attended by staff from across community services. This allowed staff to share

examples of learning across different staff groups.

Minutes from the end of life steering group, which were held every two months, indicated that

incidents had been discussed and actions had been taken to make improvements when needed.

However, the service was unable to provide any themes or trends of incidents that had been


reported. This meant that it was unclear if the service had monitored this or always aware where

improvements needed to be made to help lower the risk of further incidents occurring.

Although the service had a system to review all unexpected deaths that had occurred within

community services, we had concerns that learning had not been facilitated by reviewing any

expected deaths that had occurred. This was important as it meant that there was a risk that

potential opportunities for learning had been missed.

However, we did note that the trust had recognised this as an area for improvement, and had

implemented a process for staff to report all expected deaths using the electronic incident

reporting system. Staff who we spoke with were aware that this had been introduced a week prior

to the inspection.

We reviewed minutes from mortality groups that had been held between July 2018 and the time of

inspection. Records indicated that these had been held every two months. Although there was

evidence that all unexpected deaths had been discussed, and in some cases learning had been

identified, there was no evidence of actions being implemented to make improvements. In

addition, it was unclear how learning from mortality reviews had been disseminated to all staff

when required.

We were not assured that Duty of Candour had been applied when needed. This was because

when we reviewed all incidents that had resulted in a moderate level of harm or above, we found

that not all incidents were included on a tracker that was used to identify the progress of each

stage of the Duty of Candour.

This is a legal duty on hospital trusts to inform and apologise to patients if there have been

mistakes in their care that have led to significant harm. The duty of candour aims to help patients

receive accurate truthful information from health providers.




In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents

(SIs) in end of life care services, which met the reporting criteria set by NHS England between

August 2017 and July 2018.

Serious Incidents – SIRI (trust Data)

Between 1 August 2017 and 31 July 2018, trust staff in this core service reported no serious

incidents.




The service followed the most up to date guidance when implementing policies and procedures,

including the Supporting Care Improving Outcomes guidance (National Institute for Clinical

Excellence, 2004), End of Life Strategy (Department of Health, 2015) as well as the Care of Dying

Adults in the Last days of life (National Institute for Clinical Excellence, 2017).

The service had responded to the Department of Health’s End of Life Strategy (2015) by

introducing advanced care planning. This is an approach used when the medical team are

uncertain if a patient will recover despite treatment being provided. It supports patients and

relatives to continue with treatment, but also facilitates discussion about their wishes for the future

if the treatment is unsuccessful.

The responsibility for advanced care planning was shared between the service and local GPs. The

service had introduced advanced care planning documents for staff to use when having

discussions with patients and relatives. However, we found that not all district nursing staff were

aware of these forms, or their responsibility to complete them.

In addition, the service had not made any arrangements to monitor the application of this. This

meant that it was unclear if advanced care planning was being completed consistently.

The palliative care team had responded to the review of the Liverpool care pathway in 2013 by

implementing an individual patient communication record which provided clear guidance for staff

when managing a patient at the end of life.

This document met the priorities of care of the dying person which had been set out by the

leadership alliance for the care of dying people. The key priorities are recognising and

communicating that a patient is dying, patients and those close to them are involved in all

discussions about their care, the needs of family members and others are considered when

providing care and an individual plan is implemented which considers food and drink, symptom

control, as well as psychological and spiritual support.

However, we noted that the individualised care plan had only been implemented in September

2018 as a standard document across both the Liverpool and South Sefton areas. This meant that

the service had not yet been able to assess the effectiveness of the document as the specialist

palliative care team were in the process of embedding this into the end of life education

programme that was being delivered to all district nursing staff.


The trust used a universal malnutrition scoring tool. This was used to identify patients who were at

risk of malnutrition. Compliance with this was monitored through internal audits and key

performance indicators.

We found that this had been completed for all patients whose records we reviewed. In addition, we

found that a referral had been made to a dietitian when needed. For example, on one occasion, a

patient had struggled to swallow and a referral had been made in a timely manner.


In response to the Liverpool Care Pathway being removed, a communication record had been

implemented to support staff when treating a patient at the end of life. Part of this record

considered the need for clinically assisted hydration which was used when patients were no longer

able to eat and drink normally.

The trust had a procedure to support staff to administer subcutaneous fluids when required. This is

where fluids can be administered by an injection into a patient’s skin to make sure that they remain

hydrated.

Records indicated that between November 2017 and November 2018, although 47 referrals had

been made for patients in the Liverpool area, only nine referrals had been made for patients at the

end of life in South Sefton. However, it was unclear if all patients had received a referral when

needed as this had not been measured.

We had concerns that nutrition and hydration had not always been discussed with patients and

families when needed. This was because results of an audit that had been completed in June

2018 indicated that this had only been discussed on 23% of occasions. The service had

recognised that improvements had been required, and had responded by including this topic as

part of the palliative care education package for all staff.

Pain relief

Both GPs and members of the palliative care team could prescribe pain relief for patients when

required. Several members of the palliative care team were nurse prescribers, which meant that

they could prescribe pain relief immediately when needed.

However, members of the night district nursing team informed us that they had not been trained as

nurse prescribers, meaning that they had to refer patients to a GP if they required pain relief to be

prescribed or needed further support out of hours.

The palliative care team also provided support and advice about the administration of pain relief

for patients at the end of life. In addition, the palliative care team provided pain management

support to all other patients in the community.

Staff from the district nursing team informed us that they used a pain scale of 1-3 to assess a

patient’s level of pain. Staff also informed us that an abbey pain tool was used on occasions when

needed. This is a tool that is used to help patients who are unable to communicate clearly to

express the amount of pain that they are in.

Appropriate medication for pain management was available for staff to use and anticipatory

prescribing was managed well. We reviewed a total of 17 records and found that patients who had

complained of pain had been given pain relief when needed.

However, pain scores had not always been documented clearly. This meant that it was unclear

how the effectiveness of the pain relief that had been administered had been measured.

An audit that had been completed in June 2018 indicated that 85% of patients had been pain free

at the time of death. This meant that pain relief had been prescribed and administered effectively

in these cases.


Patients and relatives that we spoke with confirmed that pain had been managed well.

Patient outcomes

The service had collected data to assess the efficacy of the treatment that they provided,

identifying areas that needed further improvement. Members of the palliative care team had been

actively involved in this process and were able to identify areas of both positive and negative

performance.

However, we had concerns that an audit that was completed in June 2018 had not captured

information from all parts of community services. This was because records indicated that all

records that had been reviewed had been for patients in the Liverpool area. This meant that it was

unclear how the service had monitored compliance with the provision of end of life care in the

South Sefton area.

Records indicated that results from a care of the dying audit (Liverpool and South Sefton) that had

been completed in June 2018 had varied.

Question % Compliance

1. Has the patient been referred to specialist palliative care? 38%

2. Was there evidence of specialist palliative care team involvement? 38%

3. Have patients and families been given information leaflets? 38%

4. Are the patients details complete? 85%

5. Are actual problems / symptoms documented? 54%

6. Has consent been obtained? 15%

7. Is the preferred method of communication completed? 15%

8. Has the preferred place of care been discussed? 85%

9. Has the preferred place of care been reviewed? 85%

10. Was recognition of dying discussed with the patient, family or carers? 85%

11. Did a discussion with the GP take place? 100%

12. Was the patient pain free at the time of death? 85%

13. Was the patient free of other symptoms at the time of death? 77%

14. Was the date and time of death recorded? 92%

15. Was the patient or family understanding of the care plan ascertained? 62%

16. Has the preferred place of death been achieved? 100%

17. Was a bereavement visit offered? 45%

18. Was a bereavement visit accepted? 20%

19. Did discussions take place with the families or carers about nutrition and hydration?

23%

20. Is there documented evidence that controlled drugs have been denatured in the patient’s home or returned to a community pharmacy?

62%


The service had acted against the findings of this audit. For example, the education programme

that was delivered to all members of the district nursing team had been strengthened and an

individualised care plan had been introduced to support staff when providing end of life care to all

patients.

In addition, the service had planned to re-audit this in January 2019, as well as measuring the

effectiveness of the individualised care plan that had been introduced.

Competent staff


As of July 2018July 2018, 94%94% of permanent non-medical staff within the end of life care core

service had received an appraisal compared to the trust target of 86%86%. Appraisals were

important as they allowed staff to discuss positive and negative aspects of their performance, so

that further improvements could be made.


Between 1 August 2017 and 31 July 2018, the average clinical supervision rate for the core

service was 0%. The trust did not have a target.

Team

Clinical

Supervision

Target

Clinical

Supervision

Delivered

Clinical

supervision

rate (%)

Liverpool Palliative Care Team 35 0 0%

South Sefton Palliative Care Team 18 0 0%

Core Service Total 53 0 0%

The trust had recently introduced an electronic system for clinical supervision to be recorded when

this had been completed. However, this system was not being used effectively at the time of the

inspection.

In addition, the service had not made formal arrangements for staff to receive clinical supervision

on a regular basis. Clinical supervision is important as it provides an opportunity for staff to

discuss patients who are on their case load and seek further support and advice if needed.

However, members of the palliative care staff informed us that there was informal access to a

clinical psychologist if they had any areas of concern that they wanted to raise. In addition, staff

informed us that they had regular conversations with consultants who specialised in palliative care

as well as GPs as part of the multidisciplinary team meetings that they attended on a regular

basis.

Members of the palliative care team were given opportunity to develop their knowledge and skills

so that they could provide more effective care and treatment. For example, most palliative care

nurses had completed a nurse prescribing course. In addition, one member of staff informed us


that they had been supported to complete a formal qualification in education as a main part of their

role was to deliver education about end of life care to other district nursing staff.

The palliative care team were committed to providing education about end of life care to all nursing

staff. This was available through both e-learning as well as face to face teaching.

We noted that the palliative care team in Liverpool had been funded to have an educator who was

responsible for co-ordinating training throughout the area, as well as developing education

programmes for staff. However, staff in the South Sefton palliative care team raised concerns that

they did not have a similar role, meaning that it was sometimes difficult to achieve everything that

they wanted due to operational demand.

Other key skills in end of life care were also delivered, including topics such as assessment and

care planning, pain and symptom control, advanced care planning and care of the patient in the

last days of life. However, we noted that the education programmes delivered by the Liverpool and

South Sefton team were different. This meant that there was a risk that the care delivered across

both areas would be different.

Records indicated that end of life care training had been delivered to 81% of staff in the Liverpool

area and 75% of staff in the South Sefton area. The management team informed us that they

aimed to have delivered training to 95% of staff in both the Liverpool and South Sefton areas by

the end of December 2018.

Verification of expected death training had been delivered to 66 members of nursing staff across

the district nursing teams. This included 46 members of day staff and 20 out of hours staff.


The palliative care team were involved in several multidisciplinary team meetings, working

collaboratively with staff throughout the community. The palliative care team told us that providing

care and treatment for patients at the end of life was everybody’s responsibility. District nursing

staff throughout the service spoke highly of the palliative care team and found them to be

accessible and supportive.

Members of the palliative care teams worked closely with district nurses. For example, the

palliative care nurses visited staff bases on a regular basis. This was important as it allowed

members of the palliative care team to have discussions with district nurses about their caseload

on a regular basis as well as providing an opportunity to share information when needed.

However, it was not always clear when district nursing staff should refer a patient to the palliative

care team. This was because although there was an end of life policy, there was no clear criteria

for a referral to be made and meant that there was an increased risk that patients would not

always be referred to the palliative care team when needed.

District nurses attended gold standard framework meetings, which were held by GPs across both

the Liverpool and South Sefton areas. These meetings were important as they supported staff to

coordinate patients care and effectively. However, we were informed that the application of the

gold standard framework meetings was sometimes inconsistent. This was because some GPs

held the meetings every two weeks, and others held them every quarter.


Members of the palliative care team attended meetings and worked closely with local hospices in

both the Liverpool and South Sefton areas on a weekly basis. This provided an opportunity to

discuss patients who were known to the hospices. We attended one of these meetings, finding it to

be well attended by staff from the hospice, allied health professionals, such as physiotherapists as

well as cancer nurses.

There was access to a variety of district nursing teams, including occupational therapy, dietetics,

physiotherapy as well as speech and language therapy who were available between Monday and

Friday, during normal working hours. Staff who we spoke with were aware of these teams and

knew how to make a referral when needed.

However, one patient informed us that there had been a delay in receiving a visit from the

continence team which meant that they had to buy products themselves in the meantime. We

noted that this was because each member of staff in the continence team had a high caseload,

meaning that they had not always been able to assess patients in a timely manner.

Staff informed us that information had not always been shared effectively between hospitals and

the district nursing team when a patient had been discharged home. This meant that there was an

increased risk that the most up to date patient information had not always been available.

However, members of the palliative care team in the South Sefton area had worked with a local

trust to put together a ‘safe transfer’ checklist so that staff knew what was required to undertake a

safe transfer.

Health promotion

Staff across the community service encouraged patients to make healthy lifestyle changes and

promoted ways for patients to manage their own health. This included referrals to smoking

cessation services and wellbeing services.

We observed occasions when staff had recognised that relatives had needed support so that they

were able to continue to care for patients at home. This included making referrals to external

services that could provide support at night time, enabling relatives to get some rest. However,

staff informed us that there had sometimes been delays in accessing these services.


The trust had a consent to capacity and treatment policy which was in date and was available for

staff to access on the intranet. Some staff were aware of this and knew how to access it.

Staff who we spoke with were not always clear about the need to document when they had

obtained consent from a patient. We reviewed six sets of records, finding that consent had not

been documented on two occasions. In addition, an audit that had been undertaken in June 2018

indicated that consent had been documented correctly on 15% of occasions.

Staff informed us that decisions about mental capacity were made by a GP or a member of

medical staff on occasions when a patient had been admitted to hospital.

However, staff were not always aware about the principles of mental capacity and when a full

mental capacity should be undertaken. For example, during a home visit that we attended, we


observed that a patient had reduced mental capacity to decide about their own care and

treatment. Although it had been noted from a previous visit that the patient had capacity, the

patient’s condition had changed but a referral was not made to a GP so that an assessment could

be undertaken.

We reviewed four do not attempt cardiopulmonary resuscitation orders, finding that these had not

been discussed with the patient on two occasions. On one of these occasions, the do not attempt

cardiopulmonary resuscitation order had not been discussed with the patient as they had

fluctuating capacity at the time the decision had been made (this is when a patient’s capacity is

reduced for a short period of time due to several reasons, including an acute episode of illness).

Records indicated that although the patient had regained capacity, this had still not been reviewed

with the patient. This meant that there was a risk that care and treatment would not reflect the

patient’s wishes.

Although do not attempt cardiopulmonary resuscitation orders were implemented and discussed

with patients and relatives by GPs or medical staff, the service had not monitored compliance with

the correct completion of do not attempt cardiopulmonary resuscitation orders in community

settings. This was important as there was a risk that areas of poor compliance would not be

identified, particularly as staff did not always understand their responsibility to challenge a decision

that had been made when needed.

We did note that an audit of compliance on ward 35 (a community inpatient ward) had been

completed in October 2018 measuring the correct completion of do not attempt cardiopulmonary

resuscitation orders. However, the sample size of this was small as it only captured three patient

records.


Mersey Care NHS Foundation Trust told us that 97 Deprivation of Liberty Safeguard (DoLs)

applications were made to the Local Authority between 1 August 2017 and 31 July 2018. None of

these were pertinent to end of life care services.



Compassionate care

The palliative care and district nursing teams were committed to providing high quality,

compassionate care. Palliative care team members were proud of the type of service that they

provided and were keen to maintain high standards of care at all times.

We saw examples of positive interactions between staff and patients who were at the end of life.

Conversations were had in a sensitive and respectful manner. Patients and relatives that we

spoke to were keen to tell us that their own experience had been similar.

We spoke to 10 patients and relatives. Comments included ’we are extremely happy with the care

that we are getting’ and ‘we are more than happy, we can’t fault it and that staff are very helpful’.

The chaplain had planned to measure patient experience as this was not currently being done.

Staff informed us of several situations when they felt that staff had gone ‘the extra mile’ to care for

patients and relatives. For example, on one occasion staff had committed to looking after a

patient’s dog during their admission to hospital. This meant that the dog was still at the patient’s

home address when they had discharged and staff informed us how much of a difference that this

had made in the days before the patient had passed away.

On another occasion, staff informed us about an incident when they had struggled to secure

continued healthcare funding for a patient who did not have many possessions. All staff helped to

raise money so that they could buy the patient several basic items which enabled them to stay at

their home address.

Staff could tell us how they cared for the deceased, ensuring that dignity was maintained after

death. However, there was sometimes limited evidence documenting what actions had been taken

after a patient had passed away. For example, staff had not always documented if medical

devices such as cannulas (a plastic tube which is inserted into a vein to administer medication)

had been removed.

There had been a small number of concerns raised by relatives that district nurses had not

attended a home address in a timely manner to care for a patient who had passed away. Members

of the management team informed us that these incidents had been because of operational

demand.

Emotional support

The emotional requirements of patients were considered as part of the individual communication

record that was used when it had been recognised that a patient was at the end of life. We

reviewed a sample of records and found that there had been a regular reassessment of patient’s

needs completed which included nutrition, hydration, pain relief, personal hygiene and anxiety on

all occasions.


Staff gave us examples of when they had supported patients and relatives through difficult

situations. For example, we were informed about one occasion when a patient had become

increasingly agitated. Staff had ensured that the patient had remained at home by supporting extra

visits which supported the patient’s relatives as well as the patient.

Staff informed us that psychology services could be accessed through local hospices or GPs to

support patients and relatives when needed.

However, records indicated that bereavement support had only been available to a small number

of families after a patient had passed away. A care of the dying audit that had been undertaken in

June 2018 indicated that only 45% of families had been offered bereavement support as well as a

bereavement visit following a patient’s death. In addition, only 20% of the families had accepted a

bereavement visit.

The trust employed a chaplain. However, staff were unable to easily access this service. This was

because access to the chaplain by community services had not been agreed since the services in

Liverpool and South Sefton had been acquired. Staff liaised with patient’s own churches and

organisations to meet the patient’s individual spiritual needs. In addition. On occasions, advice

from local hospices had been sought by referring patients to the service when needed.


Palliative care team members and other staff communicated with patients and relatives in a way in

which they understood. Patients and relatives that we spoke to confirmed this to be the case.

Records that we reviewed showed that patients and relatives were involved in their own care and

treatment. Treatment options that were available were discussed and patients were given the

choice of how they wanted their care to proceed.

At times when it was uncertain if patients would recover despite treatment being provided,

conversations were had so that patients had a choice, for example, what their preferred place of

care would be in the event of further deterioration. These discussions were supported using

standardised documentation such as individualised care plans.

Advice leaflets were available for staff to give to relatives which answered frequently asked

questions and gave advice about important topics such as the dying process and what to expect,

medication as well as support and contact details for several different organisations.

Other information was also available which provided practical advice to relatives about what

actions to take when a patient had passed away. This included an overview of how a death is

verified as well as who to contact.




The service worked closely with GPs and other multidisciplinary teams to identify patients who had

a life limiting illness and were in the last 12 months of life as early as possible. This was important

as it allowed time for staff to communicate and plan care and treatment with patients and their

relatives.

Members of staff from the palliative care team informed us that they had introduced training to all

staff so that they were able to verify the expected death of a patient. This was introduced as GPs

had sometimes taken a long time to attend a home address after a patient had passed away.

Although a high number of district nurses had received training to verify a patient’s death, some

staff informed us that they did not feel confident to do this. In addition, nursing staff were not

always available to attend a patient’s home immediately after they had passed away. We reviewed

11 patient records for patients who had passed away, finding that a GP had verified a patient’s

death on all but one occasion, which meant that this system of nurses verifying a patient’s death

was not yet fully effective.

Advanced care planning was discussed as part of gold standard framework meetings that were

coordinated by GPs in both the Liverpool and South Sefton areas. Advanced care planning is

important as it gave patients the opportunity to discuss how they would like their care to look as

their illness progressed.

However, it was unclear about whose responsibility it was to complete advanced care plans.

Although we saw some evidence on electronic records that this had been considered, it was

unclear about what the responsibilities of district nurses were in this process. The service had

developed advanced care planning documents, but we did not see any evidence of these having

been completed in any patient records that we reviewed.

We did note that advanced care planning had been added to the end of life care education

programme that was delivered to all staff.


The management team had introduced a care after death section as part of a patient’s

individualised care plan. This included important information such as if the patient’s GP had been

informed of the patient’s death as well as if verbal and written advice about next steps had been

given to the patient’s relatives or carers.

However, we found that this had not been completed on nine out of 11 occasions. This meant that

it was unclear if staff had followed the care after death standard operating procedure fully, and

more importantly, it was unclear if support had been provided to relatives when needed.

The service had introduced advice leaflets to give to relatives after a patient had passed away.

This was important as it provided information about the next steps, including the removal of


equipment and medicines from their home as well as practical advice about what to expect from

funeral directors and how to collect a death certificate.

Staff had not received training on the management of patients in line with cultural preferences or

differences. However, staff informed us that they worked in collaboration with family members and

relatives so that they could meet the needs of patients. Chaplaincy services were accessed

externally when required as staff informed us that arrangements to access the chaplain who was

employed by the trust had not yet been agreed.

Specialist services, such as psychological support and bereavement services were accessed

through local hospices. Staff knew what services were available and how to access them.

Members of the palliative care team informed us that they had encountered problems in accessing

services for patients who had mental health problems. We were informed that although patients

received an initial assessment, follow up appointments had not always been undertaken in a

timely manner. This meant that it was unclear if the needs of patients who had mental health

problems had always been met.

There was access to a language line which provided translation services for patients and relatives.

The trust had undertaken an audit on the use of this system and records indicated that between

April and July 2018, 93% of face to face requests had been fulfilled when needed. There was also

24 hours a day, seven days a week access to sign language interpreters.

The trust had introduced dementia awareness training which was available to all staff. However,

records from July 2018 indicated that only 17% of palliative care staff had completed this.


Between November 2017 and October 2018, the trust had reported 4,648 deaths. Records

indicated that during the same period, the palliative care teams in both Liverpool and South Sefton

had received a total of 2,081 referrals (45% of occasions).

The palliative care team planned to triage all referrals within 24 hours and to clinically review all

patients within 72 hours. In addition, the palliative care team planned to triage all urgent referrals

within four hours However, the service had not monitored these targets. This meant that it was

unclear if the palliative care team had triaged patients in a timely manner.

Members of the management team informed us that there had been occasions when urgent

referrals had not been triaged in a timely manner. This was because staff had labelled the referral

as non-urgent on the electronic records system.

Referrals to the specialist palliative care team were made by several healthcare professionals,

including district nurses and GP’s. We reviewed five initial assessment forms that had been

received, finding that they had been managed in a timely manner. Initial assessments included

diagnosis, psychological and spiritual assessment, complex social needs as well as medication

and preferred place of care.

We did note that staff who we spoke with informed us that they had found the palliative care team

to be responsive and that they had not had any problems when they had needed to seek advice.


There was a team of district nurses who provided cover at night time. This included supporting

patients who were at the end of life. The night team had access to syringe drivers if a patient

deteriorated, meaning that they could administer anticipatory medicines if required.

However, members of staff informed us that they were not always able to deliver treatment in a

timely manner as they had to cover a large geographical area. There had been a small number of

incidents reported when there had been a delay in treatment or a visit had not been facilitated by a

member of the out of hours team when needed.

An audit had been undertaken in June 2018, which identified that 85% of patients had achieved

their preferred place of care. However, we noted that this audit only covered the Liverpool area.

This meant that it was unclear if this had been achieved for patients in the South Sefton area.

Records indicated that between April and November 2018, the service had supported

approximately 200 urgent discharges for patients who were at the end of life in the Liverpool

locality. Urgent discharges had been supported by the community assessment team who liaised

with staff from a hospital as well as members of the palliative care team when needed. However, it

was unclear how many urgent discharges had been facilitated in the South Sefton locality as this

information had not been recorded.

Staff informed us that there had been difficulties in accessing appropriate places of care on

occasions when a patient had deteriorated and could not remain at home safely. For example, in

the Liverpool area, access to funded beds in local hospices were no longer available. This meant

that some patients were managed in beds that did not always suit their needs or preferences. For

example, on occasions, only nursing home beds had been available.

The district nursing and specialist palliative care teams could make referrals to an external charity

which provided a night sitting service which was used to support relatives who needed support.

This service was also available to visit to support patients with personal care. However, this was

only available in the Liverpool area, and was not offered in the South Sefton area.

In addition, district nursing staff informed us that patients sometimes had to wait for up to 12

weeks to access this. Also, this service was only available for up to 12 weeks. Staff informed us

that there was no time in their caseloads to fit these patients in when the care had finished and

therefore patients could wait months to be seen. We raised this with management at the time of

inspection who informed us that this had not been monitored.

Records indicated that there had not always been timely access to occupational therapy services.

Although that there had been an increase in the number of referrals for patients at the end of life,

the occupational therapy team had not always had sufficient staff to meet the needs of patients.

Records indicated that between April 2018 to November 2018, patients had waited an average of

2 weeks to be seen by a member of the team. Although staff informed us that they aimed to see

patients within a week of referral, it was unclear if there was a formal standard for this.

An audit of avoidable hospital admissions for the South Sefton area had recently been completed.

This audit reviewed the arrangements that had been in place on occasions when hospital

admission had been potentially avoidable. Records indicated that 13 out of 20 patients did not

have a care package, 17 out of 20 patients did not have an advanced care plan and 11 out of 20


patients had not been prescribed anticipatory medicines. However, the audit report had not

identified if any of these factors had resulted in avoidable admissions.

Accessibility

The largest ethnic minority group within the trust catchment area is White other with 1.75% of the

population.

Ethnic minority group

Percentage of catchment population (if known)

First largest White Other 1.75

Second largest Chinese 0.8

Third largest Other 0.7

Fourth largest Black African 0.7

Waiting times

There is no information pertaining to end of life care services.

The trust has identified services as measured on ‘referral to initial assessment’ and ‘assessment to

treatment’. However, there is no data pertaining to end of life care services.


The trust had an up to date complaints policy which was available to all staff on the intranet. The

policy highlighted that an initial response to a complaint had to be made within three working days

and that a full response was required within 25 working days for straight forward cases and 40

working days for more complex cases.

There was a trust wide complaints team who were responsible for co-ordinating any complaints or

concerns that had been received from patients or relatives.

Complaints

End of life care received four complaints between 1 August 2017 and 31 July 2018.

Total Complaints

Fully upheld Partially upheld Not upheld Referred to

Ombudsman Upheld by

Ombudsman

4 1 2 1 0 0

During the inspection, we reviewed all four complaints that had been made, finding that there had

been two occasions when the response time of 40 working days had not been met. The service

had taken 49 and 62 working days respectively to resolve the complaints. Holding letters had been

sent to inform the complainant that there would be a delay in responding to the complaint, which

was in line with trust policy.


In addition, records indicated that the service had received seven concerns from relatives about

the end of life care that had been provided. These had not escalated to a full complaint as they

had been managed locally by a member of the management team. However, it was unclear on

reviewing these what action had been taken to feed any learning back to staff.

For example, one concern had been raised in October 2018, raising concerns that poor

documentation by a member of the district nursing team had delayed the coroner in issuing a

death certificate. There was no documented evidence of what action had been taken to learn from

this concern.

Compliments

The trust received 157 compliments during the last 12 months from 1 August 2017 and 31 July

2018. Nine of these related to end of life care, which accounted for 6% of all compliments received

by the trust.



Leadership

The community nursing division, including both palliative care teams had a clear leadership

structure. Community services were run using a locality based model, which meant that all

services in an area had been run by a designated leadership team. Each locality had an associate

director, a clinical lead, a care manager and a governance manager.

Because of this model, both palliative care teams were run under different localities. This was

important as up until the time of inspection, both teams had operated differently. In addition, the

trust had acquired the South Sefton palliative care service in June 2017. The Liverpool palliative

care team had only been acquired in April 2018.

Both staff from the district nursing and the palliative care teams informed us that the locality

leadership teams had not always been visible. However, staff also informed us that the care

managers and clinical leads had become more visible in recent months.

It was unclear if the trust had identified a member of the executive or non-executive team to have

responsibility for overseeing the delivery of end of life care. Although, the trust informed us

following the inspection that there was an executive lead, we did not see any documented

evidence of this being the case on reviewing executive’s portfolios. In addition, staff who were

responsible for delivering end of life care were not aware that there was an executive lead for the

service.

The trust had also employed a part time GP who was the clinical lead for end of life services. They

chaired both the end of life steering group which was held bi-monthly as well as the clinical

effectiveness sub-committee which was held for all district nursing community services. We noted

that between June 2017 and April 2018, the South Sefton palliative care team had not had a

clinical lead. Staff informed us that during this time, end of life services were nurse and GP led.

In addition, both palliative care teams had a team leader, who were responsible for coordinating

the provision of end of life care services on a day to day basis.

Vision and strategy

The trust had an overall vision, which was ‘our services, our people, our resources and our future’.

This was supported by an operational plan for 2018/2019. However, the plan only included the

South Sefton area. Key priorities for this period included to reduce the number of community

acquired pressure ulcers to zero as well as to reduce staff sickness to 6%.

The service’s main objectives were to actively promote best evidence end of life care, optimize

pain control for patients at the end of life, effectively manage patient symptoms at the end of life,

support patients to die in their preferred place of care, support carers and relatives within the

bereavement stage and to educate other clinicians.

Although both localities did not have a formal vision or strategy for end of life services, members of

the palliative care teams were able to tell us what their main priorities were. We were informed that


these had been aligned to the strategy for both the North West palliative care network and local

care commissioning groups. However, at the time of the inspection it was unclear how these would

be achieved as the service were in the process of developing an implementation plan so that

these priorities could be actioned.

The trust had undertaken a full-service review of the provision of end of life services in the South

Sefton area in May 2018. This had been completed by the palliative care team leader and had

been submitted to the trust board for review. However, this had not yet been undertaken for the

Liverpool area.

We noted that prior to a service review being undertaken, the service had developed an action

plan to make improvements to the provision of end of life services. We reviewed this, finding that

15 out of 26 actions had been completed. However, two actions did not have timescales for

completion. This meant that there was an increased risk that improvements would not be made in

a timely manner.

The service review had identified several recommendations to make further improvements to the

provision of end of life services. This included gaining wider access to bereavement support

services, develop formalised medical support, to develop workforce plans to match the increased

number of referrals and bed shortages in the South Sefton area.

However we noted that during this inspection, an action plan to make the improvements that had

been identified in the service review six months earlier had not yet been created. This meant that it

was unclear how and when the improvements would be made.

Culture

The palliative care team were very proud of the work that they had done. They were focused on

providing the best possible care and meeting the needs of the people that used the service.

We found there to be an open and honest culture within the service. Members of the palliative care

team informed us that they felt supported in reporting incidents. The palliative care team were

keen to learn and make further improvements when required.

District nursing staff spoke highly of the palliative care teams in both Liverpool and South Sefton.

They informed us that they had always been accessible and supportive.

However, some staff who we spoke with informed us that they had not always been able to trust

senior managers throughout the service and felt that there was still a blame culture. Some staff felt

that they had not always felt confident to raise issues when they arose. Although staff recognised

that there had been some improvements, they felt that further improvements were still required.

The trust had a freedom to speak up guardian. However, most staff who we spoke with were

unaware of this and did not know how to contact them if needed. A freedom to speak up guardian

is a designated member of the executive team who staff can contact anonymously about issues

that they have. This is particularly important for staff who do not feel that they can raise concerns

with a manager directly.


The executive team had recognised the need for further improvements and were in the process of

aligning all community services to the trust’s way of working. For example, the trust had

encouraged joint working between senior managers from each locality. This had been aimed at

both improving working relationships as well as sharing best practice and learning.

The trust had a lone working policy which was available to all staff on the intranet. Staff who we

spoke with were aware of this and knew how to access it. We observed staff using lone worker

devices correctly before entering each patient’s home address. In addition, all staff had access to

a panic alarm in case of an emergency and knew how to use this if needed.

However, members of the management team informed us that not all of these worked when

needed. This meant that there was a risk that staff would not always be able to seek immediate

help in the case of an emergency.

Governance

The service had a governance structure which allowed information to be shared between palliative

care services, some members of the senior management team as well as external stakeholders

and providers. However, we had concerns that members of the senior leadership team did not

always have an oversight of end of life services.

An end of life steering group meeting was held every two months and was attended by members

of the Liverpool and South Sefton palliative care teams. The meeting was chaired by the GP lead

for end of life services.

We reviewed minutes from the last three end of life steering group meeting minutes, finding that

there had been a small number of actions that required escalating to the divisional clinical

effectiveness group. Records indicated that all issues that had been identified at this meeting had

been discussed and actioned appropriately.

Both meetings had action logs which documented an owner who had responsibility for completing

actions as well as a timescale for completion. There was documented evidence that an updated

action log had been discussed at every meeting so that agreed actions were monitored for

completion.

However, it was unclear how issues that had been identified about end of life services in the

clinical effectiveness group meetings had been escalated to the senior leadership team for the

community division. This was because there was no documented evidence that end of live

services had been discussed as part of divisional governance meetings, meaning that there was

an increased risk that the senior leadership team would not always be aware of issues that were

faced when delivering end of life services.

The terms of reference for senior leadership team meetings indicated that although different staff

from across community services were required to attend this meeting, a representative from the

palliative care team had not been identified as a member of the meeting. In addition, on reviewing

the agendas and associated papers for the last four senior leadership team meetings that had

been held, there was no evidence that end of life care had been discussed.


Monthly palliative care team meetings had been planned in the Liverpool and South Sefton

localities. Between May and November 2018, records indicated that only four out of seven planned

meetings had taken place. Staff informed us that this was due to operational demand. Team

meetings are important as it provides an opportunity for staff to share learning, discuss any issues

that they may have as well as escalating areas of risk when needed.

Records that were provided following the inspection indicated that some palliative care team

meetings had taken place. However, minutes from these meetings did not always have

documented actions on occasions when issues had been identified. This meant that it was unclear

of how improvements would be made and how the completion of actions would be monitored.

The trust had an overall business continuity plan which was in date. This was important as it

provided guidance for staff on what actions to take in the event of increased operational demand.

Team leaders had completed a business continuity plan in November 2018 (prior to our

inspection) relating to patients who were at the end of life in both the Liverpool and South Sefton

areas. However, we noted that business continuity training had not been provided to staff.


The trust had an incident reporting and risk management strategy which was available to all staff

on the intranet. Members of the management team were aware of this and knew how to access it.

Members of the palliative care team were aware of how to escalate risks that were faced by the

service so that actions could be put in place to reduce the risk as much as practicably possible.

Palliative care team leaders informed us that all risks would be escalated to a care manager in

either the Liverpool or South Sefton localities.

We had concerns that not all risks for end of life services had been identified, which meant that

there was an increased risk that appropriate controls were not in place to manage these

effectively. This was because that on reviewing the risk register, we found that there had not been

any risks listed which were specific to end of life services.

Members of the management team informed us that some risks that had been included on the risk

management system for district nursing services had an impact on the effective provision of end of

life services. For example, although staffing and skill mix had been included, there were no actions

in place to manage the impact of this on end of life services.

In addition, we identified some risks during the inspection that had not been included on the risk

management system. This included the failure of staff to follow the trusts policies and procedures

in making sure that controlled drugs had been destroyed in line with legislation. Members of the

management or executive team were unaware of this risk until we formally raised our concerns

following the inspection.

The palliative care teams had some systems in place to make sure that they had oversight of any

issues that were faced in the delivery of end of life services so that improvements could be made

when needed. For example, members of the management team informed us that all reported

incidents had been reviewed during end of life steering group meetings. We reviewed minutes

from these meetings, finding that incidents had been discussed and that actions had been

implemented to reduce the risk of similar incidents happening again.


In addition, the palliative care team in both Liverpool and South Sefton had implemented some

audits to measure compliance against best practice guidance as well as trust policies and

procedures. An audit meeting had been held every two months to discuss any audits that staff had

proposed to undertake, which included local audits and others that were led by external

organisations such as the North West palliative care network. However, we were not assured that

these had been done in a way which provided oversight of all end of life services.

For example, a care of the dying audit that had been undertaken in June 2018 had only included a

records sample from the Liverpool area. This meant that the care that had been provided in the

South Sefton area had not been monitored and it was unclear if all areas for improvement had

been identified.

