avon and wiltshire mental health partnership nhs trust

Locations inspected

Name of CQC registeredlocation

Location ID Name of service (e.g. ward/unit/team)

Postcodeofservice(ward/unit/team)

Trust Headquarters RVN1H South Gloucestershire RecoveryTeam BS16 2EW

Trust HeadquartersRVN1H

Swindon Recovery Team; EarlyIntervention Team andPsychiatric Liaison Team

SN1 4BP

Trust Headquarters RVN1H Chippenham Recovery Team SN15 1JW

Trust Headquarters RVN1H North Somerset EarlyIntervention Team Team BS24 7FY

Trust Headquarters RVN1H Bristol Early Intervention Team BS6 5UB

Trust Headquarters RVN1H Bristol Recovery Team BS2 9RU

Avon and Wiltshire Mental Health Partnership NHSTrust

AdultAdult ccommunity-bommunity-basedasedserservicvicesesQuality Report

Jenner HouseLangley Park EstateChippenhamSN15 1GGTel: 01249 468000Website: www.awp.nhs.uk

Date of inspection visit: 10-12 June 2014Date of publication: 18/09/2014

1 Adult community-based services Quality Report 18/09/2014

This report describes our judgement of the quality of care provided within this core service by Avon and Wiltshire MentalHealth Partnership NHS Trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘IntelligentMonitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Avon and Wiltshire Mental Health Partnership NHSTrust and these are brought together to inform our overall judgement of Avon and Wiltshire Mental Health PartnershipNHS Trust.

Summary of findings


RatingsWe are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings willalways be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring dataand local information from the provider and other organisations. We will award them on a four-point scale: outstanding;good; requires improvement; or inadequate.

Mental Health Act responsibilities and MentalCapacity Act / Deprivation of Liberty SafeguardsWe include our assessment of the provider’s compliancewith the Mental Health Act and Mental Capacity Act in ouroverall inspection of the core service.

We do not give a rating for Mental Health Act or MentalCapacity Act; however we do use our findings todetermine the overall rating for the service.

Further information about findings in relation to theMental Health Act and Mental Capacity Act can be foundlater in this report.

Summary of findings


Contents

PageSummary of this inspectionOverall summary 5

The five questions we ask about the service and what we found 6

Background to the service 9

Our inspection team 9

Why we carried out this inspection 9

How we carried out this inspection 9

What people who use the provider's services say 10

Good practice 10

Areas for improvement 10

Detailed findings from this inspectionLocations inspected 11

Mental Health Act responsibilities 11

Mental Capacity Act and Deprivation of Liberty Safeguards 11

Findings by our five questions 13

Action we have told the provider to take 39

Summary of findings


Overall summaryAvon and Wiltshire Mental Health Partnership NHS Trustprovides community-based mental health care,treatment and support to people, their friend’s familiesand carers. It offers people a range of treatments(psychological and medication, support and advice.

Although, we found that services generally managed riskswell, we found that two of the teams did not monitor orstore medicines, or dispose of unwanted medicines, in asafe manner.

We concluded that people received effective care andtreatment by hard working, caring and competent staffwho received regular clinical supervision. Most patientsthat we talked to told us that staff treated them withdignity and respect and whenever possible, staffsupported people who used services to manage theirown health and care needs to maintain theirindependence.

The care plans that we reviewed suggested that care wasplanned and delivered in a way that took into accountthe wishes of the person. However, some of the careplans reviewed lacked detail and there was no evidencethat people’s rights were explained to them under their

‘community treatment order’ (CTO). There was alsolimited evidence that, where needed, people’s care planswere linked to their community treatment orders. Webrought this to the attention of senior staff during theinspection.

The work of the community mental health teams wasaffected by the unavailability of admission beds. Thismeant that some people were being accommodated inhospital beds that were a long distance away from theirhome. It also meant that there were, on occasion, delaysin accessing a bed. Throughout the services we visited,however, we did find good working arrangements withprimary care and third sector providers.

We saw good examples of local leadership in all of theservices we visited. Most staff were aware of the trust’svision, values and strategies, and of its local managementstructure. However, other staff felt undervalued by thetrust. There was an ‘Information Quality’ (IQ) system inplace, which enabled senior managers to regularly reviewthe service’s quality and records management, withfindings disseminated to the teams. We saw that this wasbeing effectively used by senior managers.