At the time of inspection, the service had only planned to review all unexpected deaths. Minutes of

meetings indicated that these had been discussed when completed. However, we had concerns

that learning from all deaths had not taken place as expected deaths had not been reported on the

incident reporting system and none of these had been reviewed to identify potential learning.

The senior management team informed us that the trust had recognised this as an area for

improvement and that they had planned to review all expected deaths going forward. Members of

the palliative care team informed us that they had been asked to be involved in these meetings on

a regular basis.


Information dashboards were used to monitor some community services and we found that this

information was reviewed by staff at different levels. However, members of the palliative care team

informed us that they had not always recorded information in a way that had been effective in

providing an oversight of the provision of end of life care. For example, key performance targets

such as how long it had taken a member of the palliative care team to triage a patient had not

been measured. This meant that there was an increased risk that members of the senior

management team did not always have oversight of all issues that were faced by end of life

services.

Members of the palliative care team informed us that they had made plans to introduce an end of

life care dashboard so that all information could be monitored more effectively.

However, we did note that some information had been used in a way to make improvements to the

service. For example, information from incidents that had been reported and results from audits

that had been completed had been used to make further improvements to end of life services.

The service used paper records and an electronic management information system for patient

records. There was a sharing agreement in place for access to patient information from external

healthcare providers such as GP’ who used the system for patient records and information. Staff

had access via login details and passwords.

Engagement


All community staff had been given the opportunity to take part in the annual friends and family

test survey. However, the results were not specific to end of life services. In addition, we were

informed that a low number of staff across community services had taken part in this.

The service did not have a system which allowed patients and relatives to provide feedback about

the care that they had received. This meant that there was an increased risk that areas for

improvement had not always been identified. However, the service had identified this shortfall and

the management team had made plans for this to be done in the future.

We did note that members of the management teams at different levels had developed ways in

which to communicate with all staff throughout the trust in several ways. This included emails,

newsletters as well as a webpage which allowed staff to ask the chief executive questions.


The trust had undertaken several service reviews across the community division so that

improvements could be made. Records indicated that although a service review of the South

Sefton palliative care team had been undertaken, actions from this had not yet been implemented.

In addition, a service review of the Liverpool palliative care team had not been undertaken. It was

unclear if the trust had planned for this to be done.

The executive team had recognised that the South Sefton and Liverpool palliative care teams had

worked separately up until April 2018. We were informed that although there had been occasions

when both palliative care teams had worked together, plans had been made to standardise the

service fully. However, it was unclear when this would be achieved.

Members of the palliative care teams in both Liverpool and South Sefton were committed to

making improvements to the provision of end of life services and attended several internal and

external meetings so that improvements could be made to the service locally.

For example, the service had worked with external providers to make some improvements when

needed. For example, members of the palliative care team had worked with local hospitals to

develop a safe discharge pathway for patients who were at the end of their life.

Accreditations

NHS Trusts can participate in several accreditation schemes whereby the services they provide

are reviewed and a decision is made if to award the service with an accreditation. A service will be

accredited if they are able to demonstrate that they meet a certain standard of best practice in the

given area. An accreditation usually carries an end date (or review date) whereby the service will

need to be re-assessed to continue to be accredited.

The trust prided a list of services, which have been awarded an accreditation together with the

relevant dates of accreditation. However, there was no information pertinent to end of life care

services.

Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age

Community-based mental health services for adults of working age


Location site name Team name Number of clinics Patient group (male,

female, mixed)

Baird House Community Hub

CMHT - Arundel

/ CMHT

Windsor House

100 Mixed

Northwood House CMHT - Kirkby 16 Mixed

Moss House CMHT - Moss

House 64 Mixed

Norris Green CMHT - North

Liverpool 84 Mixed

Park Lodge CMHT - Park

Lodge 68 Mixed

SSNC CMHT - South

Sefton (SSNC) 140 Mixed

Hesketh Centre CMHT – North

Sefton 87 Mixed

Morley Road

DISH

(Supported

Living Services)

Crosby

Not provided Not provided

Rathbone Eating Disorder

Daily Therapy Session

1:1 and Groups as

required

Mixed

Royal Hospital

Hospital Mental

Health Liaison

Team - RLUH

N/A Mixed

Baird Innovation Park HOT Team 8 Mixed

3 separate locations Talk

Liverpool

7 New Hall - L10 1LD

151 Dale Street - L2 2AH

St Andrews Business Centre

91 St Marys Road L19 2NL

IAPT (Talk) 791 Mixed

Haigh Road Psychotherapy N/A Mixed

Clock View

Single Point of

Access-

Clockview

N/A Mixed


Location site name Team name Number of clinics Patient group (male,

female, mixed)

Hesketh Centre

Single Point of

Access-

Hesketh

N/A Mixed



Safe and clean environment

Staff did regular risk assessments and audits of the environment. All of the locations we visited

were clean and had good furnishings. Interview rooms were fitted with alarms. The clinic rooms

were clean and had the necessary equipment needed to carry out physical examinations. We saw

that equipment had been checked regularly.

Each location had a cleaning schedule and cleaning records were up to date. Staff adhered to

infection control principles including handwashing. There were robust infection control audits and

policies in place.

Safe staffing

Park Lodge and North Sefton CMHTs had enough staff, who knew the patients and had received

basic training to keep people safe from avoidable harm. However, at Moss House there were three

vacancies for mental health practitioners and three staff that were absent due to sickness. This

had resulted in increased workloads for the remaining staff. Recruitment was taking place and

managers had agreed to remove Moss House staff from weekend duties for a period of two

months to allow for increased cover during core hours.

There were enough medical staff at each location. The service used locums to cover vacancies.

The trust acknowledged that the use of locums had been a particular issue at Moss House. All

patients had access to psychiatry and patients were seen within 24 hours in an emergency.

Managers assessed the size of individual staff caseloads regularly and helped staff to manage

them. Staff told us that their caseloads were manageable and included patients on stepped up

care.




Definition




Total number of substantive staff At 31 July 2018 690.9 N/A

Total number of substantive staff leavers 1 August 2017–31 July 2018

73.5 N/A

Average WTE* leavers over 12 months (%) 1 August 2017–31 July 2018

11% N/A




Total vacancies overall (excluding seconded staff) At 31 July 2018 -1.3 N/A

Total vacancies overall (%) At 31 July 2018 -3% 5%

Total permanent staff sickness overall (%)

Most recent month (At 31 July 2018)

6% N/A

1 August 2017–31 July 2018

5% N/A


Establishment levels qualified nurses (WTE*) At 31 July 2018 30.3 N/A

Establishment levels nursing assistants (WTE*) At 31 July 2018 2.2 N/A

Number of vacancies, qualified nurses (WTE*) At 31 July 2018 1.1 N/A

Number of vacancies nursing assistants (WTE*) At 31 July 2018 -1.2 N/A

Qualified nurse vacancy rate At 31 July 2018 4% 5%

Nursing assistant vacancy rate At 31 July 2018 -55% 5%

Bank and agency use


(qualified nurses) 1 August 2017-31 July

2018 6410 N/A

Hours filled by agency staff to cover sickness, absence or vacancies

(Qualified Nurses) 1 August 2017-31 July

2018 956 N/A

Hours NOT filled by bank or agency staff where there is sickness,

absence or vacancies (Qualified Nurses) 1 August 2017-31 July

2018 3195 N/A

Hours filled by bank staff to cover sickness, absence or vacancies

(Nursing Assistants) 1 August 2017-31 July

2018 4043 N/A



2018 22 N/A


absence or vacancies (Nursing Assistants) 1 August 2017-31 July

2018 196 N/A

*Whole-time Equivalent / minus figures mean they are oversubscribed

This core service reported an overall vacancy rate of 4% for registered nurses at 31 July 2018.

This core service reported an overall vacancy rate of -55% for registered nursing assistants.

This core service has reported a vacancy rate for all staff of -3% as of 31 July 2018.

Registered nurses Health care assistants Overall staff figures

Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)


Eating Disorders 0 0 0 0 0 0 -1.2 9.5 -13%

Kirkby CMHT 1.3 7.7 17% 0 0 0 1.3 9.3 14%

Moss CMHT -1.0 12.6 -8% 0 0 0 -1.0 12.6 -8%

North Liverpool CMHT 0.8 10 8% -1.2 2.2 55% -0.4 12.2 -3%

Core service total 1.1 30.3 4% -1.2 2.2 55% -1.3 43.6 -3%

Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%

NB: All figures displayed are whole-time equivalents

Between 1 August 2017 and 31 July 2018, bank staff filled 6410 hours to cover sickness, absence

or vacancy for qualified nurses.

In the same period, agency staff covered 956 hours for qualified nurses. Three thousand, one

hundred and ninety-five hours were unable to be filled by either bank or agency staff.

Team Available hours Hours filled by bank

staff

Hours filled by

agency staff

Hours NOT filled by

bank or agency staff

Baird House

Community

Hub 1304 1178 956 326

Moss CMHT 2053 379 0 163

CMHT - North

Liverpool 5931 657 0 847

Kirkby CMHT 1092 875 0 114

CMHT - South

Sefton (SSNC) 5812 623 0 344

CMHT -

Arundel /

CMHT

Windsor

House 3357 1033 0 587

Post

Diagnostics Nr 326 616 0 0

Psychotherap

y 1466 175 0 163

Community

MH Team

North Sefton 1781 24 0 163

Single Point of

Access 0 408 0 0

Single Point of

Access 0 191 0 0

Spa/Patient

Flow 3161 164 0 489



staff

Hours filled by

agency staff

Hours NOT filled by


Exec Nursing 815 88 0 0

Core service

total 27097 6410 956 3195

Trust Total 242318 125599 64603 31532

Between 1 August 2017 and 31 July 2018, bank staff to cover sickness, absence or vacancy for

nursing assistants filled 4043 hours.

In the same period, agency staff covered 22 hours. 196 hours were unable to be filled by either

bank or agency staff.


staff

Hours filled by

agency staff

Hours NOT filled by


Liv Health And

Wellbeing 358 318 0 196

CMHT - North

Liverpool 1304 24 0 0

CMHT - South

Sefton (SSNC) 1716 16 0 0

DISH (Brook

Road West) 0 382 0 0

DISH

(Cavendish

Road)

0 361 0 0

DISH

(Glenwylynn

Road)

0 332 0 0

DISH (Regent

Road, Crosby) 0 126 0 0

DISH

(Moorgate

Avenue)

0 522 0 0

DISH (64

Wadham

Road)

0 259 11 0

DISH (210

Wadham

Road)

0 738 0 0

Single Point of

Access 0 127 0 0

Single Point of

Access 0 841 12 0

Core service

total 3378 4043 22 195



staff

Hours filled by

agency staff

Hours NOT filled by


Trust Total 210729 442987 204924 29961

This core service had 73.5 (11%) staff leavers between 1 August 2017 and 31 July 2018.

Team Substantive

staff

Substantive staff

Leavers

Average % staff leavers

350 L9 Liverpool Junior LD (Z1FR20) 0.0 1.0 200%

350 L9 210 Wadham Road (Z1BN85) 3.0 2.0 63%

350 L9 Brook Road West (Z1BN50) 4.0 2.0 55%

350 L9 Cheshire Probation (SCF630) 1.2 0.5 45%

350 L9 S&K Acute Care (Z1VA11) 3.4 1.0 39%

350 L9 Local Psychology (Z2AB03) 4.6 1.8 37%

350 L9 64 Wadham Road (Z1BN75) 4.0 1.0 26%

350 L9 Addictions Management (Z1LK50) 0.1 0.2 24%

350 L9 Alt Ward (Z1AB71) 24.7 4.0 15%

350 L9 Southport Acute Care Team (Z1NW09) 18.0 2.0 14%

350 L9 Moss CMHT (Z1AH29) 15.1 2.0 14%

350 L9 Albert Ward (Z1AB11) 28.1 3.8 14%

350 L9 Psychotherapy (Z1EH90) 24.5 3.0 13%

350 L9 Talk Liverpool (Z2AB40) 99.0 11.8 12%

350 L9 Norris Green Community Hub (Z1AH30) 42.0 5.0 12%

350 L9 CMHT North Liverpool & Kirkby (Z1AD18)

12.4 1.4 11%

350 L9 Liverpool EI South/Central (Z1NW11) 27.8 3.0 10%

350 L9 South Sefton Neighbourhood (Z1AH38) 47.1 4.4 10%

350 L9 Community Psychology S&K (Z2AB25) 16.2 1.5 10%

350 L9 Community Psychology Liverpool (Z2AB30)

11.1 1.0 9%

350 L9 Brunswick Ward (Z1AE11) 28.8 2.0 7%

350 L9 Eating Disorders (Z1EH95) 8.3 0.5 6%

350 L9 Early Intervention (Z1NW14) 17.8 0.8 5%

350 L9 Rathbone Rehab Centre (Z1BG11) 31.2 1.0 3%

350 L9 Medical Aintree Older People (Z1AA04) 2.0 0.0 0%

350 L9 Liverpool EI Senior Medical Staff(Z1DR15)

1.0 0.0 0%

350 L9 Early Intervention Sefton Meds (Z1DR16)

1.9 0.0 0%

350 L9 Criminal Justice Liaison Team (Z1AF95) 39.1 0.0 0%

350 L9 Perinatal Liverpool (Z1VA01) 7.0 0.0 0%

350 L9 Rathbone Dir.Support (Z1BG90) 0.0 0.0 0%

350 L9 Kirkby CMHT (Z1AH34) 10.6 0.0 0%


Team Substantive

staff

Substantive staff

Leavers

Average % staff leavers

350 L9 Community Mh Team Ns (Z1NW07) 17.7 0.0 0%

350 L9 North Liverpool Neighbourhood (Z1AH33)

2.0 0.0 0%

350 L9 Dish Infrastructure (Z1BN45) 3.0 0.0 0%

350 L9 Community Clinic Team (Z1AD10) 3.0 0.0 0%

350 L9 Cavendish Road (Z1BN55) 4.0 0.0 0%

350 L9 Glenwyllin Road (Z1BN60) 4.0 0.0 0%

350 L9 Moorgate Avenue (Z1BN70) 3.0 0.0 0%

350 L9 Regent Road Crosby (Z1BN65) 4.0 0.0 0%

350 L9 MBT ASPD (SCF580) 1.0 0.0 0%

350 L9 Police Project (SCF927) 1.0 0.0 0%

350 L9 Merseyside Probation Team (SCF631) 1.0 0.0 0%

350 L9 Stafford House PIPE (SCF632) 0.8 0.0 0%


Trust Total 2658.6 294.5 13%

The sickness rate for this core service was 5% between 1 August 2017 and 31 July 2018. The

most recent month’s data [31 July 2018] showed a sickness rate of 6%.

Team Total % staff

sickness

(at latest month)

Ave % permanent staff sickness (over the

past year)

350 L9 Rathbone Dir.Support (Z1BG90) 0% 32%

350 L9 210 Wadham Road (Z1BN85) 38% 21%

350 L9 Brook Road West (Z1BN50) 0% 20%

350 L9 64 Wadham Road (Z1BN75) 0% 11%

350 L9 Community Mh Team Ns (Z1NW07) 7% 11%

350 L9 Albert Ward (Z1AB11) 15% 9%

350 L9 Kirkby CMHT (Z1AH34) 36% 9%

350 L9 Moss CMHT (Z1AH29) 0% 8%

350 L9 Community Clinic Team (Z1AD10) 0% 7%

350 L9 Alt Ward (Z1AB71) 13% 7%

350 L9 Talk Liverpool (Z2AB40) 6% 6%

350 L9 CMHT Nrth Liverpool & Kirkby (Z1AD18)

3% 5%

350 L9 Norris Green Community Hub (Z1AH30)

10% 5%

350 L9 Early Intervention (Z1NW14) 5% 5%

350 L9 Rathbone Rehab Centre (Z1BG11) 4% 5%

350 L9 Brunswick Ward (Z1AE11) 10% 4%

350 L9 Southport Acute Care Team (Z1NW09)

2% 4%

350 L9 South Sefton Neighbourhood (Z1AH38)

4% 4%

350 L9 Local Psychology (Z2AB03) 0% 4%

350 L9 Liverpool EI South/Central 9% 3%


Team Total % staff

sickness

(at latest month)

Ave % permanent staff sickness (over the

past year)

(Z1NW11)

350 L9 Criminal Justice Liaison Team (Z1AF95)

3% 3%

350 L9 Regent Road Crosby (Z1BN65) 0% 2%


0% 2%

350 L9 Cheshire Probation (SCF630) 16% 2%

350 L9 Cavendish Road (Z1BN55) 0% 1%

350 L9 Moorgate Avenue (Z1BN70) 0% 1%

350 L9 Psychotherapy (Z1EH90) 0% 1%

350 L9 S&K Acute Care (Z1VA11) 5% 1%

350 L9 Early Intervention Sefton Meds (Z1DR16)

9% 1%

350 L9 Perinatal Liverpool (Z1VA01) 0% 1%

350 L9 Eating Disorders (Z1EH95) 0% 1%

350 L9 Community Psychology S&K (Z2AB25)

0% 1%

350 L9 Dish Infrastructure (Z1BN45) 0% 0%

350 L9 Glenwyllin Road (Z1BN60) 0% 0%


0% 0%

350 L9 Liverpool EI Senior Medical Staff(Z1DR15)

0% 0%

350 L9 Addictions Management (Z1LK50) 0% 0%

350 L9 Addictions Senior Medical Staff (Z1LK10)

0% 0%

350 L9 Merseyside Probation Team (SCF631)

0% 0%

350 L9 Stafford House PIPE (SCF632) 0% 0%

Core service total 6% 5%

Trust Total 8% 8%

Medical staff

There is no data pertaining to this core service.

We requested data regarding the establishment and vacancy rate of medical staff for the service.

Data relating to Park Lodge and North Sefton was not received. The service was covering

vacancies with locums. We did not see any impact on the service being provided as a result.

Mandatory training

The service provided mandatory training in key skills to staff. However, staff compliance with role

specific mandatory training was below target.

The compliance for mandatory and statutory training courses at 31 May 2018 was 87%. Of the

training courses listed 26 failed to achieve the trust target and of those, 11 failed to score above

75%.


The trust reported their training compliance data on an ongoing monthly basis. Statutory training

was reported as part of the monthly board report dashboard produced by Workforce and a

separate dashboard was provided by the Learning and Development team for all other courses

classified by CQC as role essential.

The training compliance reported for this core service during this inspection was the same as the

87% reported in the last year’s compliance.

Key:

Below CQC 75% Between 75% & trust

target Trust target and above

Training course This core service % Trust target % Trustwide mandatory/ statutory training total %

Role Specific Mandated Training -

Medicines Calculations (Every 3 Years) 100% 90% 63%

Mandatory Training - Safeguarding Adults

- Level 1 (Every 3 Years) 99% 95% 95%

Mandatory Training - Safeguarding

Children - Level 1 (Every 3 Years) 98% 95% 95%

Mandatory Training - Equality, Diversity

and Human Rights (Every 3 Years) 96% 95% 91%

Mandatory Training - Health & Safety

(Every 3 Years) 96% 95% 92%

Role Specific Mandated Training - Basic

Prevent Awareness (1 Time) 96% 90% 93%

Mandatory Training - Conflict Resolution

(Every 3 Years) 95% 95% 92%

Mandatory Training - Fire Safety (Every 3

Years) 95% 95% 92%

Mandatory Training - Infection Control

(Every 3 Years) 95% 95% 92%

Continuous Professional Development -

Adverse Incidents (Every 3 Years) 94% 95% 92%

Mandatory Training - Moving & Handling

(Every 3 Years) 94% 95% 90%


Controlled Drugs & High Risk Medicines 94% 90% 67%


Complaints (Every 3 Years) 92% 95% 94%


Safeguarding Adults Level 2 -Trust Model

(Every 3 Years)

90% 90% 87%


Safeguarding Children Level 2 - Trust

Model (Every 3 Years)

90% 90% 87%




Smoking Cessation (1 Time) 89% 95% 89%


Fraud Awareness (Every 3 Years) 88% 95% 89%


Suicide Prevention & Safety Planning

(Every 3 Years)

88% 95% 90%


Dementia Awareness (1 Time) 78% 95% 78%

Role Specific Mandated Training - Mental

Capacity Act - Level 1 (Every 3 Years) 77% 90% 88%


Health Act - Level 1 (Every 3 Years) 77% 90% 90%



Model (Every 3 Years)

76% 90% 76%


Safeguarding Adults Level 3 - Trust Model

(Every 3 Years)

75% 95% 76%


Personal Safety (Every Year) 75% 90% 80%


Deprivation of Liberties - Level 1 (Every 3

Years)

74% 90% 89%


Intermediate Life Support (Every Year) 69% 90% 72%

Role Specific Mandated Training - Safe

and Effective Use of Medicines (Every 3

Years)

62% 90% 63%


Personal Safety Breakaway - Level 1

(Every 2 Years)

61% 90% 50%


Life Support (Every Year) 60% 95% 70%

Role Specific Mandated Training - Rapid

Tranquilisation Training 53% 90% 61%

Mandatory Training (IG) - Data Security

Awareness - Level 1 (Every Year) 51% 95% 50%


MHA/DoL's Level 2 (Every 3 Years) 50% 90% 53%


Witness to Medication (Every 3 Years) 30% 90% 48%



(Every Year)

21% 90% 74%




Moving and Handling of Inanimate

Objects

0% 95% 56%

Core Service Total % 87% 87%

The trust’s target for mandatory training was 95%. During inspection we received updated

mandatory training figures. The figures showed that staff compliance with mandatory training was

91% and above for all mandatory training except for data security awareness training which was

below trust target at 50% compliance at Moss House. Park Lodge was 91% compliant and North

Sefton were 100% compliant for data security awareness training.

The trust’s target for role specific mandatory training was 90%. During inspection we received

updated role specific mandatory training data which showed that there had been improvements at

two of the services we visited. However, Moss House failed to meet a number of course targets.

Compliance rates for role specific training at Moss House ranged between 23% and 78% except

for safeguarding adults and children (level two) which had 93% compliance. This meant that the

trust could not be assured that all staff were able to safely manage conflict with patients or able to

apply the Mental Health Act and Mental Capacity Act.

North Sefton met the trust target for all role specific mandatory training.

Park Lodge compliance was above 75% for all role specific mandatory training except personal

safety breakaway training, which was 36%.

Assessing and managing risk to patients and staff

Assessment and management of patient risk

Staff completed and updated risk assessments for each patient and used these to understand and

manage risks individually. Staff used the trust’s standard assessment tool. Risk assessments were

recorded on the trust’s new electronic treatment and care recording system.

Staff discussed crisis plans with patients and documented it in their care and treatment plans. The

records we looked at had robust risk management plans in place, which included early warning

signs, practitioner intervention, medication, useful telephone numbers and accommodation.

Risks were raised and discussed at the multidisciplinary meetings we attended.

The service had a robust lone working policy that staff referred to when needed. Staff we spoke

with were able to describe the lone working procedures.

Safeguarding


agencies to do so. The service had a safeguarding policy and staff were provided with training on

how to recognise and report abuse and they knew how to apply it.


Safeguarding was a standing agenda item at multidisciplinary meetings.




institutional.





should take place.

This core service made 29 safeguarding referrals between 1 August 2017 and 31 July 2018, of

which 15 concerned adults and 14 children.

The most adult referrals made in the period were in October 2017 with three.

There were two peaks identified in child referrals across the period in August 2017 (three) and

September (three).

Mersey Care NHS Trust submitted details of four external case reviews commenced or published

in the last 12 months, however none that relate to this core service.

Staff access to essential information

Staff kept detailed records of patients’ care and treatment plans including risk assessments.

Records were clear, up-to-date and person centred. However, the service was going through a

migration of one electronic system to another. Not all staff had access to all relevant patient

information in a timely manner. New staff only had access to the old system by getting another

staff member with access to log into it and get the information they needed. This meant that there

were delays in accessing patient information they required to be able to deliver patient care.

The new system had become live from 1 June 2018.The service had originally set 31 October

2018 as the transfer completion date for care plans and risk assessments but at the time of

inspection North Sefton was the only location out of the three that had managed to complete the

transfer. The trust informed us that a new completion date had been set for 30 November 2018.

Training in the use of the new system had been provided for staff since January 2018 but we saw

that staff were struggling to navigate the new system efficiently.

Referrals


14 15 29


Medicines management

Staff followed best practice when storing, dispensing, and recording. Staff regularly reviewed the

effects of medications on individual patient physical health. Emergency and controlled medication

was not stored on the premises.

Track record on safety

Moss House had reported two serious incidents between 1 August 2017 and 31 July 2018, Park

Lodge had reported three and North Sefton reported one serious incident. Staff we spoke with

understood what needed to be reported and how to do it.


within two working days of an incident being identified.

Between 1 August 2017 and 31 July 2018 there were 32 STEIS incidents reported by this core

service. Of the total number of incidents reported, the most common type of incident was

‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’ with 21. One of the unexpected

deaths were instances of ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’.

A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the

available preventative measures are in place. This core service reported no never events during

this reporting period.

We asked the trust to provide us with the number of serious incidents from the past 12 months.

The number of the most severe incidents recorded by the trust incident reporting system was

broadly comparable with STEIS.

Number of incidents reported

Type of incident reported on STEIS

Ap

pare

nt/

actu

al/su

sp

ecte

d s

elf

-

infl

icte

d h

arm

meeti

ng

SI

cri

teri

a

Co

nfi

den

tial in

form

ati

on

leak/i

nfo

rmati

on

go

ve

rna

nce

bre

ach

meeti

ng

SI c

rite

ria

Dis

rup

tiv

e/ ag

gre

ss

ive

/ vio

len

t

beh

avio

ur

meeti

ng

SI c

rite

ria

Su

bsta

nce

mis

us

e w

hilst

inp

ati

en

t m

eeti

ng

SI c

rite

ria

To

tal

AMH Community - Norris Green Hub 1 1

AMH Community Sefton 1 1

AMH Community Windsor House CMHT 1 1

Arundel House CMHT 1 1

Community AMH Service 1 1

CRHT Community 1 1



Early Intervention Team 1 1

Early Intervention Team Sefton and Kirkby 1 1 2

FIRT 1 1 2

FIRT Community Services 1 1

Forensic Integrated Resource Team - Community Services 1 1

Forensic Integrated Resource team (FIRT) 1 1

Forensic Integrated Resource Team Community Services 1 1

Forensic Integrated Resource Team FIRT Community Services 2 2

Hesketh Centre 1 1

Homeless Outreach Team 1 1

Moss House 1 1

Moss House CMHT 1 1

North Liverpool CMHT 1 1

Park CMHT 1 1

Park Lodge 2 2

Scott Clinic – FIRT 1 1

Scott Clinic MSU 1 1

South Sefton CMHT Adult 2 2

South Sefton CMHT Adult (SSNC) 1 1

North Sefton 1 1

Total 21 1 4 6 32

Reporting incidents and learning from when things go wrong


appropriately. Managers investigated incidents and shared lessons learned with the whole team

and the wider service. The service provided staff with incident newsletters monthly. The Oxford

model (a tool used to provide focus and consistency) was used to take forward lessons learnt from

serious untoward incidents or complaints, and share the learning with staff and partner

organisations to help prevent them reoccurring.

The trust had a policy in relation to duty of candour.

Local division safety huddle meeting minutes confirmed that staff discussed incidents, complaints

and compliments. During the meetings, they looked at themes and shared good practice.

Staff received quality practice alerts, which included important health and safety information that

could impact on working procedures or be potential workplace hazards.







directly asked for a response. One of the prevention of future deaths reports related to this core

service, details of which can be found below.

Regulation 28: Report to prevent future deaths

The coroner issued a report in June 2018 in conclusion of an inquest were a patient took their own

life.

The Coroner’s concerns were:

A more co-ordinated approach from the mental health services is required when a patient is

being transferred from one NHS trust to another. In this case is the patient had still been on a

Care Programme Approach (CPA) there would have been a direct referral from service to

service rather than through the GP but because he was taken off the programme, the referral

was made through the GP. This has delayed the intervention and the prevented effective

information exchange on a patient who was already subject to secondary care services. In

effect, this resulted in the patient having no intervention for a number of months.

The following learning / recommendations were given by the trust:

Mersey Care NHS Foundation Trust (MCFT) and the other trust that was involved both agreed to

separately review their policies whilst ensuring that staff are clear on the processes that should be

adopted when transferring patients from one organisation to another.

The trust had since amended their policy to include the recommendations from the regulation 28

report. They have also shared their new policy with the other trust.



Assessment of needs and planning of care

Staff assessed the physical and mental health of all patients on admission. They developed

individual care plans and updated them when needed. We viewed 19 comprehensive patient care

and treatment records.

Best practice in treatment and care

Patients were not always receiving the treatment they needed. There were long waiting times for

psychological intervention with a clinical psychologist, and staff were not providing psychological

interventions. Maximum wait times for psychological assessment were between 16 and 37 weeks

and for psychological intervention were between 60 and 66 weeks across the three locations.

Veterans and patients on stepped up care were given priority appointments for assessment for

treatment and intervention. The trust was aware of the waiting times and were taking steps to

address them by training staff in psychological interventions However, the length of the wait times

was highlighted in our previous inspection report published in October 2015. This meant that the

trust had not taken effective action to reduce waiting times during the three years prior to the

current inspection.

The service provided smoking cessation at North Sefton team and held groups to support patients.

They held depot clinics and monitored patients on lithium and clozapine, co working with GPs to

ensure patients received the checks and monitoring required. Staff used ‘Health of the Nation

Outcome Scales’ to measure the health and social functioning of people with severe mental

illness, and the Liverpool University Neuroleptic Side-Effect Rating Scales (LUNSERS) to track

side-effects of antipsychotics.

The service had good links with local authorities and work together to determine support packages

for patients such as home carers.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. The service

had linked up with another trust to look at stepped up care benchmarking.

This core service participated in 22 clinical audits as part of their clinical audit programme 2017 –

2018.

Audit name Audit scope Audit type Date

completed Key actions following the audit

Physical

Health

Schizophrenia

Audit

(Community) -

2018/19

Local

Division Clinical 17/07/2018

Community Action Plan: 1. Community

Physical Health Dashboard to be

completed by the end of September to

inform us of our performance ahead of the

future audit and improve the performance

for consistency across the board. 2. Repeat

the internal audit whilst awaiting the

performance dashboard as a measure to

our ongoing performance for Q23. 3.Target




the key teams that have produced fewer

results and work out local actions to

improve their outcomes 4. Continue to

support teams to understand the

importance of the physical health and

promote the completion of the APHC which

is also supported by the Community

Physical health nurses and Assistant

Practitioners.5. The local division will

continue to support the priority of this

agenda at all levels

CPA/Non CPA

Care Planning

Q2 (July 2017

to September

2017)

Local


These results have been discussed within

the teams and remedial action plans in

development.

Dual

Diagnosis

Audit Report

Q2

Local

Division Clinical

Action taken last year was to identify a Dual

Diagnosis Lead. The actions taken to date

are: Cascading the audit and its findings to

ward managers. The provision of support to

ward teams from psychology and

psychology assistants. Identifying the

clinical training requirements to support

ward staff with dual diagnosis.

CPA/Non CPA

Care Planning

Q3 (October

2017 to

December

2017)

Local


CPA Action Plan:

1. Share the findings of the audit with all

respective Community managers and

Clinical Leads. 2. Develop a Supervision

case audit template for Team Managers to

use with Care-Co-ordinators. 3. Community

caseload review to include CPA caseload.

4. Re-Audit the CPA Standards to monitor

progress

Health

Records Audit

Secure,

Local,SpLD

and LCH

Sefton

Locality

Clinical 14/12/2017

Each Division has a breakdown of data

relating to their own area. The emphasis for

action and improvement is

countersignature of entries by staff that

cannot authorise a clinical note. There is a

review of the electronic patient records

systems in use to review how automation

can improve compliance.

Dual

Diagnosis

Audit Report

Q3

Local


1. Cascade audit and its findings to ward

managers within the Local Division paying

specific attention to Standard 3. 2.

Psychology and assistants to support

wards via staff and service user education

and support group MDT's. 3. Identify any




clinical training requirements to support

ward staff with dual diagnosis.

Consent to

Medical

Treatment

Audit

Local


The following actions have been taken:

• Update referring consultants on the

importance of ensuring all parts of the ECT

paperwork are complete

• Review ECT paperwork to ensure that

unnecessary data in not being requested

• Ensure that RiO system properly records

the consent process for ECT

MARAC Audit

Report

Local


Audit Findings have been shared with the

Safeguarding Team and relevant

Safeguarding committees. Action Plan

completed: No actions required for

Standard 2 as alerts would only be placed

on patients who are currently open to

Mersey Care and where applicable. Not all

cases heard at MARAC are given any

MARAC actions.

National

Clinical Audit

of Psychosis

Local,

Secure and

SpLD

Divisions

Clinical 13/04/2018

Recommendation 1 (by the Royal College

of Psychiatrists)

Ensure that all people with psychosis:

have at least an annual assessment of

cardiovascular risk (using the current

version of Q-Risk) receive appropriate

interventions informed by the results of this

assessment have the results of this

assessment and the details of interventions

offered recorded in their case record.

Recommendation 2

Ensure that all people with psychosis are

offered CBTp and family interventions, by:

deploying sufficient numbers of trained

staff who can deliver these intervention

making sure that staff and clinical teams

are aware of how and when to refer people

for these treatments. Recommendation 3

Ensure that all people with psychosis: are

given written or online information about

the antipsychotic medication they are

prescribed are involved in the prescribing

decision, including having a documented

discussion about benefits and adverse

effects of the medication. Recommendation

4

Ensure that all people with psychosis who




are unable to attend mainstream education,

training or work, are offered alternative

educational or occupational activities

according to their individual needs; and that

interventions offered are documented in

their care plan. Recommendation 5

An Annual Summary of Care should be

recorded for each patient in the digital care

record. This should: include information on

medication history, therapies offered and

physical health monitoring/interventions be

updated annually be shared with the patient

and their primary care

team. Recommendation 6

NHS Digital, NWIS, Commissioners, Trusts

and Health Boards should work together to

put in place key indicators for which data

can easily be collected, perhaps using an

Annual Summary of Care (see

Recommendation 5,above). This work

should be informed by the NCAP results

and the experience of the NCAP team.

National EIT

Audit

Local


The Royal College of Psychiatrists advise

that to be rated 'top performing' overall, a

team will be rated: Top Performing' in the

effective treatment domain and the timely

access domain. 'Performing well' or higher

in the well-managed service domain.

Dual

Diagnosis

Audit Report

Q4

Local


1. Monitor BiT to identify service users with

a dual diagnosis to highlight to ward

managers as to where a dual diagnosis

care plan hasn’t been formulated

2. To ensure dual diagnosis care planning

is included in the 1:1 named nurse

proforma being developed

3. Support and advice will be offered with

regards to those with dual diagnosis needs

CPA/Non CPA

Care Planning

Q4 (January

2018 to March

2018)

Local



the teams and Action Plan has been

formulated: CPA: 1. Share the findings of

the CPA Audit with all respective

Community Team Managers and Clinical

leads.

2. Present the Action Plan to the

Community Managers at the Joint

Community manager’s forum.

3. Within the Structure of supervision carry




out a documentation review and audit of at

least 1 patient record against the CPA

standards for each practitioner.

4. Through Pace and supervision ensure all

Community Practitioners are aware of the

CPA audit standards in respect of Clinical

Documentation.

5. Re-audit the CPA standards to monitor

progress

Non CPA:1. Share the audit findings with

the Clinical Leads and ensure that they are

circulated across the Community

Consultant Workforce.

2. Circulate the Audit standards to all

Community team members.

3. Re-audit against the agreed standards to

monitor progress

4. Monitor the local impact of RIO on

clinical recording.

Datix

Incidents

Audit Report

Local




development

DNA Audit

Report

Local




development.

Audit of 7

Days Follow

Up by North

Liverpool

CMHT

following

Inpatient

Admission

Local


The CMHT has performed well in this audit

and should be commended for the

promptness with which patients were

followed up. It would be interesting to audit

all 105 discharges from the CMHT to see if

anyone was not followed up and what the

reasons were. Pan to re-audit in 12 months'

time.

Physical

Health

Assessment

in patients

with Severe

Mental Illness

Local


Documentation is only first step increasing

use of Lester tool. How can we reduce

people's risks? Weight management

interventions. Close monitoring of

antipsychotics & switch. Very brief smoking

interventions. Closer collaboration with

primary care. Access to EMIS records for

clinical and audit purposes.

Antipsychotic

polypharmacy

re-audit

Local


Cases where total dose is over 100% of

BNF approved maximum should be closely

reviewed with each individual patient.




There needs to be clear discussion

identifying risks associated with

polypharmacy or a standardised form with

specific risks highlighted. To make sure all

patients with HDAT have their consent

form, risk assessment and monitoring sheet

filled in and documented in ePEX. Patients

on antipsychotic polypharmacy to be

reviewed regularly in terms of reducing

their does or stopping one of their

antipsychotic medications if needed.

Frequency of review is recommended to

depend on each patient however, we

wonder whether this should be

standardised? Re-audit with more focus on

quality of documentation.

An audit to

assess the

impact of an

SMS

Appointment

Reminder

Service on

'DNA' rates

across

CMHTs in

Mersey Care

NHS

Foundation

Trust

Local


Reasons for failure to receive reminders

should be investigated. Is there a way to

improve mobile phone records of patients?

Could the wording of the reminder affect

how patients feel about attending?

Clinic Letters

Audit

Local


Ensure PBR care cluster is quoted with

diagnosis when writing Non-CPA statement

of care letters. Briefing session for all junior

doctors on the guidelines of what to include

in clinic letters and get taught PBR

clustering. Always ensure a patient risk is

stated. Sufficient for it to be quoted either in

the body of the letter or the MSE.

Qualifying risk, such as not suicidal, is also

sufficient and can be of more value. Try to

ensure letters are dictated before the end

of the day. In addition, to check and alter

letters on ePEX as opposed to printing and

being altered by hand. To re-audit in 4-6

months’ time on a larger scale and consider

including physical health and Lester tool.

Invite other teams to do the same audit to

compare how the different CMHTs are




doing. When staff changeover takes place -

Dr leaves a written handover of outstanding

letters with their consultant and secretary.

Audit of Post

Discharge

Follow-Up by

Southport

CMHT

Local


The CMHT has performed well in this audit

and should be commended for the

promptness with which patients were

followed up. It would be interesting to audit

all discharges from the CMHT and check

further compliance. Re-audit in 12 months.

A

retrospective

audit of

electronic

recording of

metabolic

parameters of

patients on

clozapine

Local


The staff involved in the health and well-

being clinics, care co-ordinators and other

clinicians involved in care of these patients

will receive feedback of the audit findings. It

was possible to break the findings down

into specific clinics but it was chosen not to

do this and instead use this as a snap shot

of practice for now so that particular teams

do not feel marginalised or criticised. To

address the problem, it was agreed that the

standardised form be reviewed for

measurement of parameters of metabolic

syndrome used in all patients on clozapine

in the service. These forms were to be

completed in each patient's electronic

medical notes. A Re-audit will capture

performance with any improvement or

decline in recording of data. In future, this

will look at individual HWB clinics

benchmarked against other services

nationally, and the total national sample.

Education of staff in clinics regarding the

individual parameters and why these are

important. Distribute a questionnaire

amongst HWB staff to highlight knowledge

gaps i.e. why are you taking obs? What do

you do with abnormal obs? Why is GASS

important?etc. Straightforward educational

and practical interventions can lead to

significant improvements in practice, and

should serve to continue to improve

practice in this area. Modern matron will

organise Educational sessions for teams

across the clinics. It was also considered

that a similar system for monitoring be

implemented in due course for all patients

on second-generation antipsychotics.

Schizophrenia Local Clinical 29/08/2017 Development a new community physical




- Local

Division

Community

CPA Physical

Healthcare

Division health pathway with improved specialist

staff to support access and record keeping

systems and an intranet portal developed

to support the physical health pathway.

Skilled staff to deliver care

Managers made sure they had staff with a range of skills needed to provide high quality care.

They supported staff with appraisals, supervision, opportunities to update and further develop their

skills.

The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, the overall appraisal

rates for non-medical staff within this core service was 79%.

Twenty-one of the 40 teams were failing to achieve the trust’s appraisal target with Moss CMHT

reporting the lowest with 29%.

Team name

Total number

of permanent

non-medical

staff requiring

an appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

%

appraisal

s

350 L9 Local Psychology (Z2AB03) 5 5 100%

350 L9 Physical Health (AEB225) 5 5 100%

350 L9 Merseyside Probation Team (SCF631) 1 1 100%

350 L9 Catering Rathbone (Z2BD40) 5 5 100%

350 L9 Southport Acute Care Team (Z1NW09) 19 19 100%

350 L9 Cheshire Probation (SCF630) 2 2 100%

350 L9 Local Senior Management (Z1NW65) 4 4 100%

350 L9 Community Psychology S&K (Z2AB25) 16 16 100%

350 L9 North Liverpool Neighbourhood (Z1AH33) 2 2 100%

350 L9 Early Intervention (Z1NW14) 16 16 100%

350 L9 Smoking Cessation (AEB217) 1 1 100%

350 L9 Infection Control (AEB450) 3 3 100%

350 L9 Stafford House PIPE (SCF632) 1 1 100%

350 L9 Liverpool Neighbourhood 2 (Z1NW77) 1 1 100%

350 L9 Kirkby CMHT (Z1AH34) 11 11 100%

350 L9 South Sefton Neighbourhood (Z1AH38) 45 44 98%


Team name

Total number

of permanent

non-medical

staff requiring

an appraisal

Total number of

permanent non-

medical staff who

have had an

appraisal

%

appraisal

s

350 L9 Baird House Community Hub (Z1AH28) 41 40 98%

350 L9 Park Lodge(Z1AH30) 39 37 95%

350 L9 FMA's Southport (Z2CN65) 19 18 95%

350 L9 CMHT North Liverpool & Kirkby (Z1AD18) 12 11 92%

350 L9 Eating Disorders (Z1EH95) 11 10 91%

350 L9 Ambitions Sefton (Z1LK60) 70 63 90%

350 L9 Community Mental Health Team Ns (Z1NW07) 18 16 89%

350 L9 Alt Ward (Z1AB71) 24 21 88%

350 L9 Talk Liverpool (Z2AB40) 102 89 87%

350 L9 Community Psychology Liverpool (Z2AB30) 14 12 86%

350 L9 Brunswick Ward (Z1AE11) 29 24 83%

350 L9 Albert Ward (Z1AB11) 22 17 77%

350 L9 Psychotherapy (Z1EH90) 25 19 76%

350 L9 Liv Neighbourhood 1 (Z1NW75) 4 3 75%

350 L9 Social Inclusion & Participation Team (Z3DN13) 37 27 73%

350 L9 FMA's Norris Green (Z1SH15) 3 2 67%

350 L9 Catering Transport (Z2BD75) 2 1 50%

350 L9 Clinical Audit (AHB855) 2 1 50%

350 L9 Local Division Admin (Z1AD02) 130 61 47%

350 L9 Nurse Directorate Management (AEB200) 13 6 46%

350 L9 Mersey Care Community Assessment Team - Sefton

CS (Z4CH15) 10 4 40%

350 L9 S&K Neighbourhood 1 (Z1NW76) 3 1 33%

350 L9 S&K Acute Care (Z1VA11) 3 1 33%

350 L9 Moss House (Z1AH29) 14 4 29%

350 L9 Deputy Medical Director (AEA202) 2 0 0%

350 L9 Community Clinic Team (Z1AD10) 3 0 0%

350 L9 Infection Control - Sefton CS (Z4CH46) 1 0 0%

Core service total 790 624 79%

Trust wide 5565 4780 86%

The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, there was no data

pertaining to medical staff.


Between 1 August 2017 and 31 July 2018, the average rate across all 66 teams in this core

service was 50% of the trust’s target.


ways, it’s important to understand the data they provide.

Team name

Clinical supervision

sessions required

Clinical

supervision

delivered

Clinical

supervision rate

(%)

350 L9 S&K Neighbourhood 1 (Z1NW76) 10 11 110%

350 L9 Stafford House PIPE (SCF632) 3 3 100%

351 L9 Brook Place (Z1HJ10) 21 21 100%

350 L9 Early Intervention (Z1NW14) 39 39 100%


98 98 100%

351 L9 Community Mental Health Team Ns (Z1NW07)

15 15 100%

350 L9 Merseyside Probation Team (SCF631) 3 3 100%

350 L9 MBT ASPD (SCF580) 3 3 100%

350 L9 Brook Place (Z1HJ10) 41 40 98%


75 73 97%


35 34 97%

350 L9 Eating Disorders (Z1EH95) 26 25 96%

350 L9 Dish Infrastructure (Z1BN45) 83 78 94%

350 L9 Southport Acute Care Team (Z1NW09)

49 46 94%


38 35 92%

350 L9 Community Mental Health Team Ns (Z1NW07)

36 33 92%

350 L9 Brunswick Ward (Z1AE11) 29 26 90%

350 L9 Baird House Community Hub (Z1AH28)

100 89 89%

350 L9 Local Senior Management (Z1NW65) 17 15 88%

350 L9 Kirkby CMHT (Z1AH34) 15 13 87%

350 L9 Cheshire Probation (SCF630) 7 6 86%

350 L9 Local Services CQUIN (Z1NW90) 45 38 84%

350 L9 Liv Neighbourhood 1 (Z1NW75) 12 10 83%

350 L9 Psychotherapy (Z1EH90) 77 60 78%

350 L9 Albert Ward (Z1AB11) 26 20 77%

350 L9 Moss CMHT (Z1AH29) 37 28 76%

350 L9 Rathbone Rehab Centre (Z1BG11) 28 21 75%

350 L9 Liverpool Neighbourhood 2 (Z1NW77) 3 2 67%

Unknown 549 356 65%


34 22 65%

350 L9 Access (Z1NW13) 42 26 62%

350 L9 Community Clinic Team (Z1AD10) 5 3 60%

350 L9 Community Psychology S&K (Z2AB25)

51 28 55%

350 L9 Liverpool EI South/Central (Z1NW11) 56 28 50%


Team name Clinical supervision

sessions required

Clinical

supervision

delivered

Clinical

supervision rate

(%)

350 L9 Capital Project Managers (APA500) 2 1 50%

350 L9 Local Psychology (Z2AB03) 8 4 50%

351 L9 Kirkby CMHT (Z1AH34) 12 6 50%

350 L9 Local Risk & Governance (Z1NW08) 4 2 50%

350 L9 Alt Ward (Z1AB71) 27 13 48%

350 L9 Norris Green Community Hub (Z1AH30)

93 43 46%

350 L9 CMHT North Liverpool & Kirkby (Z1AD18)

33 14 42%

350 L9 Discharge to Access (Z1NW45) 5 2 40%

350 L9 S&K Acute Care (Z1VA11) 8 3 38%

350 L9 Infection Control (AEB450) 8 3 38%

350 L9 Perinatal Liverpool (Z1VA01) 21 7 33%

350 L9 Physical Health (AEB225) 9 3 33%


6 2 33%

350 L9 Police Project (SCF927) 4 1 25%

350 L9 Nurse Directorate Management (AEB200)

27 2 7%

350 L9 Health & Wellbeing (ALB400) 42 3 7%

350 L9 Bank AHP & Social Work (AEB489) 68 3 4%

350 L9 Bank Nurses (AEB480) 296 8 3%

351 L9 Sefton Bank Staff Control (Z4CH80) 846 14 2%

350 L9 Infection Control - Sefton CS (Z4CH46)

2 0 0%

350 L9 Mersey Care Community Assessment Team - Sefton CS (Z4CH15)

30 0 0%

350 L9 Learning & Development (AHP500) 9 0 0%

350 L9 Legal Services (Z2GN10) 9 0 0%

350 L9 Deputy Medical Director (AEA202) 6 0 0%

350 L9 Acc LD Nursing Programme (AHP515) 3 0 0%

350 L9 Liverpool Community Development Service (Z2AB60)

12 0 0%


Trust Total 15334 4947 32%

However, during inspection we checked the appraisal and supervision figures and identified that

improvements had been made. Moss House community mental health team had improved with

71% compliance. Park Lodge and North Sefton were 100% compliant.

Staff told us supervision was happening every four weeks but they also received unplanned

supervision through daily tasks such as at multi-disciplinary meetings, team meetings and peer

supervision. Psychologists told us they had a weekly schedule for supervision.

Information received from the trust informed us that supervision rates at the time of inspection

were 94% compliance for Park Lodge, 76% for Moss House and North Sefton was 100 %

compliant.


Multidisciplinary and interagency team work

Staff from different disciplines worked together as a team to benefit patients. They supported each

other to make sure patients had no gaps in their care. Staff held regular and effective

multidisciplinary meetings, attended by doctors, nurses, social workers, mental health

practitioners, advanced practitioners, occupational therapists, support staff and psychologists. At

the meetings, staff shared information about patients on stepped up care.

Patient records and observations confirmed effective working relationships with other relevant

teams within the organisation, for example, A&E liaison and inpatient wards. The teams had

effective working relationships with teams outside the organisation (for example, GPs, police and

voluntary organisations).

Adherence to the Mental Health Act and the Mental Health Act Code of

Practice


Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.

Staff were trained in and had a good understanding of the Mental Health Act and the Code of

Practice. Approved Mental Health Professionals were co-located within the teams we visited.

Staff had easy access to administrative support and legal advice on implementation of the Mental

Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.

The trust had relevant policies and procedures and staff had easy access to them.

Over the three teams, there were 46 patients subject to community treatment orders. A community

treatment order provides a framework for the management of patient care in the community and

gives the responsible clinician the power to recall a patient back to hospital for treatment if

necessary (Mental Health Act Code of Practice 29.6).

Staff explained to patients their rights under the Mental Health Act in relation to the community

treatment orders and repeated these as required. Staff recorded that they had reviewed the

community treatment orders and the Mental Health Act administrator sent the teams reminders of

when this was needed. The Mental Health Act administrator reminded staff when they needed to

be reviewed and informed staff of when the extension was due. Park Lodge also maintained their

own records additional to the Mental Health Act administrator.

Approved Mental Health Professional reports were not always accessible on the trust’s

computerised system unless a patient had recently been an inpatient on the acute wards. The

Local Authority kept records within their own recording system.

The Mental Health Act administrator did regular audits to ensure the Mental Health Act was

applied correctly.

As of 31 May 2018, 77% of the workforce had received training in the Mental Health Act. The trust

stated that this training is mandatory for all core services for inpatient and all community staff and


renewed every three years. At the time of inspection Moss House had a completion rate of 67%,

Park Lodge 91% and North Sefton 100% for Mental Health Act training.

Good practice in applying the Mental Capacity Act

Staff supported patients to make decisions on their care for themselves. They understood the trust

policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly.

Staff had a good understanding of the Mental Capacity Act and the provider had a policy that staff

were aware of.

Patient records confirmed that staff gave patients every possible assistance to make a specific

decision for themselves before they assumed that the patient lacked the mental capacity to make

it. For patients who might have impaired mental capacity, staff assessed and recorded capacity to

consent appropriately. They did this on a decision-specific basis regarding significant decisions.

As of 31 May 2018, 77% of the workforce had received training in the Mental Capacity Act. The

trust stated that this training is mandatory for all core services for inpatient and all community staff

and renewed every three years. At the time of inspection, Moss House had a completion rate of

67%, Park Lodge 91% and North Sefton 100% for Mental Capacity Act training.



Kindness, privacy, dignity, respect, compassion and support

Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity,

and supported their individual needs. Patients told us they felt supported and could speak to their

care coordinator about anything. We observed positive staff attitudes when interacting with

patients and meetings took place in private meeting rooms.

Patients were discussed respectfully at multidisciplinary meetings and patient information was

stored confidentially.

Involvement in care

Staff involved patients and those close to them in decisions about their care, treatment and

changes to the service.

Involvement of patients

Patients we spoke to told us they felt included in decisions about their care and treatment.

North Sefton had a women’s only group, run by a patient. It had been set up because of patients

feeling that other activities and groups were more male focussed.

Staff enabled patients to give feedback on the service using surveys. Outcomes of the surveys

were displayed in waiting rooms.

Patients, families and carers were encouraged to take part in events run by the trust. Staff directed

them to the trust website for further information.

Involvement of families and carers

The service encouraged families and carers to be involved in patients’ care and treatment (with

patients’ consent). Carers told us they felt involved.

A triangle of care assessment tool was used to monitor working relationships between patient,

mental health professionals and carers.

Patient advice and liaison service was available for patients, carers and families to assist in

resolving concerns or to provide positive feedback.



Access and waiting times

People could access the service closest to their home when they needed it. There were no waiting

lists for patient access to community mental health services, assessments and psychiatry.

The trust has identified the below services in the table as measured on ‘referral to initial

assessment’ and ‘assessment to treatment’.

The core service met the referral to assessment target in all but four of the targets listed. Access

team reported 64 days for the time from referral to initial assessment; this is one of the highest out

of all the teams. In addition, Sedgwick PL followed with 38 days, ADHD team with 35 days and

Single Point of Access Liverpool-Sefton with 34 days.

The core service met the assessment to treatment target in all of the targets listed (where

applicable).

Name of team Service Type

Days from referral to initial assessment

Days from referral to treatment

Target Is this target

national or

local?

Actual (median)


national or

local?

Actual (median)

A&E Sefton Mental Illness Acute

30 Days Local 0

Access Team Mental Illness Acute

30 Days Local 64

ACT - N.Sefton Mental Illness Acute

30 Days Local 10

Adult Liaison Aintree Mental Illness Acute

30 Days Local 1

Adult Liaison S'port Mental Illness Acute

30 Days Local 1

Arundel NH Mental Illness Acute

30 Days Local 0

Assess/Immediate Car Mental Illness Acute

30 Days Local 32

CJL Scheme Mental Illness Acute

30 Days Local 0

EIS C&S Liverpool Mental Illness Acute

30 Days Local 14 18 Weeks National 14 Days






national or

local?

Actual (median)


national or

local?

Actual (median)

EIS Kirkby Mental Illness Acute


EIS North Sefton Mental Illness Acute


EIS South Sefton Mental Illness Acute

30 Days Local 6.5 18 Weeks National 11.5 Days

EMI Liaison Aintree Mental Illness Acute

30 Days Local 1

Homelessness O'reach Mental Illness Acute

30 Days Local 9

Liverpool Liaison Mental Illness Acute

30 Days Local 0

PCMHLT Mental Illness Acute

30 Days Local 1

PD Case Mgt Team Mental Illness Acute

30 Days Local 7

Perinatal MH Team Mental Illness Acute

30 Days Local 11

PICU Mental Illness Acute

30 Days Local 7

Sedgwick (PL) Mental Illness Acute

30 Days Local 38

Tabani Mental Illness Acute

30 Days Local 5.5

Triage Car Mental Illness Acute

30 Days Local 0

ADHD Team Adult Mental Illness

30 Days Local 35






national or

local?

Actual (median)


national or

local?

Actual (median)

Adult Community Arundel

Adult Mental Illness

30 Days Local 6

19

Adult Community Kirkby


30 Days Local 3

12.5

Adult Community Moss House


30 Days Local 3.5

5

Adult Community Norris Green


30 Days Local 8

12

Adult Community North Sefton


30 Days Local 2

8

Adult Community Park Lodge


30 Days Local 6.5

11.5

Adult Community South Sefton


30 Days Local 3

5.5

Adult Community Windsor


30 Days Local 4

7

Aspergers Service Liverpool


30 Days Local 24

43.5

Aspergers Service Sefton


30 Days Local 28

42

Bed Management Team Adult Mental Illness

30 Days Local 1

Criminal Justice Liaison Team


30 Days Local 0

1

DISH Adult Mental Illness

30 Days Local 14

21.5

Early Intervention Liverpool


30 Days Local 20

25






national or

local?

Actual (median)


national or

local?

Actual (median)

Early Intervention North Sefton


30 Days Local 7

12

Early Intervention South Sefton-Kirkby


30 Days Local 13

13

Health & Wellbeing Broadoak


30 Days Local 28

28

Health & Wellbeing Clockview


30 Days Local 1.5

14

Health & Wellbeing ECT Adult Mental Illness

30 Days Local 0

0

Health & Wellbeing Hesketh


30 Days Local 5

29

Homeless Outreach Team


30 Days Local 6.5

22.5

Personality Disorder HUB


30 Days Local 14

23.5

Single Point of Access Liverpool-Sefton


30 Days Local 34

31

Single Point of Access North Sefton


30 Days Local 11

26.5

Triage Car Adult Mental Illness

30 Days Local 0

7

Personality Disorder HUB


30 Days Local 14

23.5

FOS Team (urgent) Community

7 days

10 days

Fos Team (Non-urgent) Community

25 days

31 days


The facilities promote comfort, dignity and privacy

The design, layout, and furnishings of the service supported treatment, privacy and dignity at

North Sefton.

Meeting rooms were clean, had good furnishings and promoted privacy and dignity. However, at

Park Lodge conversations could be overheard from the clinic room by other staff and one meeting

room was out of use due to infestation.

Patients’ engagement with the wider community

Staff supported patients with activities outside the service, such as work, education and family

relationships. Patients were directed to other services when required. Information leaflets and

notice boards in waiting rooms gave detail of other services and groups available such as walking,

creative writing, film, comedy and cycling groups.

The service referred patients, carers and families to the ‘life rooms’. The ‘life rooms’ was a trust

service that provided patients with advice on returning to work, money management, housing and

community services. The ‘life rooms’ held physical health and mental wellbeing sessions and

provided patients with access to pathway advisors, information technology and education advice

and support.

Meeting the needs of all people who use the service

The service was not accessible to all who needed it. We found concerns regarding wheelchair

access to Park Lodge and Moss house including the toilet facility at Moss House not being fit for

purpose for wheelchair users. Managers and staff agreed with our concerns when we raised them

and have put immediate measures in place to rectify some of the access concerns. The trust was

developing a business case to remedy the physical environment for wheelchair users.

The trust accepted that the building at Park Lodge was not fit for purpose. It was already on the

trust risk register. The trust confirmed they were taking steps to rectify it.

Staff helped patients with communication, advocacy and cultural support. Each location was close

to local transport links and support and advice leaflets were available in a range of languages.

Carers told us they felt frustrated about the use of locums and lack of continuity.

Listening to and learning from concerns and complaints

The service treated concerns and complaints seriously, investigated them and learned lessons

from the results, and shared these with all staff through email, supervision, team meetings,

multidisciplinary meetings and weekly safety meetings. Patients we spoke with told us they knew

how to complain.

This core service received 67 complaints between 1 August 2017 and 31 July 2018. Thirteen

(19%) of these were upheld, 14 (21%) were partially upheld and 18 (27%) were not upheld. None

were referred to the Ombudsman.


Team Name

Fu

lly u

ph

eld

No

t u

ph

eld

Oth

er

(ple

as

e d

es

cri

be in

co

mm

en

ts c

olu

mn

)

Part

ially u

ph

eld

Un

der

inv

esti

gati

on

Wit

hd

raw

n

To

tal co

mp

lain

ts

Moss House CMHT 3 3 2 2 2

12

Southport CMHT

3 3 4 2

12

South Sefton CMHT Adult (SSNC) 3 2

1 3

9

ACCESS Team 1 1 1 2

5

North Liverpool CMHT

3

2

5

Park CMHT

1 1 1 2

5

Kirkby CMHT (Adult)

2

1

3

Arundel House CMHT

1

1

2

Early Intervention Team Sefton and Kirkby

2

2

Psychotherapy Service 1

1

2

South Sefton CMHT OP (SSNC) 2

2

Windsor House CMHT

1

1 2

Ambition Bootle 1

1

CMHT Crosby and Maghull

1

1

Early Interventions Team

1

1

Eating Disorders Services

1

1

N/A 1

1

North Liverpool OP CMHT 1

1

Grand Total 13 18 9 14 12 1 67

This core service received no compliments during the last 12 months from 1 August 2017 and 31

July 2018. However, during inspection we saw compliments that had been received in the form of

thank you and CQC comment cards.


Is the service well led?

Leadership

Managers were visible in the service and were approachable for patients and staff.

The trust operated a ‘free up Friday’, where service managers invited senior managers to visit a

location and work a shift. Staff confirmed that senior managers had attended the locations within

the service.

Managers at all levels in the trust had the right skills, knowledge and abilities to perform their roles.

The managers demonstrated a good understanding of the service they managed and could

explain how the teams worked.

Staff told us that they knew who their divisional managers were and that they visited regularly.

A leadership programme was being used to support staff with development opportunities. Staff

confirmed they had accessed it.

Vision and strategy

The trust had a vision for what it wanted to achieve and workable plans to turn it into action

developed with involvement from staff, patients, and key groups representing the local community.

The trust vision and values were on display in communal areas of the locations and staff we spoke

to knew what they were.

Staff professional development objectives incorporated the trust’s vision and values.

Culture

Managers across the trust promoted a positive culture that supported and valued staff, creating a

sense of common purpose based on shared values.

Staff told us they felt respected and valued.

Staff had access to physical health and wellbeing support through the trust’s occupational health

service.

During the reporting period (1 August 2017 and 31 July 2018), there were no cases where staff

have been either suspended, placed under supervision or were moved to a different team.

Governance

The service had robust policies and procedures in place to promote safety including lone working,

infection prevention and control, reporting of incidents and learning from incidents. We saw that

patients were treated well and staff had built professional relationships with them. The service had

a clear framework that staff used at team meetings to ensure specific topics were being discussed


and promote consistency. It included safeguarding, serious incidents, lessons learnt, monthly

patient experience results, staffing levels, divisional priorities, complaints and compliments.

Staff understood arrangements for working with other teams both within the trust and externally, to

meet the needs of patients.

The trust provided a document detailing their 34 highest profile risks. Each of these has a current

risk score of 15 or higher. None related to this core service.


The trust had effective systems for identifying risks, planning to eliminate or reduce them, and

coping with both the expected and unexpected. Managers contributed to the trust’s risk register

and their concerns matched those on the risk register. For example, the building at Park Lodge

was on the trust risk register. Information was accessible and identified areas for improvement and

actions.

Surveillance meetings were taking place weekly to discuss and highlight concerns across the

division. Staff made notifications to external bodies when needed which included safeguarding

alerts to local authorities.


The trust collected, analysed, managed and used information to support all its activities, using

secure systems with security safeguards.

The service took part in 22 clinical audits including national audits which were in line with best

practice.

All staff working at the locations we visited had personal secure access to phones and computers.

Electronic systems were used to log and update patients’ individual care and treatment records

after all contact was made with patients, including following referrals to the local authority. This

was to ensure that the most up to date information was available for relevant staff. However,

during the migration from the previous electronic system, not all information had been transferred

over, causing difficulties for new staff that did not have access to the old system.

Engagement

The service had good links with external organisations including the local authority for support with

accommodation for patients.

Patients had been invited to take part on the interview panel when recruiting staff.

Managers and staff had access to feedback from patients and used it to make improvements,

such as giving families and carers the option to speak privately with staff when required and with

consent of the patient.


Staff were encouraged to discuss improvement and innovative ideas.


Staff had been supported to trial the use of a global positioning systems (GPS) when out in the

community. Staff informed us that work still needed to be done because the system was not

consistent in detailing real time location.






There were no accreditations for this core service.

Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age

Long stay/rehabilitation mental health wards for working age adults


Location site name Ward name Number of beds Patient group (male,

female, mixed)

Walton Centre Brain Injuries Rehabilitation Ward 12 Mixed

Rathbone Rathbone Rehabilitation

Inpatients/Community Team 25 Mixed



Safe and clean care environments

Safety of the ward layout

All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff

could clearly see all areas of the ward and knew about any ligature anchor points and actions to

mitigate risks to patients who might try to harm themselves.

Over the 12-month period from 1 August 2017 to 31 July 2018 there were no mixed sex

accommodation breaches within this core service.

There were ligature risks on two wards within this core service. The trust had undertaken recent

(from 1 January 2017 to 15 August 2018) ligature risk assessments at two wards.

One ward presented a high risk and the other a low level of ligature risk. The risks are due to

service users being in high risk areas like bathrooms, bedrooms and toilets unsupervised.

However, patients were risk assessed prior to admission, and the nature of the rehabilitation

service was to return the patient to the community, where ligature risks are difficult to overcome.

The Rathbone rehabilitation unit had both male and female patients, each having their own en-

suite bathroom. Male patients sleep on the upper floor of the unit, female patients have their

rooms on the ground floor. The unit met the Department of Health standards expected of a mixed-

sex accommodation. The brain injury rehabilitation unit also had both male and female patients, all

on the same floor, but the patient room areas were clearly defined and monitored to ensure that no

mixed-sex accommodation breaches would happen.

Maintenance, cleanliness and infection control

For the most recent Patient-led assessments of the care environment (PLACE) assessment

(2017) the locations scored similar or higher than the similar trusts for all four aspects overall (with

the exception of the dementia friendly category, as this was not assessed at Rathbone or the Brain

Injury Rehab ward (Sid Watkins unit).

Site name Core service(s) provided Cleanliness Condition

appearance

and

maintenance

Dementia

friendly

Disability

Rathbone Hospital

Community based mental health

services or adults of working age

Long say/rehabilitation mental

health wards for working age adults

Secure/forensic

Substance Misuse

Wards for people with LD or Autism

99.4% 97.7% - 100%

Brain injury

Rehabilitation (Sid

Watkins unit)

Long stay/rehabilitation mental

health wards for working age adults 99.1% 98.9% - 100%



appearance

and

maintenance

Dementia

friendly

Disability

Trust overall 98.8% 97.3% 81.3% 89.9%

England average

(Mental health

and learning

disabilities)

98.0% 95.2% 84.8% 86.3%

Both units were very clean and tidy, with all areas inspected maintained at a high level of

cleanliness. Furniture was well maintained and of a standard that reflected the rehabilitation status

of the wards. Cleaning rosters were up to date. Each room in the service had a nurse call button

and all staff carried alarms. Inspection team members were supplied with alarms as a matter of

procedure.

Each bedroom was en-suite, and male and female areas were segregated. There was no reason

for a male patient to pass a female bedroom to access a toilet, or a female to pass a male

bedroom to access a bathroom.

Clinic room and equipment

Both the Rathbone site and the Sid Watkins site had a separate physical health room, including an

examination couch and machines to measure blood pressure and blood sugar monitoring

equipment. All equipment at both services had been recalibrated and checked prior to the

inspection. Emergency bags were present, both were routinely checked and had labels attached

regarding expiry dates of equipment within the bag. The Rathbone service was situated across

two floors, and both floors had an emergency bag. Oxygen cylinders were checked and found to

be well within expiry dates, with gauges showing full. Drug stocks and drug fridges were checked,

and found to be in order, with relevant checks carried out regularly. Ligature cutters were in

locations that were labelled, and accessible to staff.

Safe staffing

Nursing staff

The service had enough nursing and medical staff, who knew the patients and received basic

training to keep people safe from avoidable harm. Ward managers could bring in extra or covering

staff when needed. We saw that ward inductions were taking place for bank staff, as well as new

permanent staff to the ward. We saw no evidence that leave agreed under the Mental Health Act

was being cancelled, although staff did inform us that leave could be re-arranged depending on

ward circumstances. We were told that ward activities were not being cancelled, and patients told

us this during interviews.




Definition





Total number of substantive staff 31 July 2018 28.1 N/A


2.7 N/A


9% 13%


Total vacancies overall (excluding seconded staff) 31 July 2018 -3.8 N/A

Total vacancies overall (%) 31 July 2018 -6% 5%


Most recent month (31 July 2018)

9% 8%

01 August 2017–31 July 2018

6% 8%


Establishment levels qualified nurses (WTE*) 31 July 2018 22.1 N/A

Establishment levels nursing assistants (WTE*) 31 July 2018 30.1 N/A

Number of vacancies, qualified nurses (WTE*) 31 July 2018 -1.4 N/A

Number of WTE vacancies nursing assistants 31 July 2018 0.3 N/A

Qualified nurse vacancy rate 31 July 2018 -6% 5%

Nursing assistant vacancy rate 31 July 2018

1% 5%

Bank and agency Use


(qualified nurses) 01 August 2017–31

July 2018 3058 N/A


vacancies (qualified nurses) 01 August 2017–31

July 2018 256 N/A


absence or vacancies (qualified nurses) 01 August 2017–31

July 2018 179 N/A


(nursing assistants)

01 August 2017–31

July 2018 5259 N/A


vacancies (nursing assistants)

01 August 2017–31

July 2018 1458 N/A


absence or vacancies (nursing assistants)

01 August 2017–31

July 2018 88 N/A

*Whole-time Equivalent / minus figures mean that the service is oversubscribed

This core service reported an overall vacancy rate of -6% over establishment for registered nurses

at 31 July 2018.


This core service reported an overall vacancy rate of 1% for registered nursing assistants.

This core service has reported a vacancy rate for all staff of -6% over establishment as of 31July

2018.


Ward/Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Rathbone Rehab Centre -1.2 12.2 -9% 1.1 14.3 8% -1.1 32.1 -3%

Brain Injury Support -0.2 10.0 -2% -0.7 15.7 -5% -2.7 29.7 -9%

Core service total -1.4 22.1 -6% 0.3 30.1 1% -3.8 61.8 -6%

Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%




In the same period, agency staff covered 256 hours for qualified nurses. 179 hours were unable to

be filled by either bank or agency staff.

Ward/Team Available hours Hours filled by bank

staff

Hours filled by

agency staff

Hours NOT filled by


Brain Injury

Unit 1629 961 97 33

Rehabilitation

Centre 1776 2097 159 147

Core service

total 3405 3058 256 179

Trust Total 242318 125599 64603`` 31532



In the same period, agency staff covered 1458 hours. Eighty-eight hours were unable to be filled

by either bank or agency staff.


staff

Hours filled by

agency staff

Hours NOT filled by bank

or agency staff

Brain Injury

Unit 2561 2913 953 117

Rehabilitation

Centre 3296 2346 505 -29



staff

Hours filled by

agency staff


or agency staff

Core service

total 5858 5259 1458 88

Trust Total 210729 442987 204924 29961


Ward/Team Substantive

staff

Substantive staff

Leavers

Average % staff

leavers

350 L9 Brain Injury Support (Z1BK90) 27.0 2.7 11%

350 L9 Rehab Senior Med Staff

(Z1BR10) 1.0 0.0 0%


Trust Total 2658.6 294.5 13%



Ward/Team Total % staff sickness

(at latest month)

Ave % permanent staff

sickness (over the past

year)

350 L9 Brain Injury Support (Z1BK90) 9% 7%

350 L9 Rehab Senior Med Staff (Z1BR10) 0% 0%


Trust Total 8% 8%

The below table covers staff fill rates for registered nurses and care staff during July, August and

September 2018.

Both wards had under filled for registered nurses for all day shifts across all three months.

The Brain Injury Unit had over filled for care staff for night shifts for all months reported.

Key:

> 125% < 90%

Day Night Day Night Day Night


Nurses

(%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

July 18 August 18 September 18

Brain Injury

Unit 78.3 127.7 100.0 133.8 87.0 124.6 100.0 148.4 73.0 126.5 100.0 138.2

Rehabilitation

Centre 85.3 108.9 100.0 100.0 84.1 109.9 100.0 99.0 83.2 108.8 100.0 100.0

Where qualified staff numbers were low, the service had a full or higher quota of health care

assistants.

Medical staff

There was no useable data provided for medical locum usage.

Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone

completed it.

The compliance for mandatory and statutory training courses at 31 July 2018 was 35%. Of the

training courses listed 25 failed to achieve the trust target of between 90% and 95%, and of those,

10 failed to score above 75%. However, data held by ward managers showed that the trust figures

were not accurate, and that recording of the mandatory training of staff did not reflect that the ward

results were higher than the trust data. Mental Health Act training and Mental Capacity Act training

is shown as being 96% for both courses, however data later used in the report stated the figure

was 100% for both courses.

The training compliance data is reported on an ongoing monthly basis. Statutory training is

reported as part of the monthly board report dashboard produced by Workforce and a separate

dashboard is provided by the Learning and Development team for all other courses classified by

ourselves as role essential.