Summary of findings


The five questions we ask about the service and what we found

Are services safe?All the services had a proven track record on safety and haddeveloped service-based learning from incidents. We saw evidencethat the trust had effectively anticipated and managed potentialrisks to the service.

Monthly caseload reviews and the risk management systems inplace showed us that staff were able to meet the people’s needs.While there were not enough staff in one service, the trust told uswhat steps they were taking to address these concerns.

Incidents and ‘near misses’ were recorded and reportedappropriately through the trust’s online reporting system. Two of theteams, south Gloucestershire and Swindon, did not monitor or storemedicines, or dispose of unwanted medicines, in a safe manner. Wedrew this to the attention of the trust’s chief pharmacist.

Staff received mandatory safeguarding training and were aware oftheir responsibilities for identifying and reporting safeguardingconcerns.

Staff also knew about the trust’s lone worker policy. We saw thatthey took precautions, such as joint visits, as required, and thesewere supported by clear risk assessments.

There were clear contingency plans in place, for example forcommunication breakdowns and disruptions to other trust services,and staff were aware of these.

Are services effective?People received effective care and treatment by competent staff.Care provided was based on a comprehensive assessment ofindividual’s needs and monitored through use of the Health of theNation Outcome Scales (HoNOS). Staff also used a ‘clustering tool’to assess individual risk, which determined the level of support theyreceived.

Some of the care plans that we reviewed were not detailed enoughand did not show evidence of people’s rights being explained undertheir ‘community treatment order’ (CTO). There was also limitedevidence that, where needed, people’s care plans were linked totheir community treatment orders.

Overall, staff received mandatory training. However, mandatorytraining in health and safety, conflict management, adultsafeguarding and infection control had not been undertaken bymany of the staff in one team. We saw that the trust had drawn up a

Summary of findings


staff learning needs action plan where issues were identified. Somestaff expressed concern that opportunities for training andprofessional development had been reduced and that there waslittle on offer in addition to the core mandatory training provided.

The trust benchmarked people’s outcomes using, for example,Patient Reported Experience Measures (PREMS) and PatientReported Outcome Measures (PROMS). We found that the trustworked together with multi-agency partners, such as police and thelocal authority safeguarding teams.

Most staff received monthly clinical supervision. These sessionswere used to review caseloads and provide additional clinicalsupport, as required. However, staff in one team had not receivedtheir annual appraisal.

Are services caring?Services were delivered by caring and compassionate staff. Wefound that staff demonstrated confidentiality when discussingpeople’s care and treatment needs.

People were treated with dignity and respect. We observed, and sawin our detailed review of 25 care and treatment records, thatpeople’s and their carers’ wishes were taken into account in theplanning and delivery of their care.

Most people told us that staff were supportive and had involvedthem directly in their care. They were also satisfied with the care andsupport they received from staff.

Staff told us that they provided emotional support to people to helpthem cope with their care and treatment. They said that this supportwas available when people needed it. Wherever possible, peoplewere also supported to manage their own health and care needs tomaintain their independence.

Are services responsive to people's needs?We found that people’s needs and wishes were met when assessing,planning and delivering care and treatment. There was also anemphasis on avoiding admission to hospital wherever possible.

Referrals were managed well and there were effective assessmentprotocols in place. However, staff told us that there was a shortageof mental health inpatient beds across the trust. This meant thatsome people were being accommodated in hospital beds that werea long distance away from their home. Improvements need to bemade to make sure that the trust works with commissioners toreview the number of inpatient beds available throughout the trust.

Summary of findings


However, other people were concerned about access to services andthe lack of continuity between the different care co-ordinators whowere supporting them. We brought these concerns to the attentionof senior trust staff during our inspection.

Where possible, appointments were made to fit in with people’slives, for example, school and family commitments. We saw that theservice had good working arrangements in place with primary careand third sector providers, and there was evidence that the trust wasreaching out to ‘hard to reach’ groups. For example some staff had aspecial interest in Black and minority ethnic (BME) work and therewere clear links with a BME support group.

People knew how to raise concerns and complaints, and weresupported by staff to raise any concerns about their care. We alsosaw that the trust had a good system in place for managing anyformal complaints.

Are services well-led?We saw good examples of local leadership in the services we visited.Staff told us that they felt well supported by their immediate linemanager and knew who the trust’s senior leaders were.

There were monthly management meetings and managers told usthat they used these as learning and development opportunities.The services managed people’s clinical risk and we saw thatfeedback from people was recorded effectively.