Key:



Training course This core service %

Trust target %

Trust-wide mandatory/ statutory

training total %

Role Specific Mandated Training - Basic Prevent Awareness

(1 Time) 100% 90% 93%

Continuous Professional Development - Fraud Awareness

(Every 3 Years) 99% 95% 89%

Continuous Professional Development - Adverse Incidents

(Every 3 Years) 98% 95% 92%

Continuous Professional Development - Complaints (Every 3

Years) 97% 95% 94%



Trust target %


training total %

Role Specific Mandated Training - Deprivation of Liberties -

Level 1 (Every 3 Years) 96% 90% 89%

Role Specific Mandated Training - Mental Capacity Act -


Role Specific Mandated Training - Mental Health Act - Level 1

(Every 3 Years) 96% 90% 90%

Role Specific Mandated Training - Controlled Drugs & High

Risk Medicines 95% 90% 67%

Continuous Professional Development - Suicide Prevention

& Safety Planning (Every 3 Years) 94% 95% 90%

Mandatory Training - Safeguarding Children - Level 1 (Every

3 Years) 94% 95% 95%

Role Specific Mandated Training - Safeguarding Adults Level

2 -Trust Model (Every 3 Years) 93% 90% 87%

Role Specific Mandated Training - Safeguarding Children

Level 2 - Trust Model (Every 3 Years) 93% 90% 87%

Continuous Professional Development - Smoking Cessation

(1 Time) 92% 95% 89%

Mandatory Training - Safeguarding Adults - Level 1 (Every 3

Years) 92% 95% 95%

Role Specific Mandated Training - Safe and Effective Use of

Medicines (Every 3 Years) 89% 90% 63%

Mandatory Training - Infection Control (Every 3 Years) 88% 95% 92%

Role Specific Mandated Training - Moving and Handling of

People (Every Year) 88% 90% 48%

Role Specific Mandated Training - Intermediate Life Support

(Every Year) 88% 90% 72%

Mandatory Training - Health & Safety (Every 3 Years) 85% 95% 92%

Mandatory Training - Fire Safety (Every 3 Years) 84% 95% 92%

Mandatory Training - Moving & Handling (Every 3 Years) 84% 95% 90%

Role Specific Mandated Training - Basic Life Support (Every

Year) 82% 90% 70%

Mandatory Training - Equality, Diversity and Human Rights

(Every 3 Years) 80% 95% 91%

Mandatory Training - Conflict Resolution (Every 3 Years) 79% 95% 92%

Role Specific Mandated Training - Personal Safety (Every

Year) 77% 90% 50%

Role Specific Mandated Training - Medicines Calculations

(Every 3 Years) 74% 90% 63%

Role Specific Mandated Training - Safeguarding Adults Level

3 - Trust Model (Every 3 Years) 73% 90% 76%



Trust target %


training total %

Role Specific Mandated Training - Safeguarding Children

Level 3 - Trust Model (Every 3 Years) 73% 95% 76%

Continuous Professional Development - Dementia

Awareness (1 Time) 72% 95% 78%

Continuous Professional Development - Moving and

Handling of Inanimate Objects 68% 95% 56%

Role Specific Mandated Training - Witness to Medication

(Every 3 Years) 65% 90% 62%

Role Specific Mandated Training - Rapid Tranquilisation

Training 60% 90% 61%

Role Specific Mandated Training - MHA/DoL's Level 2 (Every

3 Years) 56% 90% 53%

Role Specific Mandated Training - Personal Safety

Breakaway - Level 1 (Every 2 Years) 50% 90% 50%

Mandatory Training (IG) - Data Security Awareness - Level 1

(Every Year) 45% 90% 50%


Data provided during the inspection showed that mandatory training at both sites had achieved

trust targets.




manage risks individually. They minimised the use of restrictive interventions and followed best

practice when restricting a patient. Risk assessments were completed on a weekly basis, with

evidence noted of the updating of risk assessments after any incident. Discharge summaries held

crisis plans, informing patients of what to do and who to approach in the event of a possible

relapsed or need for treatment. We saw no evidence of advance decisions at the service.

Use of restrictive interventions

This core service had four incidents of restraint (on four different service users) and no incidents of

seclusion between 1 August 2017 and 31 July 2018.

The below table focuses on the last 12 months’ worth of data: 1 August 2017 to 31 July 2018.

Ward name Seclusions Restraints Patients

restrained

Of restraints, incidents of

prone restraint

Rapid

tranquilisations

Rathbone

Rehabilitatio

n Ward

0 2 2 0 (0%) 0 (0%)



restrained


prone restraint

Rapid

tranquilisations

Brain

Injuries

Rehabilitatio

n

0 2 2 0 (0%) 0 (0%)

Core service

total 0 4 4 0 (0%) 0 (0%)

There were no incidents of prone restraint.

There were no instances of rapid tranquilisation over the reporting period.

There have been no instances of mechanical restraint over the reporting period.

There have been no instances of seclusion over the 12-month reporting period. Neither ward

inspected has a seclusion room.

There have been no instances of long-term segregation over the 12-month reporting period.

Safeguarding



apply it.




institutional.





should take place.

This core service made three safeguarding referrals between 1 August 2017 and 31 July 2018

year, of which three concerned adults and none children.

Number of referrals


3 0 3

The three referrals were made in December 2017, May and July 2018, all with one referral made

in those months.


Mersey Care NHS Foundation Trust has submitted details of three serious case reviews

commenced or published in the last 12 months [1 June 2017 and 31 May 2018]. However, none

relate to this core service.

Staff told us that relationships with local safeguarding structures were good. A policy was in place

for children visiting the units, and this was adhered to.


Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and

easily available to all staff providing care. Staff present were familiar with the system and easily

located information that we were trying to find.



effects of medications on each patient’s physical health. We attended a medicine round taking

place at the Rathbone rehabilitation unit, and saw good practice taking place. Patients were taken

into the clinic, seated, asked for identifying details, symptoms were discussed and questions

asked regarding how the patient felt, before the medication was administered. Staff washed their

hands between patients, and medication administration records completed. We reviewed 31

medication administration records across the service: the records were recorded correctly and

accurately.

All admissions were planned, allowing medicine reconciliation to be well organised and effective. A

pharmacist visited the units weekly, with a pharmacy technician also visiting the wards. We were

told that the pharmacist checked the medication cards on each visit, and we saw evidence of audit

by staff to also check medication records.




Between 1 August 2017 and 31 July 2018 there were no STEIS incidents reported by this core

service.











directly asked for a response. None of these related to this core service.



and the wider service. When things went wrong, staff apologised and gave patients honest

information and suitable support. We saw evidence that duty of candour policy was being followed

by the service.

De-briefing was available should it be required post-incident: however, it had not been necessary

at the service.





individual care plans and updated them when needed. We reviewed nine sets of care records that

confirmed this. All patients had copies of their care plans. On the brain injuries unit, a file was kept

in the room of each patient that had copies of care plans for patients to access at any time. Care

plans were holistic, individualised, but some care plans included jargon that might confuse

patients. We saw that physical health monitoring was on-going, and was up to date from

admission to the time of inspection. The Rathbone unit had a physical health nurse in post, with a

trained nurse associate on the brain injury rehabilitation unit. Physical health monitoring was

recorded and assessed against the recommendations of the responsible clinician regarding

existing physical ailments, as well as general physical health monitoring.


Staff provided a range of treatment and care for patients based on national guidance and best

practice. Staff supported patients with their physical health and encouraged them to live healthier

lives.

This core service participated in eight clinical audits as part of their clinical audit programme 2017

– 2018.



REILS Red

Bag

(Emergency

bag) Audit

Secure, Local

and SpLD

Divisions

Clinical and

Environment 09/08/2017

The areas for improvement were

signposting to emergency ILS bags and

contents lists being present in the bags.

This has been factored into routine

monitoring at ward level to improve

compliance, and is part of regular reviews.

Individual actions were identified as

follows: SpLD: Staff need instruction

and/or flowchart for restock/resealing of

bag. Needs signage erecting to indicate to

staff the location of the emergency orange

box. Staff to be advised that AED is not

getting checked regularly. Staff to be

advised to check AED on a daily basis and

to sign to say it has been checked daily.

Secure Division: A rota to be put in place

to ensure that daily checks of AED are

done regularly, Aztrax need to check AED

as out of date and needs asset number. 2

x non- rebreather masks need replacing as

out of date. Needs signage erecting to

direct staff to nearest AED and oxygen

location, 2 x size 14g cannulas out of date




and need replacing. Local Division: Needs

signage erecting to direct staff to nearest

AED and oxygen location, an equipment

list and a flow chart for restock/reseal of

bag. Staff to be advised to check AED on a

daily basis and to sign to say it has been

checked daily. Needs 1 set of defib pads

replacing as out of date and non-

rebreather mask to go with the oxygen.

Oxygen to be reordered along with a new

bag valve mask.

Health

Records Audit

Secure,

Local,SpLD

and LCH

Sefton

Locality

Clinical 14/12/2017


relating to their own area. The emphasis

for action and improvement is

countersignature of entries by staff that

cannot authorise a clinical note. There is a

review of the electronic patient records

systems in use to review how automation

can improve compliance.

Ward

Transfers

Audit

Local

Division Clinical 27/02/2018 No action Plan (see previous column).

Named Nurse

Audit Report

Local


The Audit Findings have been shared with

the Lead Nurse for the Local Division for

her comments / actions.

The Clinical Audit Team recommended the

following:

For all named nurse sessions it should be

clearly stated at the start of the note that it

is a 1:1 Named Nurse Session.

There was evidence to suggest that a lot of

what should be discussed in a Named

Nurse session was being documented but

NOT under this heading – so this was a

documenting issue rather than it not being

done. It was either contained in a general

ward note or MDT note.

The template provided for the audit may

not be appropriate for some patients on

Older Persons Wards in particular those

with an organic diagnosis. This was due to

the weekly planned sessions, which would

not always be appropriate in these cases.

Action Plan formulated to include the




following: 1. Ward Manager to discuss

with Registered Nurses ways to maximise

opportunities to spend time on 1:1 basis

with named service users. 2. Develop and

share named nurse proforma for named

nurses to use in 1:1 sessions with service

users.

National

Clinical Audit

of Psychosis

Local, Secure

and SpLD

Divisions

Clinical 13/04/2018

Recommendation 1 (by the Royal College

of Psychiatrists)



cardiovascular risk (using the current

version of Q-Risk) receive appropriate

interventions informed by the results of this

assessment have the results of this

assessment and the details of

interventions offered recorded in their case

record. Recommendation 2


offered CBT and family interventions, by:

deploying sufficient numbers of trained

staff who can deliver these interventions

making sure that staff and clinical teams

are aware of how and when to refer people

for these treatments. Recommendation 3

Ensure that all people with psychosis: are

given written or online information about

the antipsychotic medication they are

prescribed are involved in the prescribing

decision, including having a documented

discussion about benefits and adverse

effects of the medication.

Recommendation 4

Ensure that all people with psychosis who

are unable to attend mainstream

education, training or work, are offered

alternative educational or occupational

activities according to their individual

needs; and that interventions offered are

documented in their care plan.

Recommendation 5






updated annually be shared with the

patient and their primary care




team. Recommendation 6

NHS Digital, NWIS, Commissioners, Trusts

and Health Boards should work together to

put in place key indicators for which data

can easily be collected, perhaps using an

Annual Summary of Care (see

Recommendation 5 above). This work

should be informed by the NCAP results

and the experience of the NCAP team.

Hoisting

Equipment

Audit

Local

Division

Clinical and



the teams and Action Plan has been

completed:

Loler Inspections have been completed on

all hoists. Other actions include: To

monitor the number of slings available, and

to explore options for purchasing variety of

sling styles.

Datix Incidents

Audit Report

Local




development

Nutritional

Screening and

Care Planning

(Adapted

MUST tool)

Local

Division Clinical 01/10/2017 No Action Plan

Psychological input was available at both units. At Rathbone site, the service had a part-time

clinical psychologist who did two days a week, but was assisted by a psychology assistant on a

Tuesday, and two band four psychology assistants during the rest of the week, with a new

psychology assistant due to start on site shortly after the inspection. At the brain injury

rehabilitation unit, there was a part-time psychologist covering a full-time post, the full-time

psychologist returning to the post in January 2019. There was also an assistant psychologist in

post, but this was on a fixed-term contract. We saw that there was a lot of joint working with

occupational therapists, speech and language therapists and physiotherapists at the service,

enhancing the multi-disciplinary approach within the service. We attended a psychology group

activity meeting, and saw good interaction and positive effect for patients.

Staff had access to new information technology, by way of the new care record system and the

provision of laptops. Laptops were used in multi-disciplinary meetings and named nurse one to

ones with patients.

Ratings scales were used to assess and record severity and outcomes, the service using the

Health of the Nation Outcome Scale. Staff were involved in various levels of clinical audit,

including infection control, care plan audits, risk assessment audits and Mental Health Act audits.



Managers made sure they had staff with a range of skills need to provide high quality care. They

supported staff with appraisals, supervision and opportunities to update and further develop their

skills.



The wards/teams failing to achieve the trust’s appraisal target were Brain Injury Support with an

appraisal rate of 93%.

Ward name

Total number of

permanent non-medical

staff requiring an

appraisal

Total number of

permanent non-

medical staff who

have had an appraisal

% appraisals


350 L9 Brain Injury Support (Z1BK90) 27 25 93%


Trust wide 5565 4780 86%

The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, there was no data

pertaining to medical staff for this core service.

Between 1 August 2017 and 31 July 2018, the average rate across both teams in this core service

was 53%.



Ward name Clinical supervision

sessions required


sessions delivered

Clinical

supervision rate

(%)


351 L9 Brain Injury Support (Z1BK90) 81 37 46%


Trust Total 15334 4947 32%

During the inspection, we viewed the supervision records for both Rathbone rehabilitation unit and

the brain injury rehabilitation unit, and found both units had supervision rates above 75% but

below the trust target of 95%. On Rathbone unit, the supervision figure stood at 89%, and could

not go any higher as remaining staff were not available.


We were told that staff performance issues would be addressed promptly and effectively, however

there had been no such issues in the service.

Multi-disciplinary and interagency team work


other to make sure patients had no gaps in their care.

Multi-disciplinary team meetings took place every Monday at the service, as well as ward rounds

where all patients were discussed by the multi-disciplinary team. We were told that care

coordinators were good at keeping in touch at the Rathbone site, whilst the social workers who

represented the patients at the brain injury rehabilitation unit were always available and kept in

touch with staff and patients.

Care records indicated good relationships between the service and other relevant external

organisations.


Practice



As of 31 July 2018, 100% of the workforce in this core service had received training in the Mental

Health Act. The trust stated that this training is mandatory for all core services for inpatient and all

community staff and renewed every three years.

Staff had access to administrators who audited the Mental Health Act, and knew how to contact

them. There was a copy of the current Mental Health Act Code of Practice available on both sites.

We saw documented evidence that patient rights were being explained in line with the Code of

Practice. Medication management and documentation followed the requirements of the Mental

Health Act Code of Practice. Both sites had notices to patients admitted informally that they could

leave the ward at any time. We saw that Mental Health Act documentation was being audited in

the service.



policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly. Staff knew

the principles of the Mental Capacity Act when speaking with the inspection team. Care records

clearly showed evidence that capacity was being considered for each patient, and that decisions

were specific to situations. Best interest meetings were taking place. Capacity was being audited

by the service.


Capacity Act. The trust stated that this training is mandatory for all core services for inpatient and

all community staff and renewed every three years.


The trust told us that no Deprivation of Liberty Safeguard (DoLS) applications were made to the

Local Authority for this core service between 1 August 2017 and 31 July 2018. Staff told us that a

Deprivation of Liberty Safeguard application would be applied for, should it be deemed necessary.





and supported their individual needs. The inspection team saw interaction between patients and

staff. Staff approached patient rooms and knocked before entering, and spoke to patients in a

friendly manner. This approach was reflected in patient experience findings

The 2017 Patient-led assessments of the care environment (PLACE) score for privacy, dignity and

wellbeing at two core service location(s) scored better than similar organisations.

Site name Core service(s) provided Privacy, dignity

and wellbeing

Rathbone Hospital

Community based mental health services or adults of

working age

Long say/rehabilitation mental health wards for

working age adults

Secure/forensic

Substance Misuse


94%

Brain injury Rehabilitation (Sid

Watkins unit)

Long stay/rehabilitation mental health wards for

working age adults 100%

Trust overall 92.7%

England average (mental health

and learning disabilities) 90.6%

Involvement in care



changes to the service. Admission to the service was planned, with welcome packs being

available to both patients and carers, and a full introduction to the service. Both units had

information leaflets regarding treatments and rights in accessible areas.

There were noticeboards that had information regarding access to advocacy support for patients.

Patient records showed advocacy involvement in meetings. We noted the use of speech and

language therapist work with patients, designed to aid patients in their communication needs and

physical problems.

We approached many patients across the service for their view concerning the service. Only

seven patients were willing to speak to the inspection team. All patients said they were involved in

their care, had copies of their care plans, and felt that staff on the units listened to them. Patients

told us they felt safe within the service.


The Patient Experience report for September and October 2018 showed an average result of

100% for all aspects reviewed, such as activities, care and treatment, cleanliness, and effective

care.

We reviewed patient community forum minutes from the brain injuries rehabilitation unit from

August to the end of October. These showed active participation by patients, and comments from

patients were noted and acted upon, feedback from patients was clearly considered.

Patient records showed that patient opinions were recorded and considered during multi-

disciplinary meetings. Patient records showed consideration of patient views with regards to

discharge from the service.


The service ran a carer’s forum, inviting carers of all patients admitted to the service. Carers were

invited regularly to ward reviews, we saw this reflected in care record notes. We spoke to five

carers of patients admitted to the service.

Carers we spoke to told us that they were involved in the care of their relatives at the service,

some more than others. Overall, carers were happy with the service being provided, although we

were told by one carer that they felt the service was not working as hard with their relative as they

did on admission. We saw that information regarding carer’s assessments were available at the

service, and a carer’s lead was available to discuss issues on the brain injury rehabilitation ward.

Carers told us that if they required specific information regarding their relative, or if they had any

questions, staff were always willing to talk to them and find the answers to their questions.


Is the service responsive? Between 1 August 2017 and 31 July 2018, the core service had a number of ward moves, as

outlined in the table below:

During the last 12 months – YR 1 (2017/2018)

During the previous 12 months – YR2 (2016/2017)

Ward name

Number of ward moves

Number of patients

How many were at 'end

of life'*

%-share of all patients

Number of patients


of life'*


Rathbone Rehab centre

0 12 0 71% 23 0 88%

1 4 0 24% 2 0 8%

2 1 0 6% 1 0 4%

3 0 0 0% 0 0 0%

4+ 0 0 0% 0 0 0%

Total 17 0 100% 26 0 100%

Brain Injury Rehab

0 34 0 85% 39 0 91%

1 5 0 13% 2 0 5%

2 1 0 3% 2 0 5%

3 0 0 0% 0 0 0%

4+ 0 0 0% 0 0 0%

Total 40 0 100% 43 0 100%

.

Access and discharge

People could access the service closest to their home when they needed it. Waiting times from

referral to treatment and arrangements to admit, treat and discharge patients were in line with

good practice. All admissions to the service were planned admissions. There was clear evidence

in care records of discharge planning, discharge being considered from admission. This was

reflected in the involvement of social works and care coordinators of patients on both sites.

Bed management

The trust provided information regarding average bed occupancies for two wards in this core

service between 1 August 2017 and 1 July 2018.

Rathbone rehab centre within this core service reported average bed occupancies ranging above

the national recommended benchmark of 85% over this period.

We are unable to compare the average bed occupancy data to the previous inspection due to

differences in the way we asked for the data and the period that was covered.


Ward name Average bed occupancy range (1 August 2017 – 31

July 2018) (current inspection)

Brain Injury Rehab 58.6% - 96%

Rathbone Rehab Centre 85.6% - 94.9%

The trust provided information for average length of stay for the period 1 August 2017 to 31 July

2018.



Ward name Average length of stay range (1 August 2017 – 31 July

2018) (current inspection)

Brain Injury Rehab 46.9 – 203.6

Rathbone Rehab Centre 244.1 – 844.9

This core service reported one out area placements between 1 August 2017 and 31 July 2018.

As of 13 August 2018, this core service had no ongoing out of area placements.

There were no placements that lasted less than one day, and the placement that lasted the

longest amounted to 2146 days. The longest stay patient was confirmed to have had very complex

needs regarding placement, and efforts were made to seek suitable placement, resulting in a

successful placement.

The out of area placement was due to the patient being placed with another provider due to this

better suiting their care or personal needs.

Number of out of

area placements

Number due to

specialist needs

Number due to

capacity

Range of lengths

(completed

placements)

Number of ongoing

placements

1 1 0 2146 0

This core service reported two readmissions within 28 days between 1 August 2017 and 31 July

2018.

One of the readmissions (50%) were readmissions to the same ward as discharge.

The average of days between discharge and readmission was six days. There were no instances

whereby patients were readmitted on the same day as being discharged but there were no

instances where patients were readmitted the day after being discharged.


Ward name Number of

readmissions

(to any ward)

within 28 days

Number of

readmissions

(to the same

ward) within 28

days

% readmissions

to the same

ward

Range of days

between

discharge and

readmission

Average days

between

discharge and

readmission

Brain Injury Rehab

1 1 50% 2-10 6

Staff told us that new admissions could be refused to the service. Each new admission was

discussed within the multi-disciplinary team, and the merits of admission were considered, with

possible problems with other patients discussed. Patients had access to their bed on return from

leave.

Discharge and transfers of care

Between 1 August 2017 and 31 July 2018, there were 56 discharges within this core service. This

amounts to 1.5% of the total discharges from the trust overall (3784).

Of the 54 discharges for this core service, 21 (38%) were delayed. We were told that the main

cause of delay in discharge was due to accommodation issues, difficulty finding the appropriate

accommodation to suit the patient. However, external issues within the relevant community could

also impact discharge. At the time of the inspection, neither the Rathbone rehabilitation unit nor

the brain injury rehabilitation unit had any delayed discharges.

The trust identified services as measured on ‘referral to initial assessment’ and ‘assessment to

treatment’. However, there was no information relating to this core service.

Facilities that promote comfort, dignity and privacy

The design, layout, and furnishings of the ward/service supported patients’ treatment, privacy and

dignity. Patients could access their rooms during the day without requesting doors to be unlocked,

and on the Rathbone site patients had their own keys to their rooms. Each room had a small safe

that allowed patients to keep valuable items secure. Patients could access their own mobile

telephone. Patients could access outdoor space. At Rathbone, patients had a large, well

maintained outdoor area with lots of seating and exercise equipment, and kept a barbecue on site,

after patients had requested that barbecues be held during the summer months. The brain injury

rehabilitation unit had a balcony area that overlooked an atrium, with glass walls allowing patients

to view the atrium area easily.

The service had rooms for therapies and activities, quiet areas, male and female lounges. There

were kitchens that allowed patients to cook their own food. This also meant that hot drinks and

snacks were available at any time.

Activities were available seven days a week. The activities were meaningful and relevant to the

patients at the service. Both sites had occupational therapists and assistant occupational

therapists, with on-going recruitment for assistants and speech and language therapists. Activities

were worked around morning routines, such as medication rounds. At Rathbone rehabilitation unit

there were activities that included daily living skills groups, a psychology group (this was attended

by an inspection team member, and excellent communication between staff and patients was


noted), music therapy, walking groups, pamper groups, computer access for patients to improve

skills, cookery groups and creative arts. The groups were aimed at preparing patients for their

eventual discharge, as well as ensuring they were active whilst admitted.

The 2017 Patient-led assessments of the care environment (PLACE) score for ward food at the

locations scored better than or the same as similar trusts.

Site name Core service(s) provided Ward food

Rathbone Hospital

Community based mental health services or adults of

working age

Long say/rehabilitation mental health wards for

working age adults

Secure/forensic

Substance Misuse


92.3%

Brain injury Rehabilitation (Sid

Watkins unit)

Long stay/rehabilitation mental health wards for

working age adults 91.3%

Trust overall 95.4%

England average (mental health and learning disabilities) 91.5%


There were opportunities for patients to do volunteer work, with courses available to patients who

wanted to learn. These were openly advertised on noticeboards on both units. A brain injury

association was working closely with the brain injury rehabilitation unit, giving many opportunities

to those diagnosed with brain injuries.

Care records indicated support given to patients to develop and maintain relationships, with

patient one to ones showing staff encouragement to patients to maintain contact with family.

Carers we spoke to told us of the input from staff that helped to keep communication open and

people in touch. Carers told us that staff were always approachable and were happy to discuss

patient needs and involve patients in dialogue.


The service was accessible to all who needed it and took account of patients’ individual needs.

Staff helped patients with communication, advocacy and cultural support. There were bathrooms

that had been adapted to enable more disabled patients to maintain personal hygiene. There were

hoists in each bedroom at the brain injury rehabilitation unit that had been built into the rooms, the

hoists allowing less mobile patients to be moved about the room and even into the en-suite

bathroom. Bedroom doors were wide enough to cope with wheelchair access, and rooms had

enough floor space around the beds to ensure mobility aids could be used safely. The Rathbone

unit had a lift to allow patients with limited mobility to move to and from the upper floor of the unit.

There were rooms for activities, and gym equipment available to patients and staff. The

gymnasium on the brain injury rehabilitation unit was very well equipped, with assisted-walking

rails, treadmills, exercise bicycles and steps for practising walking up and down stairs in a safe


environment. The games room at the Rathbone unit was well equipped, including a pool table and

table tennis equipment, and a punch bag.

We saw leaflets relating to treatments, rights, smoking cessation, advocacy, CQC, medication and

others, all easily accessible on the units. On the Brain injury rehabilitation unit, there was a poster

on a noticeboard in a variety of languages informing the reader of how to access information in

their language or linguistic translation. We were told that such leaflets or information in a different

language could be accessed by staff if required by a patient or carer. There was a variety of food

available, patients told us that the food at the service was good, and the choice was varied. Food

prepared with consideration of cultural needs was available to different faiths.

A chaplain visited the brain injury rehabilitation unit, with the service providing access to other

faiths should they be requested. The Rathbone unit had a multi-faith room on the ward that gave

consideration to a variety of faiths.


This core service received two complaints between 1 August 2017 and 31 July 2018. One of these

were upheld and one partially upheld. None were referred to the Ombudsman.

Ward

name

Total

Complaints

Fully

upheld

Partially

upheld

Not

upheld

Referred to

Ombudsman

Upheld by

Ombudsman

Brain

Injuries

Rehab

2 1 1 0 0 0

This core service received one compliment during the last 12 months from 1 August 2017 to 31

July 2018 which accounted for <1% of all compliments received by the trust as a whole.

There were noticeboards containing detailed information on how to complain, and this was also

detailed in the welcome pack for both carers and patients. Patients told us they knew how to

complain, but none of those interviewed had exercised that right. Complaints were handled either

informally or formally by the service, depending on the complexity or severity. As the information

provided by the trust indicated, the service only had two complaints in a 12-month period.



Leadership

Managers at all levels in the trust had the right skills and abilities to run a service providing high-

quality sustainable care. Unit managers knew who their senior managers were, and could show

that senior managers had visited the ward. Leadership opportunities were available for managers

in the unit, and these opportunities had been taken up by managers in the service.

Vision and strategy



The trust also set goals for zero suicides for people in care, no force first (zero physical or

medication-led restraint), physical health and a just culture.

Each site in the service followed the values of the trust, and staff we spoke to were aware of the

values and could talk about what they meant to themselves and the patients. Managers felt that

their opinions had been listened to in the formulation of the values, and the trust often included all

staff in surveys aimed at improving the service.

Culture


sense of common purpose based on shared values. Focus groups were held prior to the

inspection, and staff told us that they felt that they were respected and valued. Staff at the service

told us that they felt respected and valued. We were told by staff that they felt the team morale in

the service was good, and they felt supported by their line managers.

Relationships between staff and senior multi-disciplinary team members were reported to be good.

An inspection team member observed a discussion between senior medical staff and ward staff,

the discussion showed differences of opinion, but the staff reached an amicable solution to the

problem. Staff knew how to use the whistle-blowing process.

During the reporting period, there were no cases where staff had been either suspended, placed

under supervision or moved to a different ward

Governance

The trust used a systematic approach to continually improve the quality of its services and

safeguarding high standards of care by creating an environment in which excellence in clinical

care would flourish.

The trust used an electronic system to monitor and inform the service of its position in relation to

key performance indicators, to be used as a gauge of performance. Audit results relating to the

service were highlighted, and outlined such aspects as action plans for care plans, medical

revalidation reports, risk assessment audits, infection control, bed occupancy and payment by


results clustering. These indicators and audits showed that the service was acting upon findings

and using the information to take forward the service.

Mangers felt they had enough authority to do their job, and they had access to administrative

support. The service played an active role in the trust restrictive practice group, with a view to

reviewing restrictive practice across the trust, and this was supported at board level. This was

displayed as it was an active aspect of the board meeting in July 2018, attended by inspection

team members.




The trust has provided a document detailing their 34 highest profile risks. One of the 34 corporate

risks had a current risk score of 15 or higher. However, none related to this core service.

Managers told us that entries to the risk register could be made by staff, by relaying such risks to

the manager of the unit, the manager of the unit then applying for the register to be amended

accordingly.


The trust collected, analysed, managed and used information well to support all its activities, using

secure systems with security safeguards.

The trust had recently changed its computer system. The system was secure with security

safeguards. We viewed the new system in use during the inspection, and it was seen to be

effective, coupled with the auditing of information that had been put securely into the system to

feed into the performance monitoring tool used to gauge performance.

Engagement

Unit managers told us that they were fully engaged with the trust in taking the service forward.

Leadership meetings took place that included service managers. Quality reports for the trust

indicated that the service had identified aspects of the service that needed to be improved, such

as supervision, and it was clear that the service had improved on those aspects. There was also

improvement in wider agency involvement with the trust.







The trust provided which services have been awarded an accreditation together with the relevant

dates of accreditation. However, there was no information pertinent to this core service.


However, the brain injury rehabilitation unit had been accepted on the day of inspection with

accreditation by a national Approved Provider scheme from a national brain injury charity. The

accreditation demonstrated commitment to continuous service improvement and ensuring a

workforce trained and skilled in working with individuals with brain injury

Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units

Acute wards for adults of working age and psychiatric intensive care units



female, mixed)

Broadoak Albert Ward 24 Male

Clock View Alt Ward 17 Mixed

Broadoak Bed management Not applicable Mixed

Broadoak Brunswick Ward 23 Mixed

Clock View Dee Ward 17 Female

Broadoak Harrington ward 19 Female

Clock View Morris Ward 17 Male

Clock View Newton Ward

(PICU) 12 Mixed

Hesketh Centre

Park Unit

(merged

Rowbotham)

24 Mixed

Windsor House Windsor House

inpatient service 24 Mixed




All wards were safe, clean, well equipped, well furnished, and well maintained.


The wards were provided across four sites, and each building was of a different age and design.

The older buildings were at the Broadoak Unit, the Hesketh Centre and Windsor House. These

wards were not consistent with current guidance on the design of mental health units. Sleeping

accommodation was mainly provided in dormitories with a small number of single occupancy

rooms on each site. Each dormitory had four beds, and each bed area was curtained off to

maintain patients’ privacy. The units had limited access to outdoor space. Clock House Hospital

was a relatively new build and had been designed with consideration to reducing risks. Wards at

Clock House hospital had ensuite single bedrooms for all patients, and direct access to outdoor

areas.

The wards complied with guidance on eliminating mixed-sex accommodation. There were

designated corridors for men and women’s rooms and dormitories. There were dedicated female

lounges in all wards.


accommodation breaches within this core service. However, we were informed that a male patient

had recently been admitted to a bed in a female area at the Broadoak Unit. This had happened at

night, the patient had been on 1-1 observation, and had moved to a male bed the following day.

Four of the nine wards were single sex – two for men and two for women.

Staff could clearly see all areas of the ward, or were aware of blind spots and mitigated against

them. Staff were aware of any ligature anchor points and actions to mitigate risks to patients who

might try to harm themselves. There were ligature risks on all wards within this core service. The

trust had undertaken recent (from 1 January 2017 to 15 August 2018) ligature risk assessments at

nine wards. All nine wards presented a high level of ligature risk, and the trust provided various

reasons for this. However, the trust had taken actions for each to mitigate ligature risks. Bedrooms

and bathrooms were fitted with anti-ligature fittings such as door-less wardrobes, collapsible

curtain rails, and inbuilt sensor taps. Staff had access to alarms, and patients had access to nurse

call systems.


The wards were mostly clean and well maintained. Infection control audits were carried out, and

personal protective equipment and handwashing equipment was available for staff. Clinical waste

and sharps were disposed of safely.

For the most recent Patient-led Assessments of the Care Environment (PLACE) assessment

(2017) the location(s) scored higher than the similar trusts for three of the four aspects overall.

Dementia friendly environment was the only aspect to score below the England average. People

with dementia are not routinely admitted to wards in this core service.



appearance

and

maintenance

Dementia

friendly

Disability

HESKETH

CENTRE

Acute/PICU

MH - Community-based mental

health services for adults of working

age

MH - Community mental health

services for people with a learning

disability or autism

99.5% 96.0% - 96.6%

CLOCK VIEW

HOSPITAL

Acute/PICU

MH - Wards for older people with

mental health problems

MH - Community-based mental

health services for adults of working

age

99.6% 97.2% 79.9% 89.9%

BROADOAK UNIT

(BROADGREEN

HOSPITAL SITE)

Acute/PICU 99.0% 96.0% - 90.3%

WINDSOR HOUSE Acute/PICU 98.4% 97.7% - 96.6%

Trust overall 98.8% 97.3% 81.3% 89.9%

England average

(Mental health

and learning

disabilities)

98.0% 95.2% 84.8% 86.3%

Seclusion room (if present)

Seclusion rooms were equipped in accordance with the Mental Health Act code of practice. There

were two seclusion rooms – one on Newton ward, the psychiatric intensive care unit at Clock View

Hospital, and one at Park ward at the Hesketh Centre. The seclusion room on Newton ward was

part of a dedicated suite. The seclusion room on Park ward was at the end of a corridor near the

clinic and medication rooms. Staff observed the patient from the corridor, and had a screen they

put across the corridor to maintain the patient’s privacy.


The clinic rooms were clean and well stocked. Each of the wards had a clinic room separate from

the medication. Staff carried out routine checks of the rooms and their contents. Medical devices

were in working order, clean and routinely maintained and calibrated. Each ward had a

resuscitation bag, which included emergency equipment and medication, and an automatic

external defibrillator. The bags were routinely checked, topped up and sealed. Ward staff checked

the expiry date on the seal. The bag on one ward did not have a dated seal, but this was resolved

during our inspection.


Safe staffing

Nursing staff

Maintaining safe staffing levels was an ongoing challenge, as there were difficulties in recruiting

qualified nurses and in some areas healthcare assistants. This led to the regular use of bank and

agency staff. At times, some wards had only one qualified nurse on a shift and some shifts were

not fully staffed. Patients and staff told us that one-to-one sessions, leave and activities were

occasionally cancelled due to staffing levels. Most of the patients and staff we spoke with raised

staffing levels and the pressure this placed on staff as a concern.

The trust had systems for reviewing staffing on a daily and weekly basis, which identified potential

shortfalls and acted to address them. The trust had an ongoing staffing and recruitment strategy,

that aimed to recruit and retain staff. Senior and local managers had a clear understanding of the

challenges, and of the action that was being taken to address them.




Definition




Total number of substantive staff 31 July 2018 206.5 N/A


25.4 N/A


12% 12.6%


Total vacancies overall (excluding seconded staff) 31 July 2018 -45.7 N/A

Total vacancies overall (%) 31 July 2018 15% over

establishment

5%


Most recent month (31 July 2018)

11% 8%

01 August 2017–31 July 2018

10% 8%


Establishment levels qualified nurses (WTE*) 31 July 2018 118.2 N/A

Establishment levels nursing assistants (WTE*) 31 July 2018 135.4 N/A

Number of vacancies, qualified nurses (WTE*) 31 July 2018 -20.5 over

establishment

N/A



Number of WTE vacancies nursing assistants 31 July 2018 -12.2 over

establishment

N/A

Qualified nurse vacancy rate 31 July 2018 17% over

establishment

14%

Nursing assistant vacancy rate 31 July 2018 9% over

establishment

-18%

Bank and agency Use


(qualified nurses) 01 August 2017–31

July 2018 12030

N/A


vacancies (qualified nurses) 01 August 2017–31

July 2018 1387

N/A


absence or vacancies (qualified nurses) 01 August 2017–31

July 2018 3010

N/A


(nursing assistants)

01 August 2017–31

July 2018 104591

N/A


vacancies (nursing assistants)

01 August 2017–31

July 2018 8334

N/A


absence or vacancies (nursing assistants)

01 August 2017–31

July 2018 4994

N/A

*Whole-time Equivalent / minus figures mean that they are oversubscribed

This core service reported an overall rate of 15% over establishment for all staff at 31 July 2018.

This core service reported a rate of 17% over establishment for registered nurses.

This core service reported a rate of 9% over establishment for registered nursing assistants.

However, this information provided by the trust was not consistent with our discussions with ward

staff. The wards had vacancies and were not over establishment, so there appears to be an error

in the information supplied.

Registered nurses Nurses assistants Overall staff figures

Ward/Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Windsor House -1.5 12.5 -12 0.9 14.6 6 -3.6 33.1 -11

Albert Ward -3.2 12.2 -26 0.8 12.8 6 -3.4 33.0 -10

Alt Ward (Clockview) -2.7 12.7 -21 -2.5 13.8 -18 -10.3 34.5 -0.-30

Morris Ward (Clockview) -0.7 12.7 -6 -4.0 15.6 -25 -3.1 34.4 --9

Dee Ward (Clockview) -2.4 13.2 -18 -2.3 15.3 -15 -5.9 36.5 --16


Harrington Ward 0.3 12.2 2 0.5 11.9 4 -1.2 30.1 -4

Brunswick Ward -2.2 12.2 -18 0.0 12.8 0 -4.2 33.0 -13

Newton Ward (Clockview) -4.6 14.3 -33 -4.7 19.7 -24 -8.7 35.0 -25

Park/Rowbotham Unit -3.6 16.4 -22 -0.8 18.9 -5 -5.4 37.2 --15

Core service total -20.5 118.2 --17 -12.2 135.4 -9 -45.7 306.6 -15

Trust total -151.7 1115.9 -14 7.6 643.2 1 -320.9 2741.6 -12


Between 1 August 2017 and 31 July 2018, of the 18,562 total working hours available, bank staff

filled 12030 hours to cover sickness, absence or vacancy for qualified nurses.

In the same period, agency staff covered 1387 hours for qualified nurses. In addition, 3010 hours

were unable to be filled by either bank or agency staff.


staff

Hours filled by

agency staff

Hours NOT filled by


Albert 1776 1606 152 473

Brunswick 1776 403 120 310

Harrington 1776 651 38 -88

Park/Rowbotha

m 2460 1740 423 701

Windsor House 1831 966 69 202

Alt 1667 936 44 363

Dee 1745 3237 116 148

Irwell 1745 1371 252 -15

Morris 1667 254 44 200

Newton 2118 868 131 715

Core service

total 18562 12030 1387 3010

Trust Total 90109 70728

13446

14705

*Percentage of total shifts

Between 1 August 2017 and 31 July 2018, of the 35179 total working hours available, 104591

hours were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.

In the same period, agency staff covered 83334 Hours. In addition, 4994 hours were unable to be

filled by either bank or agency staff.



staff

Hours filled by

agency staff


or agency staff

Albert 3270 5826 5961 77

Brunswick 3270 4109 3025 370

Harrington 3120 8472 6024 285

Park/Rowboth

am 3275 9020 5252 16

Windsor

House 3555 8020 5499 386

Alt 3629 11182 4202 1145

Dee 3880 12958 4308 772

Irwell 3831 20788 14680 828

Morris 3930 13706 12091 303

Newton 3418 10510 22293 811

Core service

total 35179 104591 83334 4994

Trust Total 90109

70728

13446

14705

* Percentage of total shifts



staff

Substantive staff

Leavers

Average % staff

leavers

Acute Senior Med Staff (Z1AR10) 13.5 4.1 28%

Newton Ward (Z1BP01) 26.3 6.0 21%

Assessment Service Clock View

(Z1NW10) 0.0 1.0 15%

Morris Ward (Z1AB73) 31.8 4.0 14%

Windsor House (Z1AA11) 30.5 2.9 10%

Harrington Ward (Z1AD11) 29.9 2.8 10%

Dee Ward (Z1AB74) 30.7 0.6 2%

Park/Rowbotham Unit (Z1NW01) 32.3 3.0 9%



staff

Substantive staff

Leavers

Average % staff

leavers

Inpatient Psychology S&K (Z2AB41) 6.6 0.0 0%

Inpatient Psychology Liverpool (Z2AB38) 5.0 1.0 15%

Core service total 206.5

25.4 12%

Trust Total 2658.6

294.5 13%


most recent month’s data (31 July 2018) showed a sickness rate of 11%. This compared with the

trust’s overall sickness rate of 8% over the last year, and 8% in the most recent month (July 2018).


(at latest month)

Ave % permanent staff sickness

(over the past year)

Acute Senior Med Staff (Z1AR10) 0% 1%

Harrington Ward (Z1AD11) 9% 12%

Assessment Service Clock View (Z1NW10) #DI0%/0! 9%

Dee Ward (Z1AB74) 9% 8%

Inpatient Psychology S&K (Z2AB41) 0% 0%

Morris Ward (Z1AB73) 20% 15%

Newton Ward (Z1BP01) 9% 8%

Park/Rowbotham Unit (Z1NW01) 7% 8%

Inpatient Psychology Liverpool (Z2AB38) 20% 21%

Medical North Sefton Acute (Z1NW95) 0% 0%

Windsor House (Z1AA11) 12% 11%


Trust Total 8% 8%


September 2018.

Five wards had low fill rates (<90%) for registered nurses for all day shifts across all three months.

This included Brunswick, Harrington, Park/Rowbotham, Alt, Morris and Newton.


Morris ward had over filled (>125%) for care staff for day and night shifts for all months reported.

Key:

> 125% < 90%


Nurses

(%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

July 18 Aug 18 Sep 18

Albert 81.7 116.7 96.5 105.5 95.2 121.5 100.0 102.2 98.1 114.2 96.4 112.4

Brunswick 64.4 129.0 96.9 114.0 59.2 140.9 100.0 130.1 69.3 141.7 100.0 131.1

Harrington 47.0 140.9 103.4 134.4 47.6 128.0 103.4 104.3 70.0 130.0 100.0 123.3

Park/Rowbotham 84.2 111.0 58.6 109.7 80.9 107.1 57.4 100.8 82.9 112.2 68.0 101.6

Windsor House 94.7 96.1 94.9 98.6 100.8 96.0 100.0 106.5 98.3 105.4 103.2 110.0

Alt 67.2 105.6 96.7 93.1 71.0 108.1 100.0 100.0 65.8 116.7 100.0 100.8

Dee 93.5 105.6 100.0 107.9 64.5 120.7 100.0 114.6 70.0 122.7 100.0 109.1

Morris 88.7 151.7 100.0 162.6 74.9 140.5 100.0 156.9 65.8 155.5 100.0 164.5

Newton 87.1 121.2 49.9 160.9 78.2 128.6 49.9 162.1 88.3 139.6 60.0 184.5

Medical staff

There was adequate medical cover during the day and night, and a doctor could attend the ward

quickly in an emergency. All wards had one or two consultant psychiatrists, and patients were

seen and reviewed regularly by the consultant and other ward doctors. Following the absence of

the consultant on Brunswick ward, senior medical cover had been provided by other consultants in

the service. However, this could be out of hours and patients told us they often had to wait to see

a doctor.

Mandatory training

The service provided mandatory training in key skills to all staff, which the majority of staff had

completed.

The compliance for mandatory and statutory training courses at 31 May 2018 was 86%. Of the

training courses listed 27 failed to achieve the trust target and of those, nine failed to score 75% or

above. At inspection we found that most staff had completed their mandatory training, and were

well above 75%.

Key:


targets Trust target and above


Trust target % Trustwide mandatory/ statutory training total %



95% 95%


Adults - Level 1 (Every 3 Years) 97%

95%

95%

Continuous Professional

Development - Complaints (Every 3

Years) 97%

95%

94%


Development - Adverse Incidents

(Every 3 Years) 96%

95%

92%


Basic Prevent Awareness (1 Time) 96%

95%

93%


Development - Fraud Awareness

(Every 3 Years) 95%

95%

89%


Development - Suicide Prevention &

Safety Planning (Every 3 Years) 94%

95%

90%

Mandatory Training - Conflict

Resolution (Every 3 Years) 93%

95%

92%


(Every 3 Years) 92%

95%

92%

Mandatory Training - Fire Safety

(Every 3 Years) 92%

95%

92%


Development - Smoking Cessation (1

Time) 91%

95%

89%

Mandatory Training - Equality,

Diversity and Human Rights (Every 3

Years) 91%

95%

91%

Mandatory Training - Moving &

Handling (Every 3 Years) 91%

95%

90%

Mandatory Training - Infection

Control (Every 3 Years) 91%

95%

92%


Mental Health Act - Level 1 (Every 3

Years) 90%

90%

90%


Safeguarding Adults Level 2 -Trust

Model (Every 3 Years) 89%

90%

87%


Safeguarding Children Level 2 -

Trust Model (Every 3 Years) 89%

90%

87%


Mental Capacity Act - Level 1 (Every

3 Years) 88%

90%

88%


Deprivation of Liberties - Level 1 88%

90% 89%


(Every 3 Years)


Controlled Drugs & High Risk

Medicines 85%

90%

67%


Safeguarding Adults Level 3 - Trust

Model (Every 3 Years) 83%

90%

76%


Safeguarding Children Level 3 -

Trust Model (Every 3 Years) 83%

90%

76%


Safe and Effective Use of Medicines

(Every 3 Years) 82%

90%

63%


Medicines Calculations (Every 3

Years) 79%

90%

63%


Development - Dementia Awareness

(1 Time) 76%

95%

78%


Personal Safety (Every Year) 66%

90%

80%


Basic Life Support (Every Year) 66%

90%

70%


Intermediate Life Support (Every

Year) 66%

90%

72%


MHA/DoL's Level 2 (Every 3 Years) 64%

90%

53%


Rapid Tranquilisation Training 64%

90%

61%

Mandatory Training (IG) - Data

Security Awareness - Level 1 (Every

Year) 50%

90%

50%


Witness to Medication (Every 3

Years) 42%

90%

62%


Development - Moving and Handling

of Inanimate Objects 36%

95%

56%



(Every 2 Years) 23%

90%

50%






practice and the Mental Health Act when restricting patients to keep them and others safe.

Assessment of patient risk

All patients had a risk assessment completed when they were admitted, using a standard risk

assessment tool within the electronic care record. The risk assessments and related care plans

were updated following multidisciplinary team meetings, and after significant incidents.

Management of patient risk

We reviewed 34 care records and found that care plans were usually updated in response to

changes in risk. However, we found one record where a patient had self-harmed/talked of suicide

and although the patient’s care had been reviewed in response to this, there was not a specific

care plan about this. This was acknowledged as an omission by staff, who said this would be

rectified.

Staff aimed to reduce the use of one-to-one observations with patients unless they were deemed

necessary. As alternatives, intermittent observations and activities were used to try and engage

patients. The wards used zoning, so that patients assessed at being at higher risk of harm were in

areas that were more regularly observed. The trust was in the process of implementing safety

plans for patients. These were written with and often by the patient, and contained clear

statements about the support patients needed to keep them safe, and how and when they wanted

staff to respond to them. The self-harm project had implemented alternatives to self-harm such as

ice packs.

Staff were aware of minimising the use of restrictions that applied to all patients. There were items

that were prohibited, such as drugs and alcohol, and other items such as razors that were allowed

on the ward, but were stored securely. Items such as mobile phone chargers were risk assessed

on an individual basis, but were not routinely removed from patients. Patients were not routinely

searched, but searches were carried out following an individual risk assessment.

Smoking was not managed in accordance with the trust’s smoking policy. The policy on all trust

sites was that smoking was not allowed on the premises. However, patients smoked at the

Broadoak Unit and Clock View Hospital, and staff told us it was an ongoing problem at all the

sites. At Clock View Hospital patients smoked in the courtyard. At the Broadoak unit patients

smoked in the entrance to the locked staircase that went down to the garden. On one ward a

patient was observed to be smoking in the lounge. Nicotine replacement therapy was available for

patients. Staff told us it was a difficult situation to manage, as patients were told they could not

smoke on the wards, but it was tolerated as staff did not want to physically restrain a patient to

stop them smoking.

All the wards were locked, and staff controlled access in and out of the ward. Staff told us that

informal patients were free to leave as they wished, but needed to be assessed first. There was

inconsistent use of signage to remind informal patients of their rights regarding leaving the ward.

In the care records, some informal patients had restricted leave. Staff told us this was discussed


with the patient and they had agreed to this. However, this was not always clearly documented in

the care records, and it was not clear that informal patients were always made aware of their

rights.


Staff participated in the provider’s restrictive interventions reduction programme. Staff were clear

about the trust’s ‘no force first’ policy, and used de-escalation and alternatives to manage a

situation, and only used restraint or rapid tranquilisation if this was unsuccessful. This was

discussed with staff, and care records described attempts that had been made to de-escalate

situations before restraining or secluding a patient.

At the last inspection we highlighted that patients who received rapid tranquilisation were not

always routinely monitored afterwards. At this inspection there were few patients who had

received rapid tranquilisation, but the records we saw were completed satisfactorily. If patients

refused to have their observations taken, then they were observed by staff.

The seclusion rooms were not in used during our inspection. A sample of records showed that

when seclusion was used, the rationale was recorded and the patient was monitored.

Consideration was given to the least restrictive option. Patients were reviewed and monitored in

accordance with the Mental Health Act Code of Practice.

This core service had 450 incidents of restraint (on 357 different service users) and 46 incidents of


Over the 12 months, there was a decline in the incidence of restraints in the core service until the

last three months of the period when incidents rose again. Prone restraints and rapid

tranquilisations followed a similar pattern.

There were no incidents of long term segregation or mechanical restraints.


restrained


prone restraint

Rapid

tranquilisations

Albert Ward 0 61 75 15 (25%) 18 (30%)

Alt Ward

(Admission) 1 24 18 0 (0%) 7 (29%)

Brunswick

Ward 0 36 37 5 (14%) 8 (22%)

Dee

(Female) 0 24 21 4 (17%) 10 (42%)

Harrington

Ward 0 41 41 6 (15%) 10 (24%)

Morris

(Male) 1 31 38 4 (13%) 6 (19%)

Newton

(PICU) 32 152 63 19 (13%) 37 (24%)

Park Unit

Ward 12 45 30 4 (9%) 4 (9%)



restrained


prone restraint

Rapid

tranquilisations

Windsor

House

Inpatient

Ward

0 36 34 2 (6%) 12 (33%)

Core service

total 46 450 357 59 (13%) 112 (25%)

There were 59 incidents of prone restraint which accounted for 13% of the restraint incidents.

Over the 12 months, rates of both prone restraint and rapid tranquilisation remained relatively

stable for the majority of the period.

There were no instances of mechanical restraint over the reporting period.

There were 46 instances of seclusion over the reporting period. Over the 12 months, incidences of

seclusion ranged from zero to eight.

53 50

36

48

37 3833

36

2219

32

46

12

6

2

9

46

4 4

0 0

4

8

13

7

13 13

7

10 10

7

2

5

10

15

0

10

20

30

40

50

60

Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18

Total restraints over the 12 month period

Number of incidents of the use of restraints Number of prone restraints

Number of mechnical restraints Number of incidents resulting in the use of rapid tranquilisation


There were no instances of long-term segregation over the 12-month reporting period.

Safeguarding



apply it. The Broadoak Unit and Clock View Hospital had a police liaison officer, who could be

contacted for advice and support.

The Broadoak Unit and Clock View Hospital both had a family room that could be used by any of

the wards there. Park ward and Windsor House did not have a dedicated family room, but made

arrangements for children to visit the unit safely.




institutional.





should take place.


which 131 concerned adults and four children.

8

3

7

6

4 4

5

0

3

0

3 3

0

1

2

3

4

5

6

7

8

9


Total seclusions over the 12 month period

Number of incidents of the use of seclusion

Referrals


131 4 135


The number of adult safeguarding referrals in ranged from four to 19. With peaks in referrals

occurring in August 17 and November 17 with 19 each.

The number of child safeguarding referrals ranged from zero to three.

Mersey Care NHS Foundation Trust has submitted details of four serious case reviews

commenced or published in the last 12 months, however none that relate to this core service.



easily available to staff providing care. Patients’ care records were stored electronically. All clinical

staff had access to the electronic system, by using their own access card and password. Any

paper records were scanned into the electronic system. Information on the system was accessible

by both inpatient and community staff.



effects of medications on each patient’s physical health.

All the wards had regular visits from a pharmacist and technician, and routine checks of

medication procedures were carried out by nursing staff. Overall, medication was stored correctly,

although we found some liquid medication on two wards that did not have an open date recorded.

(Liquid medication can have a shortened shelf-life when opened, before the printed expiry date).

Medicines reconciliation was carried out initially by the doctor admitting a patient, and followed up

by the pharmacist.

Medication charts were completed correctly. The capacity to consent to medication was

documented in most care records, but was not always easy to find. Physical health monitoring was

usually carried out, but again was not always consistently. We found three occasions where

physical health monitoring with regards to medication was not carried out as stated. This was

acknowledged by the manager who told us they would address this. Patients were not given ‘as

necessary’ medication for extended periods, as its use was regularly reviewed.

Most patients were on medication within the recommended British National Formulary limits. The

trust’s policy was clear about the action that should be taken and the documentation that should

be used when patients were on high dose antipsychotic therapy. However, although patients were

monitored correctly, the recording and implementation of this was not consistently applied by staff,

and we were told of different approaches by staff. Patients who were on high dose antipsychotic

therapy (anti-psychotic dose above recommended British National Formulary limits) had the

necessary physical health checks carried out, and their medication reviewed.







‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’ with eight. The only unexpected

death was an instance of ‘Sub-optimal care of the deteriorating patient meeting SI criteria’.






comparable with STEIS.



on STEIS

Albert Alt AMH

Servic

e

(inpati

ent)

Harrin

gton

Bruns

wick

Dee Park

Unit

Morris Newt

on

Total

Apparent/actual/suspected

self-inflicted harm meeting SI

criteria

0 2 2 1 1 0 2 0 0

8

Unauthorised absence

meeting SI criteria

2 0 1 0 0 2 0 1 1

7

Environmental incident

meeting SI criteria

1 1 0 0 1 0 0 0 0

3


1 0 0 0 1 0 0 0 0 2

Disruptive/ aggressive/ violent

behaviour meeting SI criteria

0 1 0 0 1 0 0 0 0

2

Confidential information

leak/information governance

breach meeting SI criteria

0 0 0 1 1 0 0 0 0

2

Accident e.g. collision/scald

(not slip/trip/fall) meeting SI

criteria

1 0 0 0 0 0 0 0 0

1

Sub-optimal care of the

deteriorating patient meeting

SI criteria

0 1 0 0 0 0 0 0 0

1

Total 5 5 3 2 5 2 2 1 1 26


Staff knew what incidents to report, and how to report them. Most staff we spoke with were familiar

with the duty of candour, and the need to be open and honest with patients and their families if


things went wrong. Staff received feedback following incidents through supervision, team meetings

or trust-wide emails.

Staff told us post-incident debriefs were carried out and discussed in the handovers and safety

huddles on the wards. Staff told us that following serious incidents they had been supported by

their managers, and contacted by the trust’s staff support team which included occupational health

and psychological support.






directly asked for a response. This third case was related to this core service. It involved the death

of a patient following self-harm. The trust had taken action following this which included

improvements to the support available to patients who self-harm or have a personality disorder.

This included the introduction/increase of psychologists to the inpatient ward, an emotional coping

skills group, and care plans developed with patients and caseworkers from the personality

disorder hub.





individual care plans and updated them when needed. All patients had a comprehensive

assessment of their needs, and a care plan which was regularly reviewed. The quality of the care

plans varied between patients. Not all the care plans were personalised, recovery orientated and

clearly included the views of the patient. We saw care plans that were more prescriptive, and the

patient’s views, strengths and weaknesses were not clearly identified. The trust had introduced a

new electronic care record (RiO) in June 2018, and information was not consistently recorded in

the same place. However, we did not find evidence that this had impacted on patients’ care. The

trust had identified this as an issue, and were in the process of introducing care plans with

standard domains across the trust.




lives.

Patients had access to occupational therapy and psychology. Patients had their physical health

assessed, responded to and monitored effectively. Most wards had a band four assistant

practitioner, who was trained in physical health care, and carried out physical health monitoring.

Patients prescribed clozapine (an antipsychotic with potentially severe side effects) were

monitored correctly. Prescribing of antipsychotic medication was in accordance with the National

Institute for Health and Care Excellence guidance. Most patients were prescribed medication

within the recommended British National Formulary limits.

Staff used rating scales to monitor and improve outcomes for patients. These included the routine

use of health of the nation outcome scales, and the Liverpool University neuroleptic side effect

rating scale.

Occupational therapists routinely used the model of human occupation assessment tool, and

others as necessary such as the occupational case analysis interview record and assessment of

motor and process skills. The occupational therapists also carried out activities of daily living

assessments of patients and did home visits as required. They provided groups on the wards and

in the occupational therapy department where available. Some of the wards were piloting the use

of the dynamic appraisal of situational aggression tool, and working with patients to manage and

lower their potential for aggressive behaviour.

Psychologists provided individual sessions with patients, therapeutic groups, reflective sessions

with staff, and assessments and formulations of patients. The range of groups provided included

an emotional coping skills groups (dialectic behaviour therapy focused for people with a

personality disorder), kind mind (compassion focused therapy), and making sense (for people

experiencing hallucinations or delusional thinking).


The trust had a Perfect Care team who worked with staff to implement initiatives such as the self-

harm project and no force first. For example, they had worked with staff on Dee ward to reduce

self-harm by increasing consistency, structure and how activities were implemented on the ward.

The self-harm project was part of a wider trust focus that included an emotional coping skills

group, psychology, alternatives to self-harm (such as ice), self-soothe boxes (which included

objects that were nice to stroke), setting mutual expectations with patients, and the daily huddle

where the multidisciplinary team to discuss issues of concern. There was a personality disorder

hub, with specialised staff working as case workers to patients with a personality disorder. As part

of this, staff could develop a plan with the patient to try and avoid admission to hospital, or if this

required it would be a crisis admission for up to 72 hours.


2018.



REILS Red Bag (Emergency bag) Audit

Secure,

Local and

SpLD

Divisions

Clinical and Environment

09/08/2017

The areas for improvement were signposting to emergency ILS bags and contents lists being

present in the bags. This has been factored into routine monitoring at ward level to improve compliance, and is part of regular reviews.

Individual actions were identified as follows: SpLD: Staff need instruction and/or flow chart for restock/resealing of bag. Needs signage erecting to indicate to staff the location of the emergency orange box. Staff to be advised that AED is not getting checked regularly. Staff to be advised to check AED on a daily basis and to sign to say it

has been checked daily. Secure Division: A rota to be put in place to ensure that daily checks of AED are done regularly, Aztrax need to check AED as

out of date and needs asset number. 2 x non rebreather masks need replacing as out of date. Needs signage erecting to direct staff to nearest AED and oxygen location, 2 x size 14g cannulas out of date and need replacing. Local Division:

Needs signage erecting to direct staff to nearest AED and oxygen location, an equipment list and a

flow chart for restock/reseal of bag. Staff to be advised to check AED on a daily basis and to sign to say it has been checked daily. Needs 1 set of

defib pads replacing as out of date and non rebreather mask to go with the oxygen. Oxygen

to be reordered along with a new bag valve mask. GP

Communication

Community

Clinic and

Inpatient Q2

(July 2017 to

September

2017)

Local


There is a full programme of work reviewing the

provision of administrative support to both

inpatient and community teams. In parallel the

backlog of letters has been outsourced to bring all

correspondence in line with the NHS contract

requirements.

Health Records

Audit

Secure,

Local,SpLD

and LCH

Sefton

Locality

Clinical 14/12/2017

Each Division has a breakdown of data relating to

their own area. The emphasis for action and

improvement is countersignature of entries by

staff that cannot authorise a clinical note. There is

a review of the electronic patient records systems




in use to review how automation can improve

compliance.

Nutrition

Support for

Adults

Secure,

Local and

SpLD

Divisions

Clinical 31/01/2018 No action plan - requested by CCG to show

compliance with NICE guidance.

GP

Communication

Community

Clinic and

Inpatient Q3

(October 2017

to December

2017)

Local







requirements.

CQUIN GP

Communication

Inpatient - taken

from Q2

Local


These results have been discussed within the

teams and remedial action plans in development.

Ward Transfers

Audit

Local


Consent to

Medical

Treatment

Audit

Local



Update referring consultants on the

importance of ensuring all parts of the ECT

paperwork are complete

Review ECT paperwork to ensure that

unnecessary data in not being requested

• Ensure that RiO system properly records the

consent process for ECT

Clinical

Handover at

Nurse Shift

Change

Local


The focus of the action plan has been to continue

to communicate the importance of handover

standards. There is a requirement for teams to

locally audit the quality of handovers two times

per month and compliance is monitored via the

self-assessment process. This audit is to be

repeated in 2018.

Named Nurse

Audit Report

Local


The Audit Findings have been shared with the

Lead Nurse for the Local Division for her

comments / actions.


following:

For all named nurse sessions it should be clearly

stated at the start of the note that it is a 1:1

Named Nurse Session.

There was evidence to suggest that a lot of what

should be discussed in a Named Nurse session

was being documented but NOT under this




heading – so this was a documenting issue rather

than it not being done. It was either contained in a

general ward note or MDT note.

The template provided for the audit may not be

appropriate for some patients on Older Persons

Wards in particular those with an organic

diagnosis. This was due to the weekly planned

sessions which would not always be appropriate

in these cases.

Action Plan formulated to include the following: 1.

Ward Manager to discuss with Registered Nurses

ways to maximise opportunities to spend time on

1:1 basis with named service users. 2. Develop

and share named nurse proforma for named

nurses to use in 1:1 sessions with service users.

Risk

Assessments

on Admission

Local


The audit findings have been shared widely with

Liaison Services and Single Point of Access to

ensure that the requirements to update risk

assessment prior to admission is fully understood.

This audit is to be repeated in 18/19 and the

scope increased to include 'stepped up care'.

National Clinical

Audit of

Psychosis

Local,

Secure and

SpLD

Divisions

Clinical 13/04/2018

Recommendation 1 (by the Royal College of

Psychiatrists)



cardiovascular risk (using the current version of

Q-Risk) receive appropriate interventions

informed by the results of this assessment have

the results of this assessment and the details of


record.

Recommendation 2

Ensure that all people with psychosis are offered

CBTp and family interventions, by:

deploying sufficient numbers of trained staff who

can deliver these interventions making sure that

staff and clinical teams are aware of how and

when to refer people for these treatments.

Recommendation 3

Ensure that all people with psychosis: are given

written or online information about the

antipsychotic medication they are prescribed are

involved in the prescribing decision, including

having a documented discussion about benefits

and adverse effects of the medication.

Recommendation 4

Ensure that all people with psychosis who are

unable to attend mainstream education, training or

work, are offered alternative educational or

occupational activities according to their individual

needs; and that interventions offered are

documented in their care plan. Recommendation




5

An Annual Summary of Care should be recorded

for each patient in the digital care record. This

should: include information on medication history,

therapies offered and physical health

monitoring/interventions be updated annually be

shared with the patient and their primary care

team.

Recommendation 6

NHS Digital, NWIS, Commissioners, Trusts and

Health Boards should work together to put in

place key indicators for which data can easily be

collected, perhaps using an Annual Summary of

Care (see Recommendation 5, above). This work

should be informed by the NCAP results and the

experience of the NCAP team.

Level 1

Observations

Audit

Local


The ward managers for each in-patient ward will

carry out a spot check every week of the Level 1

observation sheets. Also, this issue will be

documented as an agenda item at future ward

managers' meetings.

GP

Communication

Community

Clinic and

Inpatient Q4

(January 2018

to March 2018)

Local







requirements.

Ligature Audit

Report

Local

Division

Clinical and



teams and remedial action plans in development.

GP

Communication

Community

Clinic and

Inpatient April

2018

Local







requirements.

Datix Incidents

Audit Report

Local



teams and remedial action plans in development

GP

Communication

Community

Clinic and

Inpatient May

2018

Local







requirements.

Audit of

Adherence to

NICE Guidance

on Long Acting

Reversible

Contraception

Local


Discuss at local audit meetings. Disseminate to

Ward Managers. Add to physical health

pathway/admission pack. Discuss

mechanism/pathway for referring eg GP. Re-audit

in 12 months.




Audit - DVLA

guidance in

Psychiatry

Local


Posters regarding DVLA driving restrictions

displayed on the ward to prompt the conversation.

Advice leaflets available to patients - these are

already produced by MIND and Mersey Care.

Education of clinicians - juniors and consultants

as well as nursing staff. It is part of social history

when clerking in. Should it be part of our risks

assessment? Guidance isn't limited to inpatient

discharges - we should be considering in all our

patients.

A cross

sectional audit

of inpatient

antipsychotic

depot injection

prescribing

practice

Local


Depots signed for on one document only. The

name, dose, time and site of injection should be

clearly documented on electronic records utilising

a brief, standardised proforma. Electronic

prescribing should be rolled out which most

certainly is the best way of avoiding these errors.

Learning must occur from avoidable errors.

Smoking Audit Local


To ensure that all patient admitted to the general

adult ward has their smoking status checked on

admission and that, those patients that smoke,

are offered brief smoking cessation advice,

referral to the hospital smoking cessation adviser

and nicotine replacement therapy (NRT) or an e-

cigarette. To ensure that any patient that is a

smoker has an individualised smoking cessation

care plan. To ensure that any patients who smoke

who request NRT have this reviewed on their

prescription card(s) on a regular basis to ensure

the NRT should continue to be prescribed (i.e. is

being accepted by the patient on a consistent

basis).

Physical Health

Schizophrenia

Audit (Inpatient)

Local


Inpatient Action Plan:

1. Continue to promote importance of screening

for HbA1c and Lipids – around cardo metabolic

risks

2. PHYSLOC8 can continue to monitor the

inpatient performance. This has been suspended

during the change to RIO. This needs to be active.

3. Target the key teams that have produced fewer

results and work out local actions to improve their

outcomes

4. Continue to support teams to understand the

importance of the physical health the need to

complete relevant nursing assessment forms.

5. The local division will continue to support the

priority of this agenda at all levels.

Nutritional

Screening and

Care Planning

(Adapted MUST

tool)

Local




Managers made sure they had staff with a range of skills need to provide high quality care. They

supported staff with appraisals, supervision, opportunities to update and further develop their

skills.

Patients had access to psychologists and assistants, occupational therapists and assistants and

activity workers were employed across the wards. Patients accessed other services when

required, such as dietitians, physiotherapists and speech and language therapists.



Ward name

Total number of

permanent non-

medical staff

requiring an

appraisal

Total number

of permanent

non-medical

staff who have

had an

appraisal

%

appraisals

Liverpool Operational (Z1AF90) 2 2 100%

Hope Unit (Z1AB77) 19 19 100%

Specialist O.A.Ts (Z1WA22) 1 1 100%

Catering Windsor House (Z2BD50) 3 3 100%

Liverpool Deputy Director of Operations (Z1CH50) 2 2 100%

Deputy Director of Operations S&K (Z1AD01) 2 2 100%

Park/Rowbotham Unit (Z1NW01) 33 33 100%

FMA's Arundel (Z2BA10) 2 2 100%

FMA's Broadoak (Z2BA30) 20 20 100%

FMA's Windsor House (Z2BA50) 3 3 100%

Windsor House (Z1AA11) 27 26 96%

Hospital Assistants Rathbone (Z2BA40) 25 24 96%

Newton Ward (Z1BP01) 24 23 96%

Harrington Ward (Z1AD11) 27 25 93%

FMA's Clock View (Z2CN70) 37 34 92%

Dee Ward (Z1AB74) 28 25 89%

Inpatient Psychology Liverpool (Z2AB38) 5 4 80%

Catering Broadoak (Z2BD30) 4 3 75%

Liverpool Neighbourhood 3 (Z1NW79) 4 3 75%

Morris Ward (Z1AB73) 29 21 72%

Inpatient Psychology S&K (Z2AB41) 6 3 50%


Liverpool Health & Wellbeing (Z1AF93) 3 1 33%

Core service total 306

279 91%

Trust wide 5986

5106 85%

The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, there was no appraisal

data for medical staff.

The trust did not provide a narrative regarding how they measure clinical supervision.

Between 1 May 2017 and 31 July 2018, the average rate across all 14 teams in this core service

was 72%. No target was provided.


ways, it’s important to understand the data they provide.


sessions required

Clinical

supervision

sessions delivered

Clinical

supervision rate

(%)

Inpatient Psychology Liverpool (Z2AB38) 9 9 100%

Liverpool Deputy Director of Operations

(Z1CH50) 3 3 100%

Park/Rowbotham Unit (Z1NW01) 37 36 97%

Harrington Ward (Z1AD11) 27 26 96%

Windsor House (Z1AA11) 83 76 92%

S&K Neighbourhood 2 (Z1NW78) 9 8 89%

Dee Ward (Z1AB74) 26 22 85%

Morris Ward (Z1AB73) 33 26 79%

Newton Ward (Z1BP01) 28 20 71%

Talk Liverpool (Z2AB40) 277 176 64%

Liverpool Health & Wellbeing (Z1AF93) 8 5 63%

Hope Unit (Z1AB77) 64 36 56%

Inpatient Psychology S&K (Z2AB41) 12 4 33%

Liverpool Neighbourhood 3 (Z1NW79) 10 3 30%

Core service total 626

450 72%

Trust Total 15334

4947 32%

Multi-disciplinary and inter-agency team work




There were daily ‘red to green’ meetings on each of the wards. The multidisciplinary team

discussed the key issues for each patient, and focused on what each patient needed in order to be

discharged from hospital. This included medication, therapies, social interactions and activities,

and accommodation and support after discharge.

There were regular (usually weekly) multidisciplinary team meetings for each patient. Patients

attended the meeting, and their needs and care was discussed. When decisions were made that

the patient did not agree with, the rationale was explained to them and the patient’s views

recorded.

Staff made sure they shared clear information about patients and any changes in their care during

handover meetings. Nurses and care support workers attended a handover meeting at the

beginning of each shift.


Practice



Staff received training on the Mental Health Act and the Mental Health Act Code of Practice and

were able to describe the Code of Practice guiding principles. As of 31 July 2018, 90% of the

workforce in this core service had received training in the Mental Health Act. The trust stated that

this training is mandatory for all core services for inpatient and all community staff and renewed

every three years.

Staff had access to support and advice on implementing the Mental Health Act and its Code of

Practice. Staff knew who the Mental Health Act administrators were and when to ask them for

support. The administrators checked and managed the original paper Mental Health Act

documents. The paper documents were scanned into the electronic care record so that it was

accessible to staff. The service had clear, accessible, relevant and up to date policies and

procedures that reflected all relevant legislation and the Mental Health Act Code of Practice.

Patients had access to an independent Mental Health Act advocate.

Patients were aware of their rights under the Mental Health Act. Staff explained to each patient

their rights under the Mental Health Act in a way that they could understand, and repeated this as

necessary in accordance with the Mental Health Act Code of Practice.

Consent to treatment forms were completed for patients when necessary, and prescription charts

were consistent with the medication listed on the T2 or T3 form. We found one form where a

prescribed medication was not on the T3, and highlighted this to the manager who said they would

follow this up.





Staff gave patients support to make specific decisions for themselves and presumed patients had

the capacity to do so unless an assessment indicated otherwise. When staff assessed patients as

not having capacity, they made decisions in the best interest of patients and considered the

patient’s wishes, feelings, culture and history.

We saw examples of decisions being made in a person’s best interest when they were deemed

not to have the capacity to do this themselves. This was specific to each decision, and the

patient’s family members or an independent mental capacity advocate were part of the discussion.

Patient’s capacity to consent to treatment, including medication, was routinely assessed upon

admission. This was recorded in most cases, but not consistently in all records.




The trust told us that there were no Deprivation of Liberty Safeguard (DoLS) applications made to

the Local Authority for this core service between 1 August 2017 and 31 July 2018.





and supported their individual needs.

The patients we spoke with were mostly positive about the staff. They told us that most staff had a

positive attitude and were caring and helpful. Staff usually knocked on doors, or shouted into the

dormitories before entering. The interactions we observed between staff and patients were

supportive and respectful. Staff engaged with patients to talk about their care, even when the

patient disagreed with the staff’s opinion or it was about a difficult or distressing subject. In staff

meetings, discussions about patients was respectful and showed an understanding of each

patient’s needs.