Most staff were aware of the trust’s vision, values and strategies andof the trust’s local management structure. However, other staff feltundervalued by the trust. For example, staff reported that there hadnot been a medical advisory group for Bristol for 18 months.

The trust had an ‘Information Quality’ (IQ) system in place. Thisenabled senior managers to regularly review the service’s qualityand records management, with the findings disseminated to theteam. We saw that senior managers were using this systemeffectively.

Summary of findings


Background to the serviceAvon and Wiltshire Mental Health Partnership NHS Trustprovides community-based mental health services toadults who live in Bristol, North Somerset, SouthGloucestershire, Swindon, Wiltshire and North EastSomerset. Care is mainly provided in people's homes, butthe service also has outpatient facilities at GP surgeries,and community bases. The teams provide people, theirfriends, families and carers with support, advice,medicines and a range of therapeutic interventions.

Avon and Wiltshire Mental Health Partnership NHS Trusthas a number of local adult community care services.

These services provide ongoing, and specific, periods ofcommunity-based mental health care, treatment andsupport. The teams provide people, their friends’ familiesand carers with support, advice, medicines and a range oftherapeutic interventions.

Following our last inspection of these services, we issuedtwo compliance actions in regards to regulations 9 and 22of the Health and Social Care Act 2008. During thisinspection we found that, overall, the trust had madeimprovements to make sure that there were enough staffand that people’s care and welfare needs were being met.

Our inspection teamOur inspection team was led by:

Chair: Professor Chris Thompson, ConsultantPsychiatrist

Team Leaders: Julie Meikle, Head of Inspection

Lyn Critchley, Inspection Manager

The team included CQC managers, inspection managersand inspectors and a variety of specialists including:consultant psychiatrists, specialist registrars,psychologists, registered nurses, occupational therapists,social workers, Mental Health Act reviewers, advocates,governance specialists and experts by experience.

Why we carried out this inspectionWe inspected this core service as part of ourcomprehensive Wave 2 pilot mental health inspectionprogramme.

How we carried out this inspectionTo get to the heart of people who use services’ experienceof care, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

Before visiting these services, we reviewed informationthat was sent to us by the provider and consideredfeedback from relevant local stakeholders includingadvocacy services and focus groups.

We carried out unannounced visits to these servicesbetween 10 and 12 June 2014. We spoke with people andcarers who were using these services, and reviewed 25care and treatment records in detail.

We attended staff handovers, observed initial assessmentappointments, and accompanied trust staff oncommunity visits with the prior permission of thoseinvolved. We spoke with managers, front line staff,support staff and doctors.

We also reviewed the trust’s systems for obtainingfeedback from other people who had contact with theservice.

Summary of findings


What people who use the provider's services sayMost people were positive about the service provided.One person said that staff who had visited them had beenvery kind and supportive. Someone else told us that staffwere very good and treated them with respect.

However, other people were concerned about access toservices and the lack of continuity between the differentcare co-ordinators who were supporting them. We alsonoted that access to inpatient care close to home was notalways possible, with people receiving care from out ofarea services. People told us they found it difficult whenthey were out of the area as they had limited access tofamily and friends.

People were aware of the care and treatment they werereceiving and told us that staff were good at explainingthings to them. People had received a copy of their careplan and a list of emergency contact numbers if required.

We observed good practice and staff interacting well withpeople and their carers. Carers told us that they usuallyfelt well supported by this service, and that they foundthat staff were generally responsive and kind.

Good practiceWe found that the Swindon psychiatric liaison servicewas working well with the local acute NHS hospital trustto manage individuals’ distress. It was also workingtogether with the local suicide prevention project.

We found evidence that demonstrated that the trust wasreaching out effectively to ‘hard to reach’ groups, forexample Black and minority and ethnic (BME) andhomeless groups.

Areas for improvementAction the provider MUST or SHOULD take toimprove

• The trust must work with the commissioners of theirservice to make sure that there are enough inpatientbeds for people available locally.

• The trust should make sure that concerns identified intwo services around the administration, monitoring,storage and disposal of unwanted medicines havebeen fully addressed.

• The trust should make sure that care and treatmentplans for people receiving care and treatment undercommunity treatment orders (CTOs) are reviewed.

• The trust must make sure that all staff receive trainingand supervision.

• The trust must make sure that people’s physical healthneeds and monitored and any concerns are managedappropriately.

• The trust must make sure that caseloads are set withinnational guidance and trust policy.