The 2017 Patient-led Assessments of the Care Environment (PLACE) score for privacy, dignity

and wellbeing, three of the four core service locations scored higher than similar organisations.


and wellbeing

HESKETH CENTRE

Acute/PICU

MH - Community-based mental health services for

adults of working age

MH - Community mental health services for people

with a learning disability or autism

95.9%

CLOCK VIEW HOSPITAL

Acute/PICU

MH - Wards for older people with mental health

problems



94.0%

BROADOAK UNIT (BROADGREEN

HOSPITAL SITE)

Acute/PICU 93.2%

WINDSOR HOUSE Acute/PICU 89.0%

Trust overall 92.7%



Involvement in care





Patients were given a welcome or admission pack when they came to the ward, although it was

not clear if this always happened.

The patients we spoke with had mixed views as to how involved they were in their care planning.

The care records we looked at were also variable in the level of patient involvement. Patients were

invited to attend a multidisciplinary team meeting, usually once a week, and could ask questions

and give their views at this. Patients had their medication discussed with them and were provided

with information about it.

There were routine community meetings on each of the wards. These gave patients the

opportunity to raise concerns and give their views about the ward. This included discussions about

food, the environment, ward policies, and the activity programme. It was also an opportunity for

staff to give patients feedback, for example changes to staffing. The meetings were documented,

and showed that changes had been made in response to patient feedback. For example, changes

had been made to the menu, and visiting times had been extended at weekends. Ward activities

such as fundraising events and seasonal parties were organised through the meetings.


The trust website had a section specifically for carers that provided information and advice, and

signposted them to support. We received mixed views from carers about staff and the service

provided.

Carers and families were invited to the multidisciplinary team meetings, in agreement with the

patient. Patients were asked what information they wanted to share with others, and this was

documented.

Patients were usually admitted to a bed in the trust, but could be admitted to a bed in a different

part of the trust if their local wards were full. This caused potential difficulties for visitors if they had

to travel to a hospital that was further away.






good practice.

Bed management

All the wards in use at the time of our inspection reported average bed occupancies ranging above

the minimum benchmark of 85% in the year up to 31 July 2018. Managers and staff confirmed that

the wards were usually full. Most patients were admitted to a hospital in the trust, but some

patients were admitted to hospitals outside their catchment area if their local hospital was full.

Patients were found a bed when they returned from leave.

At the last inspection, all female patients needing a psychiatric intensive care bed were transferred

out of area, as they were not available in the trust. Newton ward had been extended since our last

inspection, to provide care for men and women. Staff told us that if a patient needed a psychiatric

intensive care bed and one was not available on Newton ward then a private bed would be found.

However, we were told that a patient who required seclusion was transferred to the seclusion

room at Park ward as the seclusion room at Newton ward was in use. The person was transferred

back to Newton ward when a bed/the seclusion room there became free.

The trust provided information regarding average bed occupancies for 14 wards in this core


The trust did not provide a target for this metric.


July 2018) (current inspection) %

Acorn1 Ward MHH

83.4%

Albert 100.1%

Alt 100.2%

Boothroyd 90.9%

Brunswick 95.1%

Dee 98.1%

Harrington 95.3%

Irwell 85.7%

Morris 100.1%

Oak1 Ward MHH 94.5%

Park & Rowbotham 98.4%


Park Unit 90.2%

Rowbotham Asses Unit 76.5%

Windsor House 95.8%


2018.



Ward name Average length of stay range in days (1 August 2017 – 31

July 2018) (current inspection)

Acorn1 Ward MHH 38-77

Albert 17-47

Alt 21-52

Boothroyd 44-75

Brunswick 26-37

Dee 26-51

Harrington 17-42

Irwell 47-94

Morris 26-38

Oak1 Ward MHH 49-101

Park & Rowbotham 15-48

Park Unit 43-58

Rowbotham Asses Unit 0-209

Windsor House 30-51

This core service reported nine out of area placements between 1 August 2017 and 31 July 2018.

There were four ongoing out of area placements.

The range of out of area placements was between 22 days and 3711 days.

Four of the nine out of area placements were due to capacity.

Number of out of

area placements

Number due to

specialist needs

Number due to

capacity

Range of lengths

(completed

placements)

Number of ongoing

placements

9 5 4 22-3711 days 4

This core service reported 242 readmissions within 28 days between 1 August 2017 and 31 July

2018.


Of the total, 81 readmissions (33%) were readmissions to the same ward as discharge. Brunswick

accounted for the most with 17.

The average of days between discharge and readmission was 11 days. There was one instance

whereby patients were readmitted on the same day as being discharged but there were 16

instances where patients were readmitted the day after being discharged.

Number of

readmissions (to

any ward) within 28

days

Number of

readmissions (to

the same ward)

within 28 days

% readmissions to

the same ward

Range of days

between discharge

and readmission

Average days

between discharge

and readmission

242 81 33 0-28 11


Between 1 August 2017 and 31 July 2018 there were 2124 discharges within this core service.

This amounts to 56% of the total discharges from the trust overall (3784). Of these, 198 (9%) were

delayed. Staff held daily ‘red to green’ meetings to discuss each patient’s progress, and the action

that needed to be taken to discharge them from hospital. This included ongoing care and

treatment on the ward, and support and accommodation required in order for a patient to be

discharged. There were routine bed management systems throughout the trust, which identified

and attempted to resolve any delayed transfers of care.

The core service met the referral to assessment target in all wards.

There were no assessment to treatment targets listed.

Name of

hospital

site or

location

Name of in-

patient ward Service Type

Days from

referral to initial

assessment

Days from

assessment to

treatment Comments,

clarification Target Actual

(mean)

Target Actual

(mean)

Clock View Inpats - Clock

View Mental Illness Acute 30 Days 9

Broadoak

Hospital Albert Ward Adult Mental Illness 30 Days 8 14.5

Clock View Alt Ward Adult Mental Illness 30 Days 5 10

Broadoak

Unit Brunswick Ward Adult Mental Illness 30 Days 11.5 19.5

Clock View Dee Ward Adult Mental Illness 30 Days 6 9

Broadoak

Hospital Harrington Ward Adult Mental Illness 30 Days 9 10

Clock View Morris Ward Adult Mental Illness 30 Days 9 13


(PICU) Adult Mental Illness 30 Days 5.5 14

Hesketh

Centre

Park/Rowbotham

Unit Adult Mental Illness 30 Days 5 21.5


Windsor

House Windsor House Adult Mental Illness 30 Days 11.5 18

Clock View Morris Ward Adult Mental Illness 30 Days 9 13


(PICU) Adult Mental Illness 30 Days 5.5 14

Hesketh

Centre

Park/Rowbotham

Unit Adult Mental Illness 30 Days 5 21.5

Windsor

House Windsor House Adult Mental Illness 11.5 18

Scott

Clinic

Medium Secure

(Urgent) Medium Secure Services 0 days

0.2

days

Assessments have been completed before the referral date.

Scott

Clinic

Medium Secure

(Non urgent) Medium Secure Services 20 days

32

days


The design, layout, and furnishings of the wards at Clock View Hospital supported patients’

treatment, privacy and dignity. The other wards had dormitories which did not promote patients’

privacy and dignity. Patients had a lockable room or cupboard where they could keep personal

belongings safely.

All four wards at Clock View hospital had single rooms with ensuite facilities. The other five wards

at the other three sites had some single rooms, but most beds were provided in 4-bed dormitories

with shared bathroom and toilet facilities. In the dormitories there was limited space for patients to

personalise the area. Patients in the dormitories had a lockable drawer or cupboard to secure their

belongings.

The four wards at Clock View Hospital each had direct and open access to a private courtyard

garden. The other wards had their own garden, but access was supervised due to potential

ligature risks and several of the wards were on the first floor so were only accessible through an

enclosed staircase. Two of the wards at the Broadoak unit shared a garden, so patients only had

access to it for half of each hour. The courtyard gardens at Clock View Hospital were used by

patients to smoke. Patients at the other sites used the locked ‘cage’ entrance to the garden stairs

to smoke when the garden stairs were locked.

The trust’s estates strategy prioritised the replacement of ward environments that were not fit for

purpose. The trust was building a new hospital, Hartley Hospital, in Southport to replace the

Hesketh Centre. The build was due to be completed in January 2020. The trust was also

undertaking a feasibility study of potential sites for a new hospital to replace wards at Broadoak

and Windsor House, with a view to submitting a business case in the near future. The trust told us

that they hoped to be able to open this new hospital in Liverpool within the next three years.

The layout of each of the wards varied, but there were quiet areas, activity rooms, lounges and

laundry rooms on each of the wards. There was a family visiting room at the Broadoak Unit and

Clock View Hospital.


Most patients had their own mobile phone, but a payphone or landline was available for patients

on all the wards if required. Patients kept their phones when they were admitted, unless there was

a specific risk or reason for the phone to be removed.

The 2017 Patient-led Assessments of the Care Environment (PLACE) score for ward food at four

locations scored higher than similar trusts. The patients we spoke with had mixed views about the

quality and portion sizes of the food. The food was cooked offsite and brought to the ward and

reheated. Patients could make hot drinks at any time.


HESKETH CENTRE

Acute/PICU



MH - Community mental health services for people

with a learning disability or autism

95.4%

CLOCK VIEW HOSPITAL

Acute/PICU

MH - Wards for older people with mental health

problems



100.0%

BROADOAK UNIT (BROADGREEN

HOSPITAL SITE) Acute/PICU 96.9%

WINDSOR HOUSE Acute/PICU 97.3%

Trust overall 95.4%




relationships. The trust ran a recovery college, called life rooms. This was based in the community

in Walton and Southport, and was accessible by the public and users of Mersey Care services. It

offered patients employment opportunities, workshops and courses, and information.



Staff helped patients with communication and cultural support.

The service made adjustments for patients with a disability. There was an accessible bathroom

and toilet on each of the wards, and lift access to wards that weren’t on the ground floor.

There were noticeboards and leaflets on each of the wards, and in the reception areas of each of

the hospitals. These provided information to patients such as about the service, illnesses, local

facilities and how to raise concerns or get support.


Staff told us that interpreters were available when required, for patients or carers who did not

speak English or who were hard of hearing.

Patients’ spiritual and cultural dietary needs were provided for. This included vegetarian food,

gluten free meals, and Halal or Kosher food.

Patients could access spiritual support. The trust had chaplains from a variety of faiths which

included Catholic, Anglican, Muslim and Buddhist. They provided support for patients and staff.

Religious materials and holy books were available for different faiths.



from the results. Most patients we spoke with said they knew how to complain, and those that had

made a complaint had received a response or feedback about it. Information was on display about

how to make a complaint. Staff told us they tried to resolve complaints, and would escalate to the

nurse in charge, manager or patient advice and liaison team when required.

This core service received 40 complaints between 1 August 2017 and 31 July 2018. Five of these

were upheld, eight were partially upheld and 15 were not upheld. One complaint was referred to

the Ombudsman and five were under investigation.

Total

Complaints

Fully upheld Partially

upheld

Not upheld Other Withdrawn Under

Investigation

Referred to

Ombudsman

40 5 8 15 5 2 5 1

This service received no compliments during the last 12 months from 1 August 2017 and 31 July

2018.



Leadership


quality sustainable care. Managers had the skills and knowledge to perform their roles, and had a

good understanding of the services they managed. They were visible in the service, and

approachable for patients and staff. Leadership training programmes were available for ward and

senior managers. However, most inpatient occupational therapists were in relatively junior

positions and there wasn’t a clear pathway for career progression.

Vision and strategy


developed with involvement from staff and patients. These were reflected by the staff we spoke

with.

The staff we spoke with were clear about the trust’s goals, and were aware of the practical

implementation of the no force first and zero suicide initiatives. Patients’ physical health care was

activity assessed and any concerns followed up upon.

Culture


sense of common purpose based on shared values.

The staff we spoke with were mostly positive about their local teams and managers, and felt

supported by them. Many staff felt that staffing levels put pressure on them, but believed they

worked together as a team to provide good care for patients.

Staff knew how to raise their concerns, either with their local managers or within the wider trust.

Some staff were off work because of work-related incidents, and some staff had been off but had

now returned. Some staff told us they had been positively supported by the trust following

incidents at work. The trust had an awards system, and we spoke with staff whose teams had won

or be nominated for awards for the service they had provided.

The sickness level within this core service was 10% in the year up to July 2018. This was higher

than across the NHS in July 2018 where the rate was 4.09%, as reported by NHS Employers. The

trust had a policy for managing and supporting staff during sickness.

During the reporting period there were no cases where staff have been either suspended, placed

under supervision or were moved to a different ward.

Governance





Managers submitted information about their wards, and used this to monitor and improve the

running of and care provided on the ward. This included several systems such as staff reporting,

incident reporting, and the business intelligence system. This information was used to reviews the

quality and safety of the environment, manage the safe staffing of the wards and their training and

supervision, manage the effective use of beds across the trust, and learn from incidents and

audits. We saw examples where changes had been made following learning from incidents. For

example, following deaths changes had been made to the environment, and psychology provision

had been implemented or increased on all the acute inpatient wards.



coping with both the expected and unexpected. This included several systems such as staff

reporting, incident reporting, and the business intelligence system. This was used for recording

and monitoring the ward’s progress against key performance indicators, such as audits and

training. The information fed into the trust’s broader governance system.

Most of the wards had a daily safety huddle. The purpose of this meeting was for members of the

multidisciplinary to get together and discuss any issues of concern on the ward, and either reflect

on previous issues or plan to address what may happen in the near future. This could include

issues such as staffing levels, bed management, or potential patient concerns. Most staff we

spoke with found this positive and useful.

The trust provided a document detailing their 34 highest profile risks. Only one of these has a

current risk score of 15 or higher (high risk) however it does not relate to this core service.

The staffing levels were identified as a risk. There were strategies for managing this, and an

ongoing recruitment and retention programme.

The service had contingency plans for responding to emergencies.



secure systems with security safeguards. This included several systems such as staff reporting,

incident reporting, and the business intelligence system. This was used for recording and

monitoring the ward’s progress against key performance indicators, such as audits and training.

The information fed into the trust’s broader governance system.

Care records were stored electronically. They were stored securely, and access was through an

individual ID card and password. A new system had been implemented in July 2018 and staff were

still getting used to it. Staff were not always clear about where information was or should be

stored, and there were differences across the wards. The trust had identified this as an issue, and

was introducing a set of standard domains within care plans to promote consistency.

Engagement

Patients and carers could get information about the trust at its services, or through the trust

website. The website had specific sections for patients and for carers. There were various direct


and electronic methods for patients and carers to give feedback to the trust, in addition to talking

directly to ward staff.

Staff accessed information about the trust through the trust intranet and website. Information was

also shared at team meetings, and by emails within the trust.


Trust-wide initiatives were ongoing within the trust, that impacted on the care provided on the

acute wards and psychiatric intensive care unit. This included the self-harm project which worked

with patients who self-harmed, and aimed to improve their coping strategies and give them less-

damaging means of dealing with their emotions.






There were no accreditations for this core service. Staff told us the wards were no longer part of

the Royal College of Psychiatrists accreditation scheme. The trust had its own internal quality

review visits, where trust staff from other service areas carried out reviews of different parts of the

trust.

Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism

Wards for people with a learning disability or autism



female, mixed)

STAR Unit, William House

Rathbone Hospital

L13 4AW STAR Unit 9 Mixed





The ward was safe, clean, well equipped, well furnished, and well maintained. Day and communal

areas were arranged around a main corridor. This meant that staff could not easily see all areas of

the ward. Staff used individual observations to reduce any risk to patients.

The ward was mixed-sex, with bedrooms for men leading off the main corridor and bedrooms for

women leading off a separated area at the end of the ward. There were closed-circuit television

cameras in communal areas. Each patient had a gender and dignity care plan. Staff explained to

each patient how their privacy and dignity would be maintained. Each patient was given easy-read

information about the closed circuit television and about privacy on the ward.



Just before our inspection, a male patient was temporarily accommodated in a single, en-suite

room in the female area of the ward due to a clinical emergency. Staff had completed a full risk

assessment. Staff had increased their observation levels during this period to ensure the safety,

privacy and dignity of the male and all of the female patients. Managers had reported this to the

NHS Commissioning Board.

Staff knew about any ligature anchor points and actions to mitigate risks to patients who might try

to harm themselves. Environmental risk assessments were completed and up to date. Bedroom

furniture and ensuite bathroom fittings were anti-ligature.

The ward had an up to date fire risk assessment in place and staff were trained in fire safety.

Eleven staff were trained to fire warden standard. Personal emergency evacuation plans were in

place for all patients who needed them. Two planned fire drills and one unplanned activation of the

fire alarm had taken place in the year prior to inspection. The ward was evacuated safely on each

occasion.

The fire safety file that we viewed on the day of inspection contained out of date information. The

trust has since provided assurance that they have archived this file.


The ward was clean and well-maintained. Certificates confirmed that the ward’s fire safety

equipment and electrical installations were checked regularly.

Staff adhered to infection control principles and completed regular infection control audits.

However, we found that soap dispensers had been removed from patients’ communal bathrooms.

Staff told us that this was due to a patient pulling them off the wall, leading to incidents. We were

concerned that patients using the communal bathrooms would be unable to wash their hands

effectively after using the toilet. This posed a risk of infection being spread on the ward. The risk

was mitigated by each patient having access to their own en-suite bathroom at all times. Wipes


and pump-action soap were also available. The trust told us that they planned to re-attach the

soap dispensers to the walls with Velcro (so that they could easily be removed again if needed)

and issue all staff with alcohol-free hand gel.

The trust had removed metal plates from door closures on the ward’s main corridor, exposing

some of the doors’ inner workings. The trust had done this following a risk assessment in 2015.

The trust had identified that the plates were not secure and could be used by patients to harm

themselves. The removal of the metal plates did not affect the integrity of the fire door and did not

pose any additional risk to patients.

For the most recent Patient-led Assessments of the Care Environment (PLACE) 2017, Rathbone

Hospital, which is where STAR unit is based, scored lower than the similar trusts for two of the

four aspects overall. Rathbone Hospital received a score similar to other trusts for condition,

appearance and maintenance scoring 97.3% compared to 97.7% nationally.

Site name Core service(s)

provided

Cleanliness Condition

appearance

and

maintenance

Dementia

friendly

Disability

Rathbone Hospital

Secure wards/forensic inpatient

Community based mental health services for adults of working age

Long stay/rehabilitation for adults of working age

Wards for people with learning disabilities or autism.

99.4% 97.7% - 81.3%

Trust overall 98.8% 97.3% 81.3% 89.9%

England average (Mental

health and learning

disabilities)

99.4% 97.7% - 100.0%

Staff did not use seclusion and there was no seclusion room on the ward.

The clinic room was clean, and the fittings met infection control guidelines. The trust’s medical

devices team had checked and calibrated the clinic room’s equipment. Ward staff regularly

checked emergency equipment and emergency medication. However, there had been no

resuscitation drill during the year preceding the inspection. This meant that the trust could not be

fully assured that staff would respond quickly and effectively in a medical emergency. The ward

had planned their next resuscitation drill to take place in January 2019.

Safe staffing

Nursing staff


The service had enough nursing and medical staff, who knew the patients and received basic

training to keep people safe from avoidable harm.

At our last inspection of STAR unit, in March 2017, we found that there were not sufficient

numbers of staff on duty to manage the level of observations.

At this inspection we found that staffing establishment was six staff (two nurses and four support

workers) for day shifts and four staff (one nurse and three support workers) for night shifts. The

ward manager told us that, as part of a recent yearly safe staffing review, the trust had agreed to

increase the staffing establishment to seven staff during the day and five at night. Staffing rotas

showed that additional staff had been brought in to support the high level of individual

observations. The usual staffing for the ward was ten staff (two nurses and eight support workers)

for both day and night shifts. The ward manager felt able to request additional staff to ensure the

safety of the unit. This meant that there were enough staff to carry out physical interventions, take

patients on escorted leave, and offer ward activities.

Support staff had designed and used their own template to allocate their duties for each shift. The

template ensured that no member of staff undertook more than two hours of continuous

observations.

The unit frequently used bank or agency staff. All bank and agency staff received an induction

before working on the ward. Most bank and agency staff did regular shifts. They knew the patients

well, and accessed supervision and incident debriefs from substantive staff.

The tables below show the numbers of substantive staff, turnover, sickness and use of bank and

agency staff.

Definition




Total number of substantive staff At 31 July 2018 31.0 N/A


2.8 N/A


10% N/A


Total vacancies overall (excluding seconded staff) At 31 July 2018 -6 N/A




20% N/A

1 August 2018 –31 July 2018

12% N/A






Number of vacancies, qualified nurses (WTE*) At 31 July 2018 -2.3 N/A


Qualified nurse vacancy rate At 31 July 2018 -21% 5%


Bank and agency Use



2018 1832 N/A



2018 263 N/A



2018 207 N/A



2018 24599 N/A



2018 18103 N/A



2018 402 N/A

*Whole-time Equivalent / minus figures = oversubscribed

This core service reported an overall vacancy rate of -21% over establishment for registered

nurses at 31 July 2018.

This core service reported an overall vacancy rate of -11% over establishment for registered

nursing assistants.

This core service has reported a vacancy rate for all staff of -14% over establishment as of 31 July

2018.


Ward/Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%

)

Star Unit -2.3 11.1 -21% -2.5 22.5 -11% -4.7 33.6 -14%

Core service total -2.3 11.1 -21% -2.5 22.5 -11% -4.7 33.6 -14%


Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%




In the same period, agency staff covered 263 hours for qualified nurses. Two hundred and seven

hours were unable to be filled by either bank or agency staff. We did not identify any negative

impact to patients relating to unfilled shifts.

Ward/Team Available

hours

Hours filled by

bank staff

Hours filled by

agency staff

Hours NOT filled by


STAR Unit 1804 1832 263 207

Core service total 1804 1832 263 207

Trust Total 242318 125599 64603 31532



In the same period, agency staff covered 18103 hours. Four hundred and two hours were unable

to be filled by either bank or agency staff. We did not identify any negative impact to patients

relating to unfilled shifts.

Ward/Team Available

hours

Hours filled by

bank staff

Hours filled by

agency staff

Hours NOT filled by


STAR Unit 3673 24599 18103 402


Trust Total 210729 442987 204924 29961

This core service had 2.8 (10%) staff leavers between 1 August 2017 and 31 July 2018. The ward

manager told us that generally turnover was low, and that the most recent member of staff to leave

had been offered another position in the trust.

Ward/Team Substantive staff Substantive staff Leavers Average % staff leavers

350 L9 Star Unit (Z1FY30) 31.0 2.8 10%


Trust Total 2658.6 294.5 13%




Sickness had reduced to around the trust average of 8% since July 2018. We saw that some staff

who had been on long-term sickness absence due to musculoskeletal issues had returned to work

with light duties.


(at latest month)



year)

350 L9 Star Unit (Z1FY30) 20% 12%


Trust Total 8% 8%


September 2018.

Star Unit had over-filled for care staff for day and night shifts for all months reported.

Key:

> 125% < 90%


Nurses

(%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Jul 18 Aug 18 Sep 18

STAR Unit 89.5 131.8 103.4 200.1 97.5 136.3 100.0 226.9 106.7 147.1 100.0 221.1

Medical staff

Between 1 August 2017 and 31 July 2018 data was provided by the trust, however it was not in a

useable format.

A consultant psychiatrist and three junior doctors covered the STAR unit and the trust’s community

learning disability teams. There was always a doctor either based on the unit or able to respond

immediately between 9am and 5pm weekdays. Staff were able to access hospital on-site medical

cover in an emergency at all other times.

Mandatory training


training courses listed eight failed to achieve the trust target of 95% and of those, one failed to

score above 75%.

The trust monitored training compliance data on an ongoing monthly basis. Statutory training was

reported as part of the monthly board report dashboard produced by the trust’s Workforce team


and a separate dashboard was provided by the trust’s Learning and Development team for all

other courses classified as role essential.

The training compliance reported for this core service during this inspection was lower than the

88% reported in the previous year.

Key:




Trust target % Trust wide mandatory/ statutory training total %


Adverse Incidents (Every 3 Years) 100 95 92


Complaints (Every 3 Years) 100 95 94


(Every 3 Years) 100 95 92



Mandatory Training - Safeguarding Adults

- Level 1 (Every 3 Years) 100 95 95


Children - Level 1 (Every 3 Years) 100 95 95



Years) 100 90 89


Capacity Act - Level 1 (Every 3 Years) 100 90 88


Health Act - Level 1 (Every 3 Years) 100 90 90






Model (Every 3 Years) 100 90 76


Smoking Cessation (1 Time) 97 95 89




Mandatory Training - Equality, Diversity

and Human Rights (Every 3 Years) 97 95 91

Mandatory Training - Fire Safety (Every 3 97 95 92



Trust target % Trust wide mandatory/ statutory training total %

Years)






Prevent Awareness (1 Time) 97 95 93






Model (Every 3 Years) 97 90 87

Role Specific Mandated Training - Safe

and Effective Use of Medicines (Every 3

Years) 91 90 63


Tranquilisation Training 91 90 61


Controlled Drugs & High Risk Medicines 91 90 67


Medicines Calculations (Every 3 Years) 91 90 63


Intermediate Life Support (Every Year) 91 90 72


Fraud Awareness (Every 3 Years) 87 95 89


Life Support (Every Year) 87 95 70



(Every Year) 87 90 74


Personal Safety (Every Year) 87 90 80


Dementia Awareness (1 Time) 86 95 78


Awareness - Level 1 (Every Year) 79 95 50


MHA/DoL's Level 2 (Every 3 Years) 75 90 53


Witness to Medication (Every 3 Years) 50 90 62



When we inspected STAR unit we viewed an updated training record. This showed that all staff

who were not on long-term absence were compliant with all training topics. The only exception

was the ‘witness to medication’ training for nursing assistants. The ward manager had planned for

a trainer to visit the ward. We did not identify any negative impact on patients due to low

compliance with this training.





practice when restricting a patient.

We looked at all nine patient risk assessments. Staff completed risk assessments within 48 hours

of patients’ admission, and updated them regularly. At our previous inspection, we found that not

all patients with epilepsy at Wavertree Bungalow had a detailed epilepsy care plan. At this

inspection of STAR unit, we found that patients with epilepsy did have a detailed epilepsy care

plan. This meant that staff knew how to keep those patients safe.


This core service had 169 incidents of restraint (on 39 different service users) and zero incidents

of seclusion between 1 August 2017 and 31 July 2018.

The below table focuses on the last 12 months’ worth of data: 1 August 2017 and 31 July 2018


restrained


prone restraint

Rapid

tranquilisations

Star Unit 0 169 39 2 (1%) 0 (0%)

There were four incidents of prone restraint, which accounted for 2% of the restraint incidents.

Over the 12 months, there were peaks in the use of restraint in November 2017 and January

2018, when there were 25 instances and 24 instances respectively.



We reviewed all nine patient care records and spoke with staff about their use of restraint.

Evidence showed that restraint was used competently, safely and only as a last resort with

minimum force.

Over the 12 months, there were no reported instances of seclusion in this core service.


Safeguarding


agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to

apply it.




institutional.





should take place.


which 117 concerned adults and no children.

Number of referrals


1

5

15

25

14

1212 12

1513

24

21

0 0 0 01 1

0 0 0 0 0 00

5

10

15

20

25

30



Number of incidents of the use of restraintsNumber of prone restraints


117 0 117

There were two peaks identified in adult referrals across the period in November 2017 and July

2018 with 13 and 16 respectively.

The majority of safeguarding referrals were made following altercations between patients where

no injury was sustained. None had resulted in an investigation by the local authority or police. The

ward manager told us that she was planning to work with staff and the local authority to clarify

thresholds for referral.

Staff we spoke with understood the trust safeguarding policy and knew how to raise a

safeguarding alert.

There was a police liaison officer linked to the ward. Staff told us that the police liaison officer had

a good understanding of the needs of people with a learning disability or autism.

Mersey Care NHS Foundation Trust submitted details of three serious case reviews commenced

or published in the last 12 months (1 June 2017 and 31 May 2018). However, none related to this

core service.



easily available to all staff providing care.

A new electronic record system had been put in place a month prior to our inspection. A group of

senior staff had transferred all of the patients’ current care plans and risk assessments over to the

new system on the day of migration. Staff were still able to access the old system to review

historic records.

Staff had created portable ‘keyrings’ with brief summaries of patients’ risk management and care

plans. This meant that staff caring for individual patients could easily access important information

when they were on the ward and in the community.


Staff followed best practice when storing, dispensing and recording medication. Staff regularly

reviewed the effects of medication on each patient’s physical health.

At our last inspection we found that there was out of date clinical stock at STAR unit. At this

inspection we found that clinical stock was in date and that there were robust systems in place to

monitor this.

At our last inspection we found that some patients’ treatment had been delayed as medication was

not available. At this inspection, all prescribed medications were available when needed.

Patients who were prescribed antipsychotics either had a reduction plan in place, or had reasons

documented in their care record for continuing these medications. This was in line with NHS


England’s ‘stopping over medication of people with a learning disability, autism or both’ (‘STOMP’)

project.

There was a clear risk assessment and management plan in place for a female patient who was

prescribed sodium valproate. Sodium valproate is associated with risks for babies exposed to the

drug during pregnancy.




Between 1 August 2017 and 31 July 2018 there were three STEIS incidents reported by this core


‘Abuse/alleged abuse of adult patient by staff’ with two.








Ab

use/a

lleg

ed

ab

use

of

ad

ult

pati

en

t b

y

sta

ff

Dis

rup

tiv

e/

ag

gre

ssiv

e/ vio

len

t

beh

avio

ur

meeti

ng

SI c

rite

ria

Gra

nd

To

tal

Star Unit 1 1

Star Unit - Rathbone Hospital 1 1

Star Unit - Rathbone site 1 1

Total 2 1 3




and wider service. When things went wrong, staff apologised and gave patients honest information

and suitable support.







directly asked for a response. However, none of these related to this core service.





individual care plans and updated them when needed.

Staff had received support from the specialist learning disability division around effective care

planning. They were now using the trust’s ‘complex case and recovery management’ care plans.

We reviewed all nine patients’ care records. All included up to date, personalised, holistic,

recovery-oriented care plans. Patients who presented with behaviours that challenged each had a

positive behaviour support plan in place. Positive behaviour support plans stated, in detail, all the

interventions required to change behaviour proactively and manage behaviour reactively. The

ward’s recovery-based approach was consistent with the Department of Health recommendations

outlined in Positive and Proactive Care: reducing the need for restrictive interventions (2014).

Staff had created portable ‘keyrings’ with brief summaries of patients’ risk management and care

plans. This meant that staff caring for individual patients could easily access important information

when they were moving around the ward and out in the community.

The ward’s admission checklist included information about trauma and protected characteristics.

This meant that staff were quickly able to plan around patients’ specific needs, for example if a

patient was only able to work with staff of a particular gender.

All patients were clerked on to the ward by a medic. This included a physical health check. All

patients also had a full nursing health review, including optometry, diet and podiatry. All patients

were assessed for pressure ulcers.




lives.

Staff consistently applied effective proactive strategies to prevent behaviour that challenges. This

had improved since our last inspection. For example, the ward manager had brought ear

defenders into the ward to offer to patients who struggled with high noise levels. When staff

applied reactive strategies, including restrictive interventions, they did so effectively and safely.

We saw that there was an embedded culture of learning and improving positive behaviour support

plans, as part of an overall multi-disciplinary approach to reviewing restraints and risks. Staff

revisions to care plans had resulted in reduced risk of staff injury following restraint of one patient,

and enabled another to continue accessing the community following an incident.

The ward’s speech and language therapist was supporting staff to communicate with a patient

using intensive interactions. The occupational therapist undertook sensory assessments and

management plans to enable effective care planning for patients with autism.


We also saw evidence of best practice in relation to patients who did not present with behaviour

that challenges. For example, staff were using cognitive-behavioural strategies to help a patient

challenge their negative thoughts about themselves and others.


2018.



REILS Red Bag

(Emergency bag)

Audit

Secure, Local

and SpLD

Divisions

Clinical and


The areas for improvement were signposting

to emergency ILS bags and contents lists

being present in the bags. This has been

factored into routine monitoring at ward level

to improve compliance, and is part of regular

reviews. Individual actions were identified as

follows: SpLD: Staff need instruction and/or

flowchart for restock/resealing of bag. Needs

signage erecting to indicate to staff the

location of the emergency orange box. Staff to

be advised that AED is not getting checked

regularly. Staff to be advised to check AED on

a daily basis and to sign to say it has been

checked daily. Secure Division: A rota to be

put in place to ensure that daily checks of

AED are done regularly, Aztrax need to check

AED as out of date and needs asset number.

2 x non rebreather masks need replacing as

out of date. Needs signage erecting to direct

staff to nearest AED and oxygen location, 2 x

size 14g cannulas out of date and need

replacing. Local Division: Needs signage

erecting to direct staff to nearest AED and

oxygen location, an equipment list and a flow

chart for restock/reseal of bag. Staff to be

advised to check AED on a daily basis and to

sign to say it has been checked daily. Needs

1 set of defib pads replacing as out of date

and non rebreather mask to go with the

oxygen. Oxygen to be reordered along with a

new bag valve mask.

Health Records

Audit

Secure,

Local,SpLD

and LCH

Sefton

Locality

Clinical 14/12/2017


relating to their own area. The emphasis for

action and improvement is countersignature

of entries by staff that cannot authorise a

clinical note. There is a review of the

electronic patient records systems in use to

review how automation can improve

compliance.

Nutrition Support

for Adults

Secure, Local

and SpLD

Divisions



Ward Transfers

Audit Local Division Clinical 27/02/2018 No action Plan (see previous column).




Named Nurse Audit

Report Local Division Clinical 27/03/2018



comments / actions.


following:

For all named nurse sessions, it should be

clearly stated at the start of the note that it is a

1:1 Named Nurse Session.


what should be discussed in a Named Nurse

session was being documented but NOT

under this heading – so this was a

documenting issue rather than it not being

done. It was either contained in a general

ward note or MDT note.

The template provided for the audit may not

be appropriate for some patients on Older

Persons Wards in particular those with an

organic diagnosis. This was due to the weekly

planned sessions, which would not always be

appropriate in these cases. Action Plan

formulated to include the following: 1. Ward

Manager to discuss with Registered Nurses

ways to maximise opportunities to spend time

on 1:1 basis with named service users. 2.

Develop and share named nurse proforma for

named nurses to use in 1:1 sessions with

service users.

Cleanliness Audit Secure and

SpLD Division

Clinical and



teams and remedial action plans in

development

Inpatient Diabetes

Audit

Secure and

SpLD

Divisions

Clinical 02/10/2017

1. All diabetic inpatients should have

frequency of CBG monitoring determined at

their First Ward review and is at the discretion

of the consultant. 2. All CBG monitoring

should be consistent - i.e. before meals. 3.

Ensure that serum cholesterol / triglyceride

profile has been done on admission bloods, if

not done within the last 6 months. If serum

cholesterol high, statin therapy should be

started as an inpatient unless contraindicated.

Levels should be checked every 6 months - if

no longer an inpatient, can be at discretion of

GP upon discharge. 4. Ensure any

hyperglycaemia, and hypoglycaemia is acted

upon and documented. For persistent

hyperglycaemia, advice should be sought

from Diabetes Specialist Nurses at RLUH,

Aintree - time frame TBC. Advice should be

documented. For hypoglycaemia, adoption of




a Trust-wide hypoglycaemia protocol should

be used and followed as much as reasonably

practical. 5. Review of diabetic status should

be done at every ward review; any episodes

of hypoglycaemia should be taken into

account, and acted upon if they haven't been

already. 6. All wards should have a named

person and designation regarding who to

contact for advice regarding diabetes

management - there should be a written

agreement regarding this and all members of

staff should be made aware. 7. Ensure blood

pressure is monitored at least daily in all

diabetic patients. If not on appropriate

antihypertensive therapy, this should be

started as an inpatient. 8. Re-audit should be

done in one year to allow for implementation

of the above.

Epilepsy

Management in

Learning

Disabilities (An

inpatient audit)

SpLD Clinical 12/12/2017

Epilepsy care plan and risk assessment to be

created by the MDT when a patient with

epilepsy is admitted to the Star Unit. This

should include contact details of the patient's

epilepsy specialist nurse. If evidence of

prolonged or repeated seizures ensure that

there is an emergency care plan in place.

Ensure that all staff involved are aware of the

care plan and where to find it on ePEX. A

local template or checklist should be

developed to ensure consistency in the

content of each epilepsy care plan based on

NICE clinical guideline 137 recommendation

1.3.1. The plan should be reviewed on at least

annually.

Mersey Care

Treasure Hunt: A

Trust Wide Audit of

Medical Equipment

Available on

Psychiatric Wards

Local and

Secure

Division

Clinical and

Environment 05/02/2018 No Action Plan

Nutritional

Screening and Care

Planning (Adapted

MUST tool)

Local Division Clinical 01/10/2017 No Action Plan



They supported staff with appraisals, supervision, and opportunities to update and further develop

their skills.


The ward multi-disciplinary team was comprised of registered learning disability nurses, a nurse

clinical lead, a ward manager, support workers, a consultant psychiatrist, an occupational

therapist, a speech and language therapist, a social worker and a clinical psychologist.

At the time of inspection, the ward’s clinical psychologist was on long-term leave. Managers had

been unable to recruit a fixed-term replacement. Psychologists from the community teams

continued to work with their own patients, and offered consultation and support to the ward. This

meant that patients continued to receive psychologically-informed care.

Team away days took place four times a year, and included training and reflective practice

sessions. Staff from another learning disability service in the trust worked on the ward during the

away days so that the whole team could attend.

At our last inspection, we found that staff had not had sufficient training in a range of areas

essential to this core service, and that there was no system to record additional training. At this

inspection we found that staff had received training in autism awareness, learning disability

awareness, epilepsy, communication skills and dysphagia. Managers were able to check staff

compliance with additional training through attendance records for away days. New staff attended

the specialist learning disability division induction, which included all of these essential topics.

The trust supported staff to implement positive behaviour support through protected time, training

and supervision. One of the trust’s specialists in positive behaviour support had delivered training

to all staff, and remained available on the ward at regular times to provide consultation around

individual patients’ needs. This meant that positive behaviour support was led by the nursing team

and was therefore central to patient care.


rates for non-medical staff within this core service was 83%. There was no data for medical staff.

Ward name

Total number of

permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff

who have had

an appraisal

%

appraisals

350 L9 Star Unit (Z1FY30) 30 25 83%


Trust wide 5565 4780 86%

Between 1 August 2017 and 31 July 2018, the average rate of compliance for clinical supervision

was 60%.





sessions required

Clinical

supervision

sessions delivered

Clinical

supervision rate

(%)

351 L9 Star Unit (Z1FY30) 282 170 60%


Trust Total 15334 4947 32%




Multi-disciplinary meetings took place twice a week. These ensured that staff understood and

reviewed patients’ needs. The handover between two shifts that we observed was effective; staff

shared information about patients’ risks and positive behaviour support plans.

The ward had good working relationships with the community learning disability teams. Staff kept

care coordinators, social workers and general practitioners informed of patients’ progress. Staff

also involved general practitioners in care planning for patients’ physical health. They linked in with

the community health services regarding high-risk areas such as acquired pressure ulcers, sepsis

and pneumonia.

The ward worked closely with commissioners and local care providers to plan patients’ discharge

into the community. We saw from patients’ care records that their needs, for example the need for

a safe long-term bespoke placement took priority over pressures to make beds available. The

trust’s approach to transition was in line with NHS England’s Transforming Care agenda.


Practice



All qualified staff had access to a flowchart explaining what needed to be done when a patient was

admitted under the Mental Health Act. Patients’ detention paperwork was stored on the electronic

record system. The ward kept clear records of leave granted to patients. Staff were aware of the

parameters of leave granted, including risk and contingency/crisis measures.

There was an Independent Mental Health Advocate attached to the ward. Staff knew how to

access and support patients to engage with the advocate.

Staff explained patients’ rights under the Mental Health Act to them at admission and routinely

thereafter. Information about patient rights was available in easy-read format. If patients lacked

capacity to understand their rights after three attempts then the multi-disciplinary team discussed

and documented that it was not in the patient’s best interest to continue to explain their rights to

them. However, there was insufficient documentation of any steps staff had taken to safeguard the

rights of a patient who lacked capacity to understand those rights. For example, it was unclear


whether staff had referred patients to the independent mental health advocate, or considered

whether to refer the patient for a tribunal. We had highlighted this same issue at a Mental Health

Act review of the ward in June 2018. The ward had not fully taken action to improve.

As 31 July 2018, 100% of the workforce in this core service had received training in the Mental



The training compliance reported during this inspection was higher than the 82% reported in the

previous year.




Care records showed that capacity to consent was assessed and recorded appropriately. Patients

were given assistance to make decisions for themselves. Staff recognised the importance of the

person’s wishes, feelings, culture and history when making best interest decisions for patients who

lacked capacity.




The training compliance reported during this inspection was higher than the 81% reported in the

previous year.

Staff made Deprivation of Liberty Safeguards applications when required. The trust told us that 10

Deprivation of Liberty Safeguard applications were made to the Local Authority for this core


The greatest number of Deprivation of Liberty Safeguard applications were made in October 2017

with three.

CQC received nine direct notifications from Mersey care NHS Foundation Trust between 1 August

2017 and 31 July 2018.

Number of DoLS applications made by month

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Apr

18

May

18

Jun

18

Jul

18 Total

Applications made

0 0 3 2 0 0 0 0 1 0 2 2 10

Applications approved

6 0 0 1 8 0 0 0 1 0 1 1 18





and supported their individual needs.

We observed staff and patient interactions on the ward and undertook a short observational

framework for inspection. CQC inspectors use the short observational framework for inspection to

capture the experiences of patients who may not be able to express this for themselves. At our

previous inspection, we found negative interactions between staff and patients at Wavertree

Bungalow and we found that staff were not following a patient’s positive behaviour support plan at

STAR unit. At this inspection, all of the interactions we observed were positive. Staff were

responsive, inclusive and respectful. They provided appropriate practical and emotional support.

For example, a patient lay down in the corridor. A staff member approached, got down on the floor

with the patient, and gently encouraged them to get up and ‘have a chat’.

We spoke with two patients. One patient said that, although they were not happy about being on

the ward, it was comfortable and safe and the staff were ‘great’. The other patient said the ward

was good. They felt able to speak to their named nurse when they felt worried.

The independent mental health advocate told us that patients were generally complimentary about

staff and the care they received.

When we spoke with staff and observed the handover meeting, we found that staff spoke about

patients in a way that was consistent with a culture of positive behaviour support. Staff had a good

understanding of individual patients’ needs.

The 2017 Patient-led Assessments of the Care Environment (PLACE) score for privacy, dignity

and wellbeing at Rathbone Hospital scored higher than similar organisations.


and wellbeing

Rathbone Hospital

Secure Wards/forensic Inpatient

Community based mental health services for adults of working age

Long stay/rehabilitation mental health wards for adults of working age

Wards for people with learning disability or autism

94.0%

Trust overall 92.7%



Involvement in care





The admission process oriented patients to the ward and the service. There was a standard trust

‘welcome pack’ available to patients but it was in a format that was not appropriate for people with

a learning disability. Staff had written an easy-read welcome pack, which was in the process of

being finalised ready for use.

Patients were actively involved in care planning. One patient had an advanced decision in place to

ensure that her wishes were respected at times when she lacked capacity. Another patient had

decorated her ward-provided ear defenders with glitter. However, the two patients we spoke with

told us that they had not been offered a copy of their care plans.

There were regular community meetings on the wards, facilitated by the occupational therapist.

We saw that issues raised by patients had been acted on. Most of the patients chose not to attend

the community meetings. The ward manager planned to move the meetings into the patients’

kitchen and encourage involvement by baking bread for breakfast. Staff gave patients the

opportunity to give feedback about the ward individually during named nurse sessions. We saw

that the ward manager also encouraged patients to approach her if they had any concerns.

Staff offered debriefs to patients following an incident.

Patients were able to get involved in decisions about their service. The new ‘complex care and

recovery management’ care plans had been co-produced with patients from the specialist learning

disability division. Patients from the specialist learning disability division were also involved in

recruiting staff. A member of the trust’s people participation programme worked at STAR unit’s

reception. He provided valued administrative support to staff and was a popular member of the

team.


Carers were actively involved in patients’ care planning (with consent or in the best interests of

patients).

We spoke with two carers. One described the staff as ‘brilliant’ and the other said that staff were

‘marvellous’. Both said they felt involved in their relative’s care, and that they had received regular

updates. Both carers said that they did not know how to complain, but would be able to find out if

they needed to.

All staff had completed a ‘carer awareness’ training. They used the Triangle of Care to promote a

working collaboration between patients, carers and staff.




People could access the service closest to their home when they needed it. Arrangements to

admit, treat and discharge patients were in line with good practice.

The ward was able to take emergency admissions, but the majority of admissions were carefully

planned. Senior staff from two different disciplines undertook pre-admission assessments to

ensure that the ward was adapted as far as possible for patients’ individual needs before they

arrived.

The ward’s consultant psychiatrist attended care and treatment review meetings with

commissioners to discuss potential admissions.

Bed management

The trust provided information regarding average bed occupancies for STAR unit between 1

August 2017 and 31 July 2018.



Ward name

Average bed occupancy range

(1 August 2017 – 31 July 2018)

(average 12 months)

Star Unit 44.4% - 71.1% (56.3%)


2018.

We are unable to compare the average length of stay data to the previous inspection due to


Ward name Average length of stay range

in days (1 August 2017 – 31

July 2018) (average 12

months)

Star Unit 210-438 (320)

This core service reported no out area placements between 1 August 2017 and 31 July 2018.

This core service reported no readmissions within 28 days between 1 August 2017 and 31 July

2018.


The trust provided us with information pertinent to the number of patients who have moved wards

per admission. In the table below is information for this core service between 1 August 2017 and

31 July 2018.

During the last 12 months – YR 1

(August 2017 to July 2018)

During the previous 12 months – YR2 (August 2016 to July 2017)

Ward name


Number of

patients

How many were

at 'end of

life'*


Number of

patients

How many were

at 'end of

life'*


Star Unit 0 5 0 100% 19 0 95%

1 0 0 0% 1 0 5%

2 0 0 0% 0 0 0%

3 0 0 0% 0 0 0%

4+ 0 0 0% 0 0 0%

Total 5 0 100% 20 0 100%


Between 1 August 2017 and 31 July 2018, there were five discharges within this core service. This

amounts to less than 1% of the total discharges from the trust overall (3784).

In the same period the trust reported 31 delayed discharges in this core service.

At the time of inspection, two patients were on the ward despite being clinically well enough to be

discharged. This was because there was no suitable community placement available to them.

Staff told us that this was the most common reason for delayed discharges. Staff met or spoke

with commissioners regularly to try to resolve these issues. Staff also created documents,

including positive behaviour support plans and communication portfolios, to assist patients and

new care providers with the transition.

The ward’s social worker took the lead on discharge planning. They started the process as soon

as patients were admitted.

The core service did not provide the number of days from assessment to treatment.


Patients had their own rooms, in which they could keep personal belongings safely. There were

quiet areas for privacy and where patients could be independent of staff.

The ward had a full range of rooms and equipment to support treatment and care, including an

external courtyard, lounge, dining room, sensory room, clinic room, multi-faith room, laundry room,

patient kitchen and arts and crafts room. The lounge, dining room, sensory room and multi-faith

room were permanently unlocked. Patients were only able to access the kitchen and the arts and


crafts room with staff support, as these rooms contained potentially dangerous items. Patients

could choose whether to keep their own bedrooms locked.

Most patients had access to their own mobile telephone to make private calls. There was a clear

risk assessment and management plan in place for those patients who did not have free access to

their mobile telephones. All patients were able to use the ward’s handheld telephone if they

wished.

At our last inspection we found that patients were not accessing meaningful activity. At this

inspection we saw that patients had access to a wide range of activities, including at weekends.

Each patient had an easy-read activity schedule that was meaningful to them and that included an

emphasis on building independence. The ward manager had released a support worker, who had

a special interest in activities, to improve patients’ activity plans.

The occupational therapist had assessed all patients’ use of the ward kitchen. Patients could use

the ward kitchen to make hot drinks and/or food at any time with the level of staff support that was

appropriate to their needs.

The 2017 Patient-led Assessments of the Care Environment (PLACE) score for ward food at the

locations scored better than similar trusts.


Rathbone Hospital Secure wards/forensic inpatient

Community based mental health services for adults of

working age

Long stay/rehabilitation mental health wards for adults

of working age

Wards for people with learning disabilities or autism

92.3%

Trust overall 95.4%




relationships.

At our last inspection we found that patients were not accessing community leave. At this

inspection we found that all patients who were granted community leave were regularly leaving the

ward to engage in meaningful activity. Staff used positive behaviour support plans to ensure that

patients who presented with behaviour that challenged were still able to engage.

The ward liaised with a colleague at the local acute trust to arrange reasonable adjustments for

patients’ visits to hospital for appointments. For example, during our visit ward staff ensured that a

parking space would be available close to the hospital entrance to reduce waiting times and

overstimulation.




Staff helped patients with communication, advocacy and cultural support.

Notices and leaflets (with the exception of the ward welcome pack) were available to patients in

easy-read format. There was accessible information on treatments, local services, patient rights

and how to complain.

Staff were able to request interpreters and/or signers when required. There were pictorial symbols

on doors to help patients understand the ward layout. Noticeboards included easy-read

information and photographs of staff. Staff we spoke with were able to tell us the best way to

communicate with individual patients.

There was a choice of food to meet requirements of religious and ethnic groups and those with

dysphagia or other dietary care plans. There was a multi-faith room on the ward for patients to use

for practising their faith or for quiet reflection. A chaplain visited the ward weekly. Staff were able

to support patients to attend a place of worship (depending on patient’s leave). ‘Cultural needs’

was a standard heading in the ‘complex care and recovery management’ care plan.

The ward was accessible to people with physical disabilities, including wheelchair users.



from the results, and shared these with all staff.

This core service received no formal complaints between 1 August 2017 and 31 July 2018.

This core service received no formal compliments during the last 12 months from 1 August 2017

and 31 July 2018.

Patients we spoke with knew how to complain. Information about how to complain was available

on the ward in easy-read format. Staff knew how to handle complaints appropriately.

Staff received feedback on the outcome of complaints through team meetings and staff

newsletters.



Leadership

Managers had the right skills and abilities to run a service providing high-quality sustainable care.

Staff told us that the ward manager had an ‘open door policy’ and that senior managers (the

modern matron and deputy chief operating officer) were approachable and visible on the ward.

Several staff said that the ward manager had made positive changes.

The ward manager had the discretion and authority to make decisions about the ward. She told us

that the trust chief executive had visited, shown a keen interest in her vision to improve the ward

environment, and personally approved the funding.

The modern matron, clinical lead nurse and staff nurses had completed the trust’s leadership

development programme, and the ward manager (who was relatively new in post) was planning to

complete it.

Vision and strategy

The trust had a vision for what it wanted to achieve and workable plans to turn it into action.

Quality and sustainability were the top priorities. The trust’s vision was developed with involvement

from staff, patients and key groups representing the local community.

The trust’s vision was to strive for perfect care. Staff we spoke with knew and understood the

trust’s vision. They were able to name the values (continuous improvement, accountability,

respect, enthusiasm and support). They said that the values were meaningful.

The ward had a local vision, which was to provide specialist care and assessment to service users

living with a learning disability. Their aim was to assess and identify treatment needs and support

patients through recovery and transition in line with the Transforming Care agenda. Staff attitudes

and behaviours were consistent with this vision and aim.

Culture

Managers promoted a positive culture that supported and valued staff, creating a sense of

common purpose based on shared values.

Staff told us that they felt happy, supported and respected. Some staff told us that they felt proud

to work on STAR unit and valued as learning disability nurses.

The ward manager’s interactions with staff and patients demonstrated a person-centred, positive

behaviour support culture. In the ward handover, each member of staff was encouraged to

contribute.

Staff knew about the trust’s whistleblowing policy and speak up guardian. The speak up guardian

had attended an away day. Staff felt confident in being able to raise concerns without fear of

retribution.


The ward manager told us that not all of her staff team were happy, and that she was aware of the

potential impact on staff of working with high-acuity patients. The ward manager had arranged for

staff to be able to access the staff support service on a drop-in basis at set times each week, and

planned an Aston team-based working session for January 2019.

Poor staff performance had been addressed promptly and effectively. Managers were able to refer

staff to occupational health if they were concerned about sickness levels. Several staff mentioned

the trust’s ‘just and learning culture’. They felt that the trust was moving towards examining

processes rather than ‘blaming’ individuals when things went wrong.

During the reporting period, there were six cases where staff had been either suspended, placed

under supervision or were moved to a different ward. Five staff had been suspended and one was

placed under supervision.

Of the six cases, all involved grade 3 staff group.

Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these

should be noted.

Ward name Suspended Under

supervision

Ward move Total

Star Unit 5 1 0 6


Governance

The ward used a systematic approach to continually improving the quality of its services and



At the time of our previous inspection, STAR unit was provided in the trust’s local division.

Following our inspection it was moved over to the trust’s specialist learning disability division. This

meant that the governance of the service was now more focused around the specific needs of the

patient group. Staff were able to access training, supervision and shadowing.

Staff at all levels were clear about their roles. They understood what they were accountable for.

Information about risk was communicated effectively from ward to board.

The trust had a transparent policy on the use of restrictive interventions, with an overarching

restrictive intervention reduction programme. The ward monitored changes in the numbers of

incidents and use of restrictive interventions, and reported this to the senior leadership team on a

weekly basis. Managers could easily use this data to compare against other factors, for example a

recent increase in short-admission patients. Staff had identified one patient as being subject to a

high number of restraints due to self-harming behaviour. The ward manager was due to present

this patient’s case at the trust’s restrictive practice meeting in November. This would give them the

opportunity to get supervision and advice from the trust’s specialists.


The trust has provided a document detailing their 34 highest profile risks. One of the 34 corporate

risks had a current risk score of 15 or higher. However, there were no high risks pertaining to this

core service.


The ward had effective systems for identifying risks, planning to eliminate or reduce them, and


There was a systematic programme of clinical and internal audit to monitor quality and operational

processes. Audits identified where action should be taken.

The ward manager could add risks to the division or trust risk register through senior leadership

team meetings. She could also raise immediate risks directly with the chief operating officer.


The ward collected, analysed, managed and used information well to support all its activities,

using secure systems with security safeguards.

There were clear and robust service performance measures, which were reported and monitored.

These included incidents, length of stay, delayed discharge and engagement in activity. There

were effective arrangements to ensure that notifications were submitted to external bodies.

Arrangements for patient identifiable records met data security standards.

Engagement

Patients views and experiences were gathered and acted on to shape and improve the service.

Staff were also actively engaged. There was transparency and openness with all stakeholders

about performance.

Managers attended regular tracker meetings with Liverpool Clinical Commissioning Group and

Liverpool City Council.


Staff attended four away days per year to work together to resolve problems and review team

objectives, processes and performance.

There was evidence of innovation on the ward in line with the culture of positive behaviour

support. Staff thought creatively to make the ward environment fit the needs of patients, for

example by making the sensory room fully soft, by providing ear defenders to patients with autism

and by taking the stance that all patients would be able to use the kitchen. It was clear from

listening to staff that they felt passionate about empowering people with a learning disability. Staff

saw incidents as challenges to be overcome rather than barriers to inclusion.







The trust provided a list of services, which have been awarded an accreditation together with the

relevant dates of accreditation. However, there was nothing pertaining to this core service.

Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems

Wards for older people with mental health problems



female, mixed)

Mossley Hill Acorn Ward (OP) 15 Mixed

Boothroyd Unit Boothroyd Ward

(OP) 20 Mixed

Clock View Irwell Ward 17 Mixed

Mossley Hill Oak ward (OP) 20 Mixed

Heys Court Heys Court 16 Mixed




All wards were safe, clean well equipped, well furnished and well maintained. There were blind spots

on Boothroyd ward, Acorn ward, Oak ward and Heys Court. Staff could not clearly see all areas to

observe patients. There were no mirrors on these wards to support observation. However, staff knew

about any ligature anchor points and observations were increased in these areas. Environmental

audits had been completed and actions put in place to mitigate any risks.




Bedroom areas were clearly designated into male and female areas with the appropriate bathroom

facilities. Patients did not need to walk past patient bedrooms of the opposite sex to reach

bathroom facilities. Each ward had a female only lounge. Guidance from the NHS Confederation

states that shared bedrooms should be separated by solid walls. Safety issues were managed by

increased observation. There were enough staff to ensure that patients were observed

appropriately.

There were single en-suite bedrooms on Irwell ward that were in separate male and female areas

of the ward. A new ward was being built to replace Boothroyd ward and was due to be open by

October 2019. New premises had been sought to replace other wards but had been found to be

unsuitable for the needs of the patient group.

There were ligature risks on three wards within this core service. The trust had undertaken recent

(From September 2017 onwards) ligature risk assessments at all locations. One of the wards

presented a high level of ligature risk due to fixtures and fittings and two wards presented a lower

risk due to fixtures and fittings. The trust had taken action to mitigate ligature risks.


For the most recent patient-led assessments of the care environment (PLACE) assessment

(2017), the location(s) scored better than the similar trusts for three of the four aspects overall,

with the exception of the dementia friendly aspect, which was lower.

During the onsite inspection each ward was seen to be clean and tidy. We saw cleaning rotas that

confirmed cleaning regularly took place. Infection control policies were being followed. Staff and

patients confirmed that the wards were always clean. A deep clean was in process during our visit

to the Mossley Hill site.


provided


appearance

and

maintenance

Dementia

friendly

Disability

HEYS COURT, GARSTON Long Stay / 97.9% 97.3% 83.2% 93.1%



provided


appearance

and

maintenance

Dementia

friendly

Disability

rehabilitation mental

health wards for

working age adults

Wards for older people

with mental health

problems

CLOCK VIEW HOSPITAL

Acute wards for adults

of working age and

psychiatric intensive

care units


with mental health

problems

Community based

mental health services

for adults of working

age

99.6% 97.2% 79.9% 89.9%

LIVERPOOL EMI (MOSSLEY

HILL HOSPITAL)


with mental health

problems

Community based


for older people

99.9% 98.4% 83.6% 95.4%

BOOTHROYD WARD


with mental health

problems

Community based


for older people

100.0% 98.4% - 100.0%

Trust overall 98.8% 97.3% 81.3% 89.9%

England average (Mental

health and learning

disabilities)

98.0% 95.2% 84.8% 86.3%


All clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs

that staff regularly checked. Staff maintained equipment well and kept it clean. Any “clean” stickers

were visible and in date. All equipment was now cleaned according to policy and records

completed to ensure this had taken place. Clinic fridge temperatures were monitored and action

was now taken when temperatures were not in range. This had improved since our last inspection.

Safe staffing


The service had enough nursing and medical staff, who knew the patients and received basic training

to keep people safe from avoidable harm. Ward managers could use regular bank staff who were

familiar with the ward, procedures and patients. For short notice staff absences; ward managers had

access to regular agency staff. The service had a high sickness rate and used bank and agency staff

to compensate for this.

Nursing staff




Definition




Total number of substantive staff At 31 July 2018 160 N/A


14.2 N/A


9% N/A


Total vacancies overall (excluding seconded staff) At 31July 2018 -14.6 N/A




9% N/A

1 August 2017–31 July 2018

10% N/A




Number of vacancies, qualified nurses (WTE*) At 31 July 2018 -1.6 N/A


Qualified nurse vacancy rate At 31 July 2018 -7% 5%


Bank and agency Use



2018 7991 N/A





2018 1116 N/A



2018 142 N/A



2018 55049 N/A



2018 29723 N/A



2018 1678 N/A

*Whole-time Equivalent / minus figures = oversubscribed.

This core service was over-established for registered nurses and nursing assistants by 7%. The

qualified nursing fill rate was low for day time shifts. This was due to a high sickness rate of 10%.


Ward/Team

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Vac

an

cie

s

Esta

bli

sh

men

t

Vac

an

cy r

ate

(%)

Acorn Ward (Mossley Hill) -1.3 11.3 -12% -1.5 15.1 -10% -2.4 33.3 -7%

Boothroyd Ward 0.0 12.0 0% 0.8 15.0 5% 0.2 35.4 1%

Irwell Ward (Clockview) -0.2 12.0 -1% -2.3 16.3 -14% -4.8 36.0 -13%

Oak Ward (Mossley Hill) -0.2 10.0 -2% -2.1 12.9 -16% -4.3 29.9 -14%

Heys Court -2.3 11.3 -21% 0.1 7.7 1% -3.3 26.0 -13%

Core service total -3.9 56.5 -7% -4.9 66.9 -7% -14.6 160.7 -9%

Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%




In the same period, agency staff covered 1116 hours for qualified nurses. 142 hours were unable

to be filled by either bank or agency staff.


staff

Hours filled by

agency staff

Hours NOT filled by


Boothroyd 1747 1258 350 -46

Acorn Ward 1629 2831 75 176



staff

Hours filled by

agency staff

Hours NOT filled by


Oak Ward 1629 2531 439 26

Irwell 1745 1371 252 -15

Core service

total 6751 7991 1116 142

Trust Total 242318 125599 64603 31532



In the same period, agency staff covered 29723 hours. 1678 hours were unable to be filled by

either bank or agency staff.


staff

Hours filled by

agency staff


or agency staff

Boothroyd 3647 6215 4089 -264

Acorn Ward 3635 16167 6015 605

Oak Ward 3407 11879 4939 510

Irwell 3831 20788 14680 828

Core service

total 14520 55049 29723 1678

Trust Total 210729 442987 204924 29961



staff

Substantive staff

Leavers

Average % staff

leavers

350 L9 Biu Senior Medical Staff (Z1BK10) 1.0 1.0 71%

350 L9 Medical Aintree Older People (Z1AA04) 5.0 1.0 20%

350 L9 Oak Ward - Mossley Hill (Z1CH21) 27.6 3.6 14%

350 L9 Irwell Ward (Z1AB31) 31.7 2.6 9%

350 L9 Acorn Ward - Mossley Hill (Z1CH35) 32.9 2.0 7%

350 L9 Boothroyd Ward SGI (Z1NW33) 34.8 2.0 6%

350 L9 Liverpool Older Peoples Senior Medical 5.0 0.0 0%



staff

Substantive staff

Leavers

Average % staff

leavers

Staff (Z1CR10)

350 L9 Heys Court (Z1CH75) 22.7 2.0 9%


Trust Total 2658.6 294.5 13%




(at latest month)



year)

350 L9 Irwell Ward (Z1AB31) 15% 18%

350 L9 Heys Court (Z1CH75) 9% 12%

350 L9 Oak Ward - Mossley Hill (Z1CH21) 16% 10%

350 L9 Boothroyd Ward SGI (Z1NW33) 6% 7%

350 L9 Liverpool Older Peoples Senior Medical Staff (Z1CR10) 20% 7%

350 L9 Acorn Ward - Mossley Hill (Z1CH35) 1% 3%

350 L9 Medical Aintree Older People (Z1AA04) 0% 2%

350 L9 Biu Senior Medical Staff (Z1BK10) 0% 0%

350 L9 Medical North Sefton Older Persons (Z1NW85) 0% 0%


Trust Total 8% 8%


September 2018.

Irwell ward and Heys Court had under-filled for registered nurses for all day shifts across the full

three-month period.

Irwell ward had over-filled for care staff for day and night shifts for all months reported.

Ward managers of Irwell ward and Heys Court explained that a shortage of registered nurses had

impacted on the quality of risk assessments, care plans and one to one time with patients. Both


ward managers had implemented an action plan. Staffing issues and the quality of patient care

had improved in the last three months.

Key:

> 125% < 90%


Nurses

(%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

July 18 August 18 September 18

Boothroyd 113.2 105.6 100.0 122.6 98.1 103.8 100.0 116.2 126.0 113.4 100.0 120.1

Acorn

Ward 99.2 137.9 100.0 121.7 97.6 148.4 100.0 130.6 96.7 135.0 100.0 120.0

Oak Ward 85.5 146.6 100.0 135.5 105.6 113.9 103.4 107.6 86.7 134.5 100.0 126.7

Irwell 76.5 170.2 94.4 166.7 60.4 163.2 100.0 163.5 61.1 189.0 96.5 211.2

Heys

Court 86.3 119.9 100.0 104.8 82.3 117.7 100.0 125.8 83.3 113.9 100.0 133.3

Medical staff

There was no useable data for medical locum shifts.

Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone

completed it. During the inspection we found that each ward had now completed mandatory

training to an appropriate level. This included basic life support, immediate life support and moving

and handling which had previously been low at the last inspection. Mandatory training figures had

also improved since the figures below were produced.

We examined mandatory training figures during the onsite inspection. All mandatory training

courses were now above 75%. Ward managers were able to demonstrate that where mandatory

training was below the trust target, staff had been booked on these courses in the near future. Or

that some staff were exempt due to being on long-term sick or maternity leave.


training courses listed 23 failed to achieve the trust target and of those, nine failed to score above

75%.

The training compliance data is reported on an ongoing monthly basis. Statutory training is

reported as part of the monthly board report dashboard produced by Workforce and a separate

dashboard is provided by the Learning and Development team for all other courses classified by

ourselves as role essential.


The training compliance reported for this core service during this inspection was lower than the

92% reported in the previous year.

Key:



Training course This core service

% Trust target %

Trustwide mandatory/ statutory training total

%


Adverse Incidents (Every 3 Years) 98% 95% 92%


Complaints (Every 3 Years) 98% 95% 94%


Smoking Cessation (1 Time) 98% 95% 89%


Prevent Awareness (1 Time) 98% 90% 93%

Mandatory Training - Safeguarding Children

- Level 1 (Every 3 Years) 97% 95% 95%


Fraud Awareness (Every 3 Years) 96% 95% 89%



(Every 3 Years)

96% 95% 90%



Years)

96% 90% 89%

Mandatory Training - Safeguarding Adults -



Capacity Act - Level 1 (Every 3 Years) 94% 90% 88%


Health Act - Level 1 (Every 3 Years) 94% 90% 90%

Role Specific Mandated Training - Safe and

Effective Use of Medicines (Every 3 Years) 92% 90% 63%


(Every 3 Years) 91% 95% 92%

Mandatory Training - Health & Safety (Every

3 Years) 90% 95% 92%


(Every 3 Years) 90% 95% 90%

Mandatory Training - Equality, Diversity and

Human Rights (Every 3 Years) 89% 95% 91%

Mandatory Training - Fire Safety (Every 3

Years) 89% 95% 92%


Training course This core service

% Trust target %

Trustwide mandatory/ statutory training total

%


Dementia Awareness (1 Time) 88% 95% 78%



(Every 3 Years)

88% 90% 87%



(Every 3 Years)

88% 90% 76%


Safeguarding Children Level 3 - Trust Model

(Every 3 Years)

88% 90% 76%


Controlled Drugs & High Risk Medicines 88% 90% 67%


Medicines Calculations (Every 3 Years) 88% 90% 63%


Safeguarding Children Level 2 - Trust Model

(Every 3 Years)

87% 90% 87%


(Every 3 Years) 86% 95% 92%


Moving and Handling of Inanimate Objects 82% 90% 56%


Life Support (Every Year) 72% 90% 70%


MHA/DoL's Level 2 (Every 3 Years) 70% 90% 53%

Role Specific Mandated Training - Personal

Safety (Every Year) 60% 90% 80%


Intermediate Life Support (Every Year) 60% 90% 72%

Role Specific Mandated Training - Moving

and Handling of People (Every Year) 59% 90% 48%

Role Specific Mandated Training - Witness

to Medication (Every 3 Years) 53% 90% 62%

Role Specific Mandated Training - Personal

Safety Breakaway - Level 1 (Every 2 Years) 50% 90% 50%


Tranquilisation Training 43% 90% 61%


Awareness - Level 1 (Every Year) 40% 95% 50%




Assessment of patient risk


manage risks individually. Staff followed best practice, the Mental Capacity Act and the Mental

Health Act when restricting patients’ freedoms to keep them and others safe. We checked eleven

patient care records and examined the risk assessments of each patient. Risk assessments were

completed for all patients on their admission to the ward. We found that staff regularly updated risk

assessments as patients’ needs or risks changed and following incidents.

Management of patient risk

Staff were aware of and dealt with any specific risk issues, such as nutrition, falls or pressure

ulcers. Following assessment, staff developed risk management plans for each individual patient.

Each patient had a falls risk assessment which was reviewed weekly. Frailty reviews were

completed weekly with input from the physiotherapist on each ward.

Staff identified and responded to changing risks to, or posed by, patients. They updated records at

least weekly and whenever clinically indicated. Staffing levels had been increased during the

evenings on each ward. The service had identified an increase in incidents during evening meal

and bed time routines. As a result, a twilight shift had been introduced to minimise risks.

Staff followed good policies and procedures for use of observation, including to minimise risk from

potential ligature points.


The wards in this service participated in the provider’s restrictive interventions reduction

programme. Sharp items were kept in a locked cupboard which patients could access on request.

All other risks were individually assessed and care planned. For patients with shared bedrooms

access to some items needed further care planning to minimise the risk to other patients. For

example, staff would increase observations whilst particular items were being used to minimise

risks. This was evident in care plans and risk assessments.

This core service had 204 incidents of restraint (on 117 different service users) and no incidents of


Over the 12 months, there was an increase in the incidence of restraint in November 2017 where

30 incidents were reported.


The below table focuses on the last 12 months’ worth of data: 1 August 2017 to 31 July 2018.


restrained


prone restraint

Rapid

tranquilisations

Acorn Ward 0 102 50 0 (0%) 4 (4%)

Boothroyd

Ward 0 49 21 1 (2%) 12 (24%)

Irwell Ward 0 17 19 0 (0%) 4 (24%)

Oak Ward 0 31 20 0 (0%) 8 (26%)

Heys Court

Ward 0 5 7 0 (0%) 0 (0%)

Core service

total 0 204 117 1 (1%) 28 (14%)

There was one incident of prone restraint, which accounted for 1% of the restraint incidents.

Over the 12 months, there were four peaks in the use of restraint in September 2017 (29), October

(28), November 2017 (29) and May 20187 (27).

Incidents resulting in rapid tranquilisation for this core services seem to have been variable with

the highest numbers in October 2017 with 10 instances. We reviewed one record of rapid

tranquilisation on Boothroyd ward. The patient had refused any physical health observations. Staff

had recorded this and utilised the correct monitoring form.


The number of restraint incidents reported during this inspection was lower than the 256 reported

in the previous 12 months.

7

2928

30

10

6

1815

7

27

17

10

0

5

10

15

20

25

30

35



Number of incidents of the use of restraints


Staff used restraint only after de-escalation had failed and used correct techniques. Staff received

training in the management of violence and aggression and moving and handling. All staff were up

to date or had been booked on the training course in the near future. We saw care records that set

out the risks when patients presented with violence and aggression and clear and detailed care

plans on the action to take. A tool to gather personal information about patients from their family

and carers had been developed. This allowed staff to understand patients triggers and de-

escalation techniques.

There were no instances of seclusion over the 12-month reporting period. We found no instances

of de-facto seclusion during the inspection visit.


Safeguarding



apply it. Staff were able to describe recent safeguarding events and how they were addressed.

Staff had completed safeguarding adults and children training and there was a safeguarding policy

that staff could access.




institutional.





should take place.


which 137 concerned adults and one child.

Number of referrals


137 1 138

There were three peaks identified in adult referrals across the period in November 2017 (17) and

December 2017 (16) and June 2018 with 16 referrals.

Mersey Care NHS Foundation Trust submitted details of three serious case reviews commenced

or published in the last 12 months [1 June 2017 and 31 May 2018]. One serious case review does

relate to this core service.


SCR/SAR Ref Number

Team/Ward Unit

Recommendation

Actions taken

Outstanding actions

SAR 5TF Older Peoples.

SAR 5TF met criteria for SAR at Liverpool Sar Sub Group and is

currently awaiting to be allocated to a reviewer/chair

N/A N/A



easily available to all staff providing care. A new electronic record system had been introduced in

June 2018. Staff could navigate the system and locate documents without difficulty.


Staff followed best practice when storing, dispensing, and recording medication. Staff regularly

reviewed the effects of medications on each patient’s physical and mental health. Prescription

cards now clearly noted any allergies. This had improved since our last inspection. However, the

disposal of medication on Oak ward was not clearly recorded. Medication that had been dropped

on the floor was not documented. The ward manager planned to rectify this immediately and

implement recording practices in line with other wards.

Covert medication was used in line with best practice and was clearly documented. We saw

examples of best interests decision checklists and mental capacity assessments. Decisions were

discussed during multi-disciplinary meetings with pharmacist input. Covert medicines care plans

with clear instructions to staff had been created and were being used.






‘Slips/trips/falls’, with eight meeting the serious incident criteria. One of the unexpected deaths

was an instance of reason ‘Other’.