Summary of findings


Locations inspected

Name of service (e.g. ward/unit/team) Name of CQC registered location

Chippenham Recovery Team,Bewley House,Chippenham Trust Headquarters

Swindon Recovery Team and Early Intervention Team,Chatsworth House, Swindon Trust Headquarters

Psychiatric Liaison Team, Victoria Centre, Swindon Trust Headquarters

Bristol Early Intervention Team, Colston Fort, Bristol Trust Headquarters

North Somerset Early Intervention Team, CoastResource Centre Trust Headquarters

Bristol Recovery Team, Brookland Hall Trust Headquarters

South Gloucestershire Recovery Team, Blackberry HillHospital Trust Headquarters

Mental Health Act responsibilitiesWe do not rate responsibilities under the MentalHealth Act 1983. We use our findings as a determinerin reaching an overall judgement about the provider.

We reviewed 25 care and treatment records within thoseservices inspected. These showed us that where requiredlegal documentation was being completed appropriatelyby staff. Those training records reviewed showed us thatstaff were receiving training on the Act.

Avon and Wiltshire Mental Health Partnership NHSTrust

AdultAdult ccommunity-bommunity-basedasedserservicvicesesDetailed findings


However we noted within the Bristol recovery team thatthere was no evidence of people’s rights being explainedunder their ‘community treatment order’ (CTO). There waslimited evidence of specific care plans linked to individualcommunity treatment orders for people who required this.

Mental Capacity Act and Deprivation of Liberty SafeguardsStaff said they were aware of the Mental Capacity Act andthe implications this had for their clinical and professionalpractice. Staff had received training on this Act. There wasevidence seen that showed us capacity assessments werebeing completed appropriately and reviewed as required.

Detailed findings


* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatoryabuse

Summary of findingsAll the services had a proven track record on safety andhad developed service-based learning from incidents.We saw evidence that the trust had effectivelyanticipated and managed potential risks to the service.

Monthly caseload reviews and the risk managementsystems in place showed us that staff were able to meetthe people’s needs. While there were not enough staff inone service, the trust told us what steps they weretaking to address these concerns.

Incidents and ‘near misses’ were recorded and reportedappropriately through the trust’s online reportingsystem. However, the trust’s chief pharmacist had raisedconcerns about the monitoring, storage and disposal ofunwanted medicines in community services. We foundthat two of the teams, south Gloucestershire andSwindon, did not monitor or store medicines, or disposeof unwanted medicines, in a safe manner. We drew thisto the attention of the trust’s chief pharmacist.

Most staff had received mandatory safeguardingtraining and were aware of their responsibilities foridentifying and reporting safeguarding concerns.

Staff also knew about the trust’s lone worker policy. Wesaw that they took precautions, such as joint visits, asrequired, and these were supported by clear riskassessments.

There were clear contingency plans in place, forexample for communication breakdowns anddisruptions to other trust services, and staff were awareof these.

Our findingsSouth Gloucestershire recovery team

Track record on safetyThe manager told us that they used the trust `IQdashboard` and risk register to identify and monitor risks.

There were mechanisms in place to report and recordsafety incidents, concerns and near misses. Staff confirmedthat the trust had an online reporting system to report andrecord incidents and near misses.

Senior staff confirmed that clinical and other incidentswere reviewed and monitored monthly, discussed by themanagement team and shared with front line staff. Thereport outlined the impact to the service, the underlyingcause as well as the risk and governance team’s comments.

The service had a local risk register and senior staff wereable to identify the current risks to the service provided.The evidence seen demonstrated to us that the service hada proven track record on safety and had learnt fromincidents that had happened.

Learning from incidents and improving safetystandard

We noted there were low levels of reporting according totrust incident data. This may indicate that not all incidentswere being reported appropriately. This was brought to theattention of senior staff during our inspection. We sawteam meeting minutes which highlighted low rates ofincident reporting to the team. However staff told us theywere encouraged to report their concerns and were able totell us how they did this.

We saw that learning from incidents was shared within theteam meetings and in individual clinical supervision. Forexample, we saw action had been taken following a root-cause analysis of a serious incident, to offer staff additionaltraining from the psychological therapies team, in riskformulation and documentation. We saw that staff workedjointly with other agencies and across services to promotesafety.

Reliable systems, processes and practices to keeppeople safe and safeguarded from abuse

Staff demonstrated knowledge on how and where to reportsafeguarding issues and received training on safeguardingadults and children. The manager told us that safeguardingconcerns were also discussed during multidisciplinaryteam meetings and at handover. There appeared to be alow level of reporting across the team and no localoverarching system of monitoring safeguarding referralsmade. There were no current safeguarding issues at thetime of inspection.

Are services safe?By safe, we mean that people are protected from abuse* and avoidable harm


Staff were aware of the lone working protocol and weobserved that they recorded their whereabouts in line withthis.

We looked in the clinic room and found that staff could notshow us if there was equipment available to undertakephysical checks, such as blood glucose monitoring, weightor blood pressure. Staff could not identify if there was alead within the team overseeing medication and infectioncontrol.

We were advised by staff that medications delivered bypharmacy were signed in by administrative staff andindividual staff members signed out medication asrequired. We found that the fridge was not working andthere had been a delay in reporting this. We found thatthere were no appropriate facilities in place to monitor,store and dispose of unwanted medication. Pharmacyboxes which contained medications were left unsecured.Concerns around monitoring, storage and disposal ofunwanted medication were raised with the trust’s chiefpharmacist.

Assessing and monitoring safety and riskThe team operated a `traffic light` risk rating and caseloadweighting system to clearly identify risk levels on theircaseload. We observed a team meeting and saw thatpeople`s risks were discussed. Staff also had regularcaseload management supervision. We saw records of thiswhich showed that staff were supported to identifyappropriate actions to be taken where there may beconcerns. Staff reported that their caseloads weremanageable at about 25 people.

We were told that service users were not normally seen atthe recovery team’s premises. However, we met with oneperson who had been to meet their care coordinator andsaw three other people waiting to be seen. We found theconsultation rooms were bare and unwelcoming. Therewere no information leaflets or pictures and they weresparsely furnished.

The rooms were set away from offices and sound-proofed,so there was no way that staff could summon assistance ifneeded.

Understanding and management of foreseeablerisks

We saw the South Gloucestershire community action plan,which set out current and potential issues which may affectthe service and how the trust planned to address these.These included areas such as staffing and increase indemand for services.

Staff could not tell us if there was an emergency procedureor defibrillator on site.

Swindon recovery team; Swindon earlyintervention team; Swindon psychiatric liaisonteam

Track record on safetyThe managers told us that they used the `IQ dashboard`and risk registers to identify and monitor risks. There weremechanisms in place to report and record safety incidents,concerns and near misses. Staff confirmed that the trusthad an online reporting system to report and recordincidents and near misses.

The trust-wide evidence provided showed us that overallthe trust was reporting concerns through the NationalReporting and Learning System (NRLS).

Senior staff confirmed that clinical and other incidentswere reviewed and monitored monthly and discussed bythe management team and shared with front line staff. Thereport outlined the impact to the service, the underlyingcause as well as the risk and governance team’s comments.

The service had a local risk register and senior staff wereable to identify the current risks to the service provided.The evidence seen demonstrated to us that the service hada proven track record on safety and had learnt fromincidents that had happened.

Learning from incidents and improvingstandards

We saw that there was shared learning from incidents atboth trust and local level. Staff were encouraged to reporttheir concerns and were able to tell us how they did this onthe electronic system. Learning from incidents was sharedwithin the team meetings and in individual clinicalsupervision.


Staff received training on safeguarding adults and childrenand there was a designated lead on safeguarding identified



within each team. Staff demonstrated knowledge on howand where to report safeguarding issues, and safeguardingconcerns were discussed during the multidisciplinary teammeetings. There were no current safeguarding issues at thetime of inspection.

There was some variation in how staff outlined theirwhereabouts in line with the lone working policy, however,staff told us that they felt safe.

There were no appropriate facilities in place to monitor,store and dispose of medication. Concerns around storageand disposal of unwanted medication were raised with thetrust’s chief pharmacist.

Assessing and monitoring safety and riskThe teams operated a `traffic light` risk rating andcaseload weighting system to clearly identify risk levels ontheir caseload. We observed the recovery and psychiatricliaison team meetings and saw that people`s risks werediscussed. Staff also had regular caseload managementsupervision. We saw that staff identified appropriateactions to be taken where there may be elevated risk.

We reviewed people`s records and saw that people`sneeds and risks were assessed and clearly documented.Risk assessments we were up to date and reflected currentindividual risks and relevant historical risk information.

We were told that as part of ongoing assessment of risk,staff would discuss a person`s capacity to consent totreatment and information sharing. When we looked atcare records, most people had consent recorded.

Understanding and management of foreseeablerisk

The recovery team operated a duty system and psychiatricliaison had daily protected assessment slots, whichensured urgent contacts to the teams were managedeffectively. Issues affecting staffing levels, such as annualleave or sickness, were managed within the teams. Staffwere aware of the trust’s contingency plans to maintainservice continuity.

Chippenham recovery teamTrack record on safety

Senior staff confirmed that clinical and other incidentswere reviewed and monitored monthly and that the unit’s

risk register was updated and regularly reviewed by themanagers. Staff told us that they had not received feedbackfrom these incidents and we saw no evidence within thestaff team meeting minutes.

We saw that people’s records identified their previous risksand behaviours as well as current assessed concerns andrisks. We observed the evaluation of the risk register duringthe daily multidisciplinary handover meeting.

The evidence seen demonstrated to us that the service hada proven track record on safety but should ensure that stafflearnt from incidents that had occurred.

Learning from incidents and improving safetystandards

We found that the trust had an online reporting system toreport and record incidents and near misses. We saw staffhad access to the system via “password” protectedcomputer systems.

We reviewed the monthly clinical incident report which wasreviewed and discussed by the management team. Thereport outlined the impact to the service; the underlyingcause as well as the risk and governance team’s comments

Staff confirmed they were encouraged to report incidentsand “near misses”. People told us that they were able tovoice their concerns to staff although they had not had todo so.

Staff confirmed that they had received training regardingincident reporting and that they felt supported by their linemanagers following any incidents or near misses.

The trust provided clear guidance on incident reporting.Staff could describe their role in the reporting process. Theevidence seen showed us that the trust had effectivesystems in place to learn from untoward incidents and hadimproved safety standards as a result.


Staff were aware of the trust’s safeguarding policies. Therecords seen showed us that staff had received theirmandatory safeguarding children’s training at level 3.However, we found confusion regarding the “prevent” adulttraining which was not identified as having beenundertaken.

Those care and treatment records seen identified anypotential safeguarding concerns. Staff confirmed they were



aware of their responsibilities to report any concerns to therelevant authorities. They were aware of the trust’swhistleblowing policy and confirmed they felt able to raiseconcerns with their line manager.

The service we visited was clean and well maintained withup to date environmental risk assessments in place whichincluded for example, ligature risk assessments.

Medicines were usually managed via the person’s generalpractitioner but the trust had a dedicated pharmacystorage facility. We were informed that the pharmacydepartment managed all medicines.

Staff told us they had concerns with the transportation ofmedicines and whether their insurance would cover them.The outcome of the concern was to have pharmacy speakwith the team about how to manage this problem. We sawno evidence that this had taken place.

Medicine care plans were in place to manage medicinesand identified whether people self-medicated and theprocedures for staff to follow when supporting people. Wewere informed that some qualified nurses conductedsecondary dispensing. We found no evidence within thetraining records of secondary dispensing training tosupport staff.

Assessing and monitoring safety and riskStaff attended daily handovers with the multidisciplinaryteam. Areas addressed included risk management and the“step-down” of people who use the services fromsecondary care to primary care. We observed a teammeeting on the day of our visit during which any concernswere highlighted and shared by the team.

The evidence seen meant that the trust was effectivelyassessing potential risks to people who use the service.


Staff told us they were aware of the lone working policy.The unit had a record of staff whereabouts and a codedmessage system to identify support needs when visitingpeople in the community. Senior staff were aware of thetrust’s contingency plans to maintain service continuity.

This meant that the trust had effectively anticipated andmanaged any potential or foreseeable risk to the service.

Bristol recovery teamTrack record on safety

There were mechanisms in place to report and recordsafety incidents, concerns and near misses. Seniormanagers confirmed that clinical and other incidents werereviewed and monitored monthly. For example we sawevidence that quality and safety were standard agendaitems on the monthly team managers meeting.

Staff reported that the local risk register was updated andregularly reviewed. Staff also received feedback on localand trust-wide incidents at their weekly team meeting.

We saw that individual care and treatment recordsidentified previous risks and behaviours as well as currentassessed concerns and risks. We observed this beingrecorded as part of an initial assessment being carried out.


Staff confirmed that the trust had an online reportingsystem to report and record incidents and near misses. Wesaw staff had access to the system via “password”protected computer systems.

We saw the monthly clinical incident reports which werereviewed and discussed by the management teams. Thereport outlined the impact to the service, any underlyingcauses as well as the risk and governance team’scomments.

Staff had received mandatory health and safety