Ap

pare

nt/

actu

al/su

sp

ect

ed

self

-in

flic

ted

harm

meeti

ng

SI

cri

teri

a

Dis

rup

tiv

e/ ag

gre

ss

ive

/

vio

len

t b

eh

avio

ur

meeti

ng

SI

cri

teri

a

Pen

din

g r

evie

w (

a

cate

go

ry m

ust

be

sele

cte

d b

efo

re in

cid

en

t

is c

los

ed

)

Pre

ssu

re u

lcer

meeti

ng

SI c

rite

ria

Slip

s/t

rip

s/f

all

s m

eeti

ng

SI c

rite

ria

Gra

nd

To

tal

Acorn Ward 1 1

Boothroyd Ward 1 1 2

Clock View 1 1

Complex Care - Boothroyd Ward 1 1

Complex Care Services - Mossley Hill

Hospital - Acorn Ward 1 1

Heys Court Ward 1 1

Irwell OP Ward 1 1

Mossley Hill Hospital 1 1

Mossley Hill Hospital - Acorn Ward 1 1

Mossley Hill Hospital - Oak Ward 1 1

North Liverpool (OP) CMHT 1 1

Oak Ward 1 1 2

Older People Complex Care Services

Acorn Ward 1 1

Total 3 1 2 1 8 15




and the wider service. When things went wrong, staff apologised and gave patients honest

information and suitable support. Staff were aware of duty of candour responsibilities and gave

examples of when this was applied.






directly asked for a response. None of these related to this core service.


Is the service effective? Assessment of needs and planning of care

During the inspection we examined 11 sets of patient notes or care plans.

Staff assessed patients’ physical and mental health on admission, using recognised assessment

tools. From these assessments, they developed person centred care plans so that patients

received individual care that met their needs as identified by them. Care plans were personalised,

holistic and recovery-oriented. They reflected patients’ lives and interests. Staff ensured the

records were updated at least every month and when clinically indicated. At Heys Court, some

records had not been reviewed regularly but the new management team had addressed this and

the records we saw had been reviewed in the last two weeks.



practice. This included psychological interventions such as cognitive behavioural therapy.

Staff supported patients with their physical health and encouraged them to live healthier lives. This

included encouraging exercise, healthy food choices and providing support with smoking cessation. All

the wards had a physical health lead. Care plans contained a section on ‘living a good life’.

Patients had good access to physical healthcare, including access to specialists when needed,

such as chiropody and diabetes. This included patient referrals to other services when this was

required. At Heys Court, a local G.P. visited every week.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and

hydration.

Staff used recognised rating scales to assess and record severity and outcomes, such as the

modified early warning scores and health of the nation outcomes scales. At Heys Court, there

were plans in place to introduce the national early warning scores 2 and training had been

arranged for the staff. This is the early warning system for identifying acutely ill patients, including

those with sepsis, in hospitals in England. Recording a patient’s score regularly means trends in

their clinical responses can be monitored to provide early warning of potential clinical deterioration

and prompt escalation of clinical care. Recording of the trends provides guidance about the

patient’s recovery and return to stability, enabling a lessening in the frequency and intensity of

clinical monitoring towards patient discharge.


2018.



Supportive

Observations

Audit

Acorn Ward

and Keats

Ward - audit

1

Clinical 06/11/2017

The head of nursing for infection control, Maria

Tyson, is to work with the 2 wards to try to

improve results, and to ensure that patient's

care plans are kept up-to-date. Also, a further

audit of the 2 wards was to be completed (see

below).




Supportive

Observations

Audit

Acorn Ward

and Keats

Ward - audit

2

Clinical 08/12/2017

Maria Tyson was to continue to work with the

ward managers on their patient care plans, and

another Trust-wide audit of Supportive

Observations will be commenced in August

2018.

REILS Red Bag

(Emergency bag)

Audit

Secure,

Local and

specific

learning

disability

Divisions

Clinical and


The areas for improvement were signposting to

emergency ILS bags and contents lists being

present in the bags. This has been factored into

routine monitoring at ward level to improve

compliance, and is part of regular reviews.

Individual actions were identified as follows:

specific learning disability: Staff need instruction

and/or flowchart for restock/resealing of bag.

Needs signage erecting to indicate to staff the

location of the emergency orange box. Staff to

be advised that automated external defibrillator

is not getting checked regularly. Staff to be

advised to check automated external

defibrillator on a daily basis and to sign to say it

has been checked daily. Secure Division: A rota

to be put in place to ensure that daily checks of

automated external defibrillator are done

regularly, Aztrax need to check automated

external defibrillator as out of date and needs

asset number. 2 x non-rebreather masks need

replacing as out of date. Needs signage

erecting to direct staff to nearest automated

external defibrillator and oxygen location, 2 x

size 14g cannulas out of date and need

replacing. Local Division: Need automated

external defibrillator signage erecting to direct

staff to nearest and oxygen location, an

equipment list and a flow chart for

restock/reseal of bag. Staff to be advised to

check automated external defibrillator on a daily

basis and to sign to say it has been checked

daily. Needs 1 set of defib pads replacing as out

of date and non-rebreather mask to go with the

oxygen. Oxygen to be reordered along with a

new bag valve mask.

GP

Communication

Community Clinic

and Inpatient Q2

(July 2017 to

September 2017)

Local




inpatient and community teams. In parallel, the

backlog of letters has been outsourced to bring

all correspondence in line with the NHS contract

requirements.

Health Records

Audit

Secure,

Local,

specific

learning

disability and

LCH Sefton

Clinical 14/12/2017

Each Division has a breakdown of data relating

to their own area. The emphasis for action and

improvement is countersignature of entries by

staff that cannot authorise a clinical note. There

is a review of the electronic patient records

systems in use to review how automation can




Locality improve compliance.

Nutrition Support

for Adults

Secure,

Local and

specific

learning

disability

Divisions



GP

Communication

Community Clinic

and Inpatient Q3

(October 2017 to

December 2017)

Local







requirements.

CQUIN GP

Communication

Inpatient - taken

from Q2

Local




development.

Ward Transfers

Audit

Local


Consent to

Medical Treatment

Audit

Local



• Update referring consultants on the

importance of ensuring all parts of the

electroconvulsive therapy paperwork are

complete

• Review electroconvulsive therapy paperwork

to ensure that unnecessary data in not being

requested

• Ensure that electronic patient recording

system properly records the consent process

for electroconvulsive therapy

Clinical Handover

at Nurse Shift

Change

Local


The focus of the action plan has been to

continue to communicate the importance of

handover standards. There is a requirement for

teams to locally audit the quality of handovers

two times per month and compliance is

monitored via the self-assessment process.

This audit is to be repeated in 2018.

Named Nurse

Audit Report

Local




comments / actions.


following:

For all named nurse sessions, it should be

clearly stated at the start of the note that it is a

1:1 Named Nurse Session.


what should be discussed in a Named Nurse




session was being documented but NOT under

this heading – so this was a documenting issue

rather than it not being done. It was either

contained in a general ward note or

multidisciplinary team note.

The template provided for the audit may not be

appropriate for some patients on Older Persons’

Wards, in particular those with an organic

diagnosis. This was due to the weekly planned

sessions, which would not always be

appropriate in these cases. Action Plan

formulated to include the following: 1. Ward

Manager to discuss with Registered Nurses

ways to maximise opportunities to spend time

on 1:1 basis with named service users. 2.

Develop and share named nurse proforma for

named nurses to use in 1:1 sessions with

service users.

Risk Assessments

on Admission

Local


The audit findings have been shared widely with

Liaison Services and Single Point of Access to

ensure that the requirements to update risk

assessment prior to admission is fully

understood. This audit is to be repeated in

18/19 and the scope increased to include

'stepped up care'.

National Clinical

Audit of Psychosis

Local,

Secure and

specific

learning

disability

Divisions

Clinical 13/04/2018

Recommendation 1 (by the Royal College of

Psychiatrists)



cardiovascular risk (using the current version of

Q-Risk) receive appropriate interventions

informed by the results of this assessment have

the results of this assessment and the details of


record.

Recommendation 2


offered cognitive behavioural therapy and family

interventions, by:

deploying sufficient numbers of trained staff

who can deliver these interventions making

sure that staff and clinical teams are aware of

how and when to refer people for these

treatments.

Recommendation 3

Ensure that all people with psychosis: are given

written or online information about the

antipsychotic medication they are prescribed

are involved in the prescribing decision,

including having a documented discussion

about benefits and adverse effects of the




medication.

Recommendation 4

Ensure that all people with psychosis who are

unable to attend mainstream education, training

or work, are offered alternative educational or

occupational activities according to their

individual needs; and that interventions offered

are documented in their care plan.

Recommendation 5






updated annually be shared with the patient and

their primary care

team.

Recommendation 6

NHS Digital, NWIS, Commissioners, Trusts and

Health Boards should work together to put in

place key indicators for which data can easily

be collected, perhaps using an Annual

Summary of Care (see Recommendation 5,

above). This work should be informed by the

NCAP results and the experience of the NCAP

team.

Level 1

Observations

Audit

Local


The ward managers for each in-patient ward will

carry out a spot check every week of the Level

1 observation sheets. Also, this issue will be

documented as an agenda item at future ward

managers' meetings.

GP

Communication

Community Clinic

and Inpatient Q4

(January 2018 to

March 2018)

Local







requirements.

Hoisting

Equipment Audit

Local

Division

Clinical and



teams and Action Plan has been completed:

Lifting Operations and Lifting Equipment

Regulations 1998 inspections have been

completed on all hoists. Other actions include:

To monitor the amount of slings available, and

to explore options for purchasing variety of sling

styles.

GP

Communication

Local

Division Clinical 07/06/2018 There is a full programme of work reviewing the





Community Clinic

and Inpatient April

2018




requirements.

Datix Incidents

Audit Report

Local




development

Falls Audit Report Local


1. Standard 4 Frailty Review Documentation

To extend the use of Frailty MDT form used on

Boothroyd Ward and to adapt it for use on

dementia services. 2. To ensure staff who are

completing the frailty review documentation

identify referrals made to other health care

professionals in the action plan on review

documentation.

GP

Communication

Community Clinic

and Inpatient May

2018

Local







requirements.

Inpatient Diabetes

Audit

Local


All diabetic inpatients should have frequency of

capillary blood glucose monitoring determined

at their first ward review and is at the discretion

of the consultant. All CBG monitoring should be

consistent, i.e. before meals. Ensure that serum

cholesterol / triglyceride profile has been done

on admission bloods, if not done within the last

6 months. If serum cholesterol high, statin

therapy should be started as an inpatient unless

contraindicated. Levels should be checked

every 6 months - if no longer an inpatient, can

be at discretion of GP upon discharge. Ensure

any hyperglycaemia is acted upon and

documented. For persistently hyperglycaemia,

advice should be sought from Diabetes

Specialist Nurses at Royal Liverpool Hospital/

Aintree - time frame to be confirmed Advice

should be documented. For hypoglycaemia,

adoption of a Trust -wide hypoglycaemia

protocol should be used and followed as much

as reasonably practical. Re-audit should be

done in one year to allow for implementation of

all the above.

Audit looking at

the quality of the

discharge process

in comparison to

the standards set

by the SD40

transfer /

Local


To ensure section 117 status is documented on

discharge letter. Educate trainees on 117

importance. Ensure all attendees at

multidisciplinary team re documented on w/r

notes. Re-audit in 12 months' time.




discharge policy

produced by

Mersey Care

Nutritional

Screening and

Care Planning

(Adapted MUST

tool)

Local




The teams comprised a range of disciplines who were appropriately qualified, skilled and

experienced, including managers, nurses, nursing assistants, occupational therapists,

pharmacists, physiotherapists, psychologists, social workers, a speech and language therapist,

activities co-ordinators and doctors, including psychiatrists and general practitioners. Some staff

took a lead role in specific areas, such as physical health care and falls.

Managers supported staff with appraisals, supervision, opportunities to update and further develop

their skills.

The trust’s target rate for appraisal compliance was 95%. As at 31 July 2018, the overall appraisal


The wards/teams failing to achieve the trust’s appraisal target were Irwell Ward with an appraisal

rate of 38%. During the inspection we reviewed updated appraisal data and found this had

increased to 97%.

Overall, the rate of appraisal compliance for non-medical staff reported during this inspection was

higher than the 74% reported in the previous year.

Ward name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


%

appraisals

350 L9 Acorn Ward - Mossley Hill (Z1CH35) 32 32 100%

350 L9 Mossley Hill Site Management (Z2GA30) 2 2 100%

350 L9 Mossley Hill Admin (Z1CH90) 3 3 100%

350 L9 Boothroyd Ward SGI (Z1NW33) 32 32 100%

350 L9 Oak Ward - Mossley Hill (Z1CH21) 25 25 100%

350 L9 FMA's Heys Court (Z1CH77) 8 8 100%

350 L9 Heys Court (Z1CH75) 22 21 95%


Ward name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


%

appraisals

350 L9 Irwell Ward (Z1AB31) 29 11 38%


Trust wide 5565 4780 86%

As at 31 July 2018, there was no data for medical staff.

Between 1 August 2017 and 31 July 2018, the average rate for supervision compliance across all

five teams in this core service was 72%.


ways; it is important to understand the data they provide.


sessions required


sessions delivered


rate (%)

350 L9 Oak Ward - Mossley Hill (Z1CH21) 26 26 100%

350 L9 Acorn Ward - Mossley Hill (Z1CH35) 30 27 90%

350 L9 Boothroyd Ward SGI (Z1NW33) 114 97 85%

350 L9 Irwell Ward (Z1AB31) 26 22 85%

350 L9 Heys Court (Z1CH75) 24 18 75%

Unknown 42 19 45%


Trust Total 15334 4947 32%

Supervision, appraisals and dysphagia training had all improved since the last inspection.

Supervision provided opportunity for staff and managers to identify learning needs. Staff had

undertaken specialist training, such as dementia and dysphagia training. Dysphagia training had

now been completed by 78% of staff. Supervision helped managers ensure staff were experienced

and qualified, and had the right skills and knowledge to meet the needs of the patient group. Staff

were now receiving regular supervision and appraisals as per the trusts policy.



other to make sure patients had no gaps in their care. However, for all the wards, access to

speech and language therapy was problematic due to staff sickness. Managers told us there were

plans to restructure the service so that the impact of sickness was reduced.


Each ward held regular multi-disciplinary team meetings. There were effective handover meetings

within the team, where staff shared information about patients. The ward teams had effective

working relationships with other relevant teams within the organisation, such as care co-ordinators

and community mental health teams.

There were good relationships with external organisations, such as the local safeguarding

authority, local and national service user and carer support groups, local dementia clinical network

and universities.


Practice






The training compliance reported during this inspection was lower than the 97% reported in the

previous year.

There were policies to provide guidance for staff, and they could seek support from the trust’s

Mental Health Act administrators.

Independent Mental Health Act advocates visited the wards and there was information about

advocacy services displayed in communal areas.

Staff explained patients’ rights under the Mental Health Act to them in a way that they could

understand, repeated it as required and recorded that they had done it. If after three attempts

patients did not retain the information, they were referred to the multi-disciplinary team where

capacity was considered.

Staff ensured that patients could take Section 17 leave (permission for patients to leave hospital)

when this had been granted. Informal patients were aware of their rights to leave.

Staff stored copies of patients' detention papers and associated records (for example, Section 17

leave forms) correctly and so that they were available to all staff that needed access to them.

Care plans referred to identified Section 117 aftercare services to be provided for those who had

been subject to detention under section 3 of the Mental Health Act.

Staff carried out regular audits to ensure that the Mental Health Act was being applied correctly.

The hospital managers monitored compliance with the Mental Health Act.


Staff supported patients to make decisions about their care for themselves. They understood the

trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly.





The training compliance reported during this inspection was lower than the 97% reported in the

previous year.

Deprivation of liberty is a situation in which a person’s freedom, or aspects of freedom, is

removed. Deprivation of Liberty Safeguards are the protections set out by the Mental Capacity Act

for people who need to be deprived of their liberty in their best interests so they can receive care

or treatment for which they do not have the capacity to consent themselves.

The trust told us that 49 Deprivation of Liberty Safeguard (DoLS) applications were made to the

Local Authority for this core service between 1 August 2017 and 31 July 2018.

The greatest number of DoLS applications were made in August 2017 with eight.

CQC received 63 direct notifications from Mersey Care NHS Foundation Trust between 1 August

2017 and 31 July 2018. Forty-six of those notifications were for this core service. This meant that

the service were now notifying the CQC of Deprivation of Liberty Safeguards authorisations for

patients. This was an improvement since the last inspection.

Number of DoLS applications made by month

Aug

17

Sep

17

Oct

17

Nov

17

Dec

17

Jan

18

Feb

18

Mar

18

Apr

18

May

18

Jun

18

Jul

18 Total

Applications made

8 3 4 3 1 4 7 7 1 4 3 4 49

Applications approved

1 0 0 1 0 3 3 5 1 0 3 2 19

There were policies about the Mental Capacity Act to provide guidance for staff, including a policy

on consent. The policy cross-referenced the Department of Health guidance ‘Reference to consent

for examination or treatment.’

Staff knew where to get advice from within the provider regarding the Mental Capacity Act,

including deprivation of liberty safeguards.

Staff gave patients every possible assistance to make a specific decision for themselves before

they assumed that the patient lacked the mental capacity to make it.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to

consent appropriately. They did this on a decision-specific basis with regard to significant

decisions.

When patients lacked capacity, staff made decisions in their best interests, recognising the

importance of the person’s wishes, feelings, culture and history.


Staff made deprivation of liberty safeguards applications when required and monitored the

progress of applications to supervisory bodies.

The hospital managers monitored compliance with the Mental Capacity Act and Deprivation of

Liberty Safeguards.




Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and

supported their individual needs.

On admission, patients were allocated a nurse who welcomed them to the ward and spent time

helping them settle in. The nurse also contacted the patient’s carer or family within the first 24

hours. There were welcome packs for patients and carers. Patients had access to advocacy. The

patient advice and liaison service ran a monthly patients’ forum and there were monthly carers’

meetings.

We saw patients and staff engaging in activities together. At meal times, staff assisted those

patients who needed it, in a caring and compassionate way that helped them maintain their

independence.

The 2017 patient-led assessments of the care environment (PLACE) score for privacy, dignity and

wellbeing at the core service location(s) scored higher than similar organisations.


and wellbeing

HEYS COURT, GARSTON Long Stay / rehabilitation mental health wards for

working age adults


92.3%

CLOCK VIEW HOSPITAL

Acute wards for adults of working age and psychiatric

intensive care units



working age

94.0%

LIVERPOOL EMI (MOSSLEY HILL

HOSPITAL)


Community based mental health services for older

people

93.3%

BOOTHROYD WARD



people

97.7%

Trust overall 92.7%



Involvement in care

Staff involved patients and those close to them in decisions about their care, treatment and changes to

the service.


There was a policy on people participation that set out a framework for patients and carers to

become volunteers. All the locations in this core service had volunteers working with them.


Staff helped patients to understand their care and treatment. They found ways to communicate

with patients who had communication difficulties, such as involving speech and language

therapists. This was described in care plans. Patients’ involvement in care planning was

sometimes challenging because of their conditions but staff made efforts to include them as much

as possible. Care plans were person centred and written so that the patient could understand,

using plain language. There was evidence of staff and patients discussing the care plan and

having regular one-to-one discussions about their care, although this was sometimes documented

in general notes rather than as a ‘named nurse’ session. Patients attended multi-disciplinary team

meetings and were involved in discussions about their care and plans for moving on.

Patients could give feedback on the service and staff supported them to do this. Each ward held a

community meeting every week. The meetings were recorded and actions from previous meetings

were updated and completed. Patients views were clearly recorded. The minutes were displayed

in the ward communal areas. Staff also used an electronic handheld device to gather patients’

views.

Information about how to give feedback was displayed in the communal areas on all the wards,

including access to advocacy.


The service implemented the ‘triangle of care’ across all wards. The triangle of care principles

ensure all carers receive consistent information and support so that they feel included and can

support the person they care for better. It encourages partnership working with carers and ensures

they are involved in care and support planning and that they are offered the information and

support they need to care safely and effectively.

Carers were invited to multi-disciplinary team meetings. They were included in plans for discharge

and were invited to attend occupational therapy home assessments. Staff gave them information

about the carer’s assessment and support groups in the community. Care plans described carers’

involvement and records documented the support offered to them.

All the wards held monthly carers’ meetings, but attendance was low. The managers were

considering how this could be improved.


Is the service responsive? Between 1 August 2017 to 31 July 2018, there were a number of patients who moved wards a

number of times after the initial admission for this core service, as outlined in the table below.

During the last 12 months – YR 1 (2018)

During the previous 12 months – YR2 (2017)

Ward name


Number of patients


of life'*


Number of patients


of life'*


Boothroyd 0 83 0 80% 92 0 84%

1 12 0 12% 12 0 11%

2 8 0 8% 4 0 4%

3 0 0 0% 1 0 1%

4+ 1 0 1% 1 0 1%

Total 104 0 100% 110 0 100%

Irwell 0 49 0 84% 21 0 95%

1 8 0 14% 1 0 5%

2 1 0 2% 0 0 0%

3 0 0 0% 0 0 0%

4+ 0 0 0% 0 0 0%

Total 58 0 100% 22 0 100%

Acorn 1 Ward MHH

0 46 0 77% 47 0 85%

1 12 0 20% 7 0 13%

2 0 0 0% 1 0 2%

3 2 0 3% 0 0 0%

4+ 0 0 0% 0 0 0%

Total 60 0 100% 55 0 100%

Oak 1 Ward MHH

0 71 0 84% 80 0 87%

1 12 0 14% 11 0 12%

2 1 0 1% 1 0 1%

3 0 0 0% 0 0 0%

4+ 1 0 1% 0 0 0%

Total 85 0 100% 92 0 100%

Heys Court

0 11 0 100% 0 0 0%

1 0 0 0% 0 0 0%

2 0 0 0% 0 0 0%


During the last 12 months – YR 1 (2018)

During the previous 12 months – YR2 (2017)

3 0 0 0% 0 0 0%

4+ 0 0 0% 0 0 0%

Total 11 0 100% 43 0 100%




good practice. When patients were moved or discharged, this happened at an appropriate time of

day.

Staff planned for patients’ discharge on admission. They formulated a discharge/leaving hospital

care plan that included the family’s wishes for the patient’s future care. They liaised with social

care professionals, care co-ordinators, other health and care professionals and other care

providers to facilitate discharge.

Bed management

The trust provided information regarding average bed occupancies for five wards in this core


Four of the wards within this core service reported average bed occupancies ranging above the

nationally recommended minimum benchmark of 85% over this period. There were beds available

for patients returning form overnight leave.



At the time of the inspection bed management was operating effectively as on the day of our visit

Boothroyd ward was discharging a patient as well as having a vacant bed. On the day of our visit

to Irwell ward, this ward had seven vacant beds. If wards had elevated levels of 1:1 observation

then they would not accept further admissions until the risk had reduced.


July 2018) (average last 12 months)

Acorn1 Ward MHH 63.4% - 97.0% (83.4%)

Boothroyd 75.7% - 98.5% (90.9%)

Irwell 72.5% - 95.3% (85.7%)

Oak1 Ward MHH 87.7% - 100.8% (94.5%)

Heys Court 81.2% - 93.8% (88%)


2018.


We are unable to compare the average length of stay data to the previous inspection due to


Ward name Average length of stay range in days (1 August 2017 –

31 July 2018) (average last 12 months)

Acorn1 Ward MHH 37.7 – 77.3 (58.0)

Boothroyd 43.6 – 74.6 (56.4)

Irwell 46.7 – 94.0 (67.9)

Oak1 Ward MHH 48.5 – 101.4 (71.2)

Heys Court 761 – 2661 (1556)

This core service reported no out area placements between 1 August 2017 and 31 July 2018.

This core service reported 11 readmissions within 28 days between 1 August 2017 and 31 July

2018.

Nine readmissions (82%) were readmissions to the same ward as discharge.

The average of days between discharge and readmission was 10 days. There were no instances

whereby patients were readmitted on the same day as being discharged but there was one

instance where a patient was readmitted the day after being discharged.

Ward name Number of

readmissions

(to any ward)

within 28 days

Number of

readmissions

(to the same

ward) within 28

days

% readmissions

to the same

ward

Range of days

between

discharge and

readmission

Average days

between

discharge and

readmission

Irwell 2 2 100% 3-11 7

Acorn 1 Ward MHH

1 1 100% 2 2

Oak 1 Ward MHH

3 1 33% 3-26 16

Boothroyd 5 5 100% 1-19 9

Core service Total

11 9 82% 1-26 10


Between 1 August 2017 and 31 July 2018, there were 297 discharges within this core service.

This amounts to 8% of the total discharges from the trust overall (3784).

Caveat: Acorn ward reported more delayed discharges than there were actual discharges for

months August 2017 and May 2018.


The graph below shows the trend of delayed discharges across the 12-month period.

The graph suggests a spike in February 2018.

Discharge from hospital was delayed by local authority funding for care homes and availability of

suitable care home placements.

A discharge coordinator was employed on Boothroyd ward. This role ensured patients records

were fully up to date prior to discharge planning meetings. There was a process to notify GP’s and

refer to community teams in a timely manner.

There is no data pertinent to this core service in relation to patients lost to follow up.

The trust has identified the services in the table below as measured on ‘referral to initial

assessment’ and ‘assessment to treatment’.

The core service met the referral to assessment target in five of the six teams.

The assessment to treatment times ranged from 1.5 days to 21 days across the six teams. No

target was provided.

Name of hospital site or

location

Name of in-patient ward

or unit

Please state

service type.



Comments,

clarification

Target Is this target national or

local?

Actual (media

n)

Targe

t

Is this target national or

local?

Actual (media

n)

Mossley Hill

Acorn Ward Complex Care

30 Days

Local 2.5

6

Boothroyd Boothroyd Ward

Complex Care

30 Days

Local 7

11

Clock View

Irwell Ward Complex Care

30 Days

Local 1.5

1.5

Mossley Hill

Oak Ward Complex Care

30 Days

Local 13.5

21

8 8

6

5

6

8

10

6 6

8

6

8

0

2

4

6

8

10

12

Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18

Number of delayed discharges



Patients had their own areas/rooms where they could keep personal belongings safely. There were

quiet areas for privacy and where patients could be independent of staff. Patients could personalise

their bedrooms.

Irwell ward and Heys Court provided patients with their own bedrooms. Only Irwell ward had en-

suite toilets with a shower. Otherwise patients were expected to sleep in shared bedrooms or bed

bays of 2, 3 or 4 patients. This did not promote dignity or privacy. Shared bedrooms had curtains

separating each bed area to increase privacy.

The trust’s estates strategy prioritised the replacement of ward environments that were not fit for

purpose. The trust was building a new hospital, Hartley Hospital, in Southport to replace the

Hesketh Centre (Boothroyd ward). The build was due to be completed in October 2019. The trust

was also undertaking a feasibility study of potential sites for a new hospital to replace wards at

Broadoak, with a view to submitting a business case in the near future. The trust told us that they

hoped to be able to open this new hospital in Liverpool within the next three years.

Staff and patients had access to the full range of rooms and equipment to support their care and

treatment, which included clinic room to examine patients, activity and therapy rooms.

All beds were furnished with a graded mattress as standard unless a patient needed an air flow

replacement one.

The accommodation was all ground floor and accessible for those with reduced mobility, with

accessible toilets and bathrooms available for patients on and all wards.

Patients could make a phone call in private or had their own mobile telephones they could use in

private.

Patients had access to outside level space, some with non-slip floor covering.

The provision of safe secure storage varied across the core service were facilities varied from lockable

furniture containing a lockable digital safe or draw, or the option of valuable items being placed in on

site secure storage. Patients had keys to their bedrooms and safe storage if they chose to and or there

was no risk identified.

Staff ensured that patients had access to appropriate spiritual support. On Irwell ward we saw the

Church of England vicar visiting patients, chatting to and having a drink with them.

Patients had a choice of food to meet the dietary requirements of religious and ethnic groups. The

food was of a good quality with a trust average food quality score of 95.4% from patient-led

assessments of the care environment. Patients could make hot drinks and snacks whenever they

liked.

The 2017 patient-led assessments of the care environment (PLACE) score for ward food at the

locations scored the same or higher than similar trusts.


Feedback from patients was that the food was of good quality. We saw pictorial menus in use on

Irwell ward to assist patients with decision making. Menus include information about whether

meals were gluten free, vegan or vegetarian.


HEYS COURT, GARSTON Caring for adults over 65 yrs

Caring for people whose rights are restricted under

the Mental Health Act

Mental health conditions

91.5%

CLOCK VIEW HOSPITAL

Acute wards for adults of working age and psychiatric

intensive care units



working age

100.0%

LIVERPOOL EMI (MOSSLEY HILL

HOSPITAL)



people

95.5%

BOOTHROYD WARD



people

98.6%

Trust overall 95.4%




relationships.

Families were signposted to carer networks groups in the community and some wards had monthly

carer meetings.

Patients on Boothroyd ward had access to the gym at the nearby Hesketh Centre.

Patients care records contained information about their accommodation needs after discharge for

example if they needed alternative or care home accommodation or adaptations made to their

homes to support their mobility. Patients were involved in and agreed with the decisions about

their accommodation needs.

When patients were having section 17 leave in the community these contained details of where

the patients were visiting, whether staff support was needed and a contact number for the patient

in case of an emergency.

On some wards there were walking groups in the local community as part of the ward based

activities programme.



The service was accessible to all who needed it and took account of patients’ individual needs. Staff

helped patients with communication, advocacy and cultural support.

On or soon after admission patients were provided with a welcome pack containing information

about the individual ward they were admitted to. This included information about the facilities, meal

and visiting times on the wards There was also a ‘getting it right’ information booklet for families,

used for obtaining specific information about meeting patients’ needs and informing patient care

plans.

The wards provided dementia friendly surroundings although they were restricted by the physical

environment. Signage was mostly pictorial, with clear signage indicating the purpose for which the

living space was used for. In toilets and bathrooms there were contrasting colours, for example,

blue toilet seats and hand rails. Each ward had an assisted bath or shower.

Lounges and bedrooms had clocks which indicated the day, date and time to orientate patients

their surroundings. Bedrooms and bays had digital calendar clocks, indicating the period of the

day, for example morning or afternoon.

The trust assessed wards using the Patient-led assessments of the care environment (PLACE)

NHS Improvement standard for a dementia friendly environment. Of the wards we visited only

Clock View Hospital received a score worse than other similar trusts for dementia friendly, scoring

79.9% compared to 84.8% nationally.

There were quiet spaces and areas where patients could meet visitors, with views onto the

enclosed garden area or outside. Flooring was non-reflective and non-slip and seating was

traditional. Boothroyd ward had family room with comfortable soft furnishings.


The service treated concerns and complaints seriously, investigated them and learned lessons from

the results, and shared these with all staff.

Wards used a weekly community meeting to discuss the ward activities, patients’ satisfaction and any

concerns they had about the service they received. Community meetings were led by staff form the

ward or occupational therapy. Agenda items and minutes from the previous meetings discussed and

feedback on progress was shared as well as any new business for discussion.

There was information displayed and information leaflets available about the Patient Advocacy Liaison

Service (PALS) to support patients who wanted to make a formal complaint about their care or

treatment. On Acorn ward patients raised concern about the soft diets provided as well as the odour of

the fish in a meal. Both concerns were rectified. On Boothroyd ward the staff used a handheld

electronic device to gain feedback from patients on their views of the service they received.

This core service received three complaints between 1 August 2017 and 31 July 2018. One of

these was partially upheld and one was not upheld. Neither were referred to the Parliamentary and

Health Services Ombudsman. The third was still under investigation.


Ward

name

Total

Complaints

Fully

upheld

Partially

upheld

Not

upheld

Under

Investigation

Referred to

Ombudsman

Upheld by

Ombudsman

Boothroyd

Ward 2 0 1 0 1 0 0

Oak Ward 1 0 0 1 0 0 0

Total 3 0 1 1 1 0 0

This core service received no compliments during the last 12 months from 1 August 2017 and 31

July 2018.



Leadership


quality sustainable care. Ward managers demonstrated effective leadership and had a good

understanding of their service and how to improve it. Leadership training was available and

managers were encouraged to attend. Staff described ward managers and senior managers as

approachable and accessible.

Vision and strategy



The trust values were embedded within policies and procedures. Staff spoke about aiming for

perfect care and a just culture. Staff were consulted regarding changes to the service and their

views considered and acted upon.

Culture


sense of common purpose based on shared values. Staff felt respected, supported and valued.

They told us they were supported by their colleagues and managers, including senior managers.

Managers dealt with poor staff performance when needed. Ward managers described using staff

discipline processes to good effect. Staff on Irwell ward and Heys Court reflected that morale had

improved since new managers were appointed. Staff felt assured that they could raise concerns

and that managers would be supportive of them. Staff were recognised for their achievements. A

staff member had been nominated for an award on Oak ward.

During the reporting period, there were two cases where staff had been either suspended, placed

under supervision or were moved to a different ward. One staff member had been suspended and

one was moved to a different ward.

Of the two cases, one involved Band 2 staff group and the other Band 3 staff group.

Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these

should be noted.

Ward name Suspended Under supervision Ward move Total

Irwell Ward 0 0 1 1

Oak Ward 1 0 0 1



Governance



care would flourish. Managers had access to effective governance systems that enabled them to

have oversight of the service.

There was an electronic dashboard which provided ward managers with up to date data on staff

training, supervision and appraisal compliance, bed occupancy rates and staffing levels.

There was an electronic incident reporting system that staff were confident to use. Information

from incidents was analysed and themes addressed.

There was a system for auditing Mental Health Act and Mental Capacity Act procedures. There

was a central Mental Health Act administrator.

The trust had identified issues on Irwell ward and Heys Court. Managers had acted on these

concerns and made improvements. Ward managers had been particularly effective in improving

the culture and performance of the wards. Comprehensive action plans had been created and

implemented. This included meeting targets for supervision, training and a reduction in staff

sickness rates. New staff had been recruited and staff on both wards described a positive and

professional atmosphere.



coping with both foreseeable and unforeseeable risks. We saw evidence of action plans being

implemented to improve the performance of the service. There was a trust wide risk register to

monitor and improve risks. The Trust had an up to date major incident action plan for serious

unplanned events. Dysphagia training had been identified on the risk register. Actions had been

implemented and a programme of staff training had been undertaken. Staff were able to raise

issues directly with ward managers or other senior staff. There was a whistleblowing process that

staff were aware of and knew how to access. There was a freedom to speak up guardian.



secure systems with security safeguards. A new electronic recording system had been in place for

approximately four months. Staff described having some initial difficulties but the system was now

working well and embedded into the service. A quality dashboard was available at ward and

service level to monitor and support improvements. Staff made notifications to external bodies as

needed.

Engagement

Staff, patients and carers had access to up-to-date information about the services they used and

about the trust, for example, through the intranet, bulletins, newsletters. The trust displayed all

their policies on the public website for anyone to access. A booklet had been developed that

described the services provided by the trust. All wards, with the exception of Oak ward had


developed their own welcome packs to help orientate patients to the ward. Oak ward was in the

process of reviewing their welcome pack.

Patients and carers had opportunities to give feedback on the service they received in a manner

that reflected their individual needs. Each ward held regular patient and carer meetings. Patient

meetings were held weekly on each ward. Carer meeting were held on a monthly basis but

attendance was poor. Ward managers were considering different ways to improve carer

engagement.

Managers and staff had access to feedback from patients, carers and staff and used it to make

improvements. We saw evidence that patient feedback was acted upon from patient meetings.

Complaints from carers were considered and acted upon where necessary. Staff were consulted

regarding changes to the service. Staff had input into the design of the new ward being built at

Boothroyd ward. Staff were also consulted regarding a proposed move of Oak and Acorn wards to

another location.

Patients and staff could meet with members of the provider’s senior leadership team to give

feedback. Senior leaders regularly visited each service.


Staff were given the time and support to consider opportunities for improvements and innovation

and this led to changes. This included the development of the “getting it right” document that

supported staff and carers to discuss the needs of patients. It included personalised information to

help support patients whilst they were an inpatient and any future care placement. The information

was added to care plans and risk assessments and shared with new providers.






The trust provided services within which have been awarded an accreditation together with the

relevant dates of accreditation. However, there was no information pertaining to this core service.

mersey care nhs foundation trust - cqc.org.uk · mersey care nhs foundation trust evidence...

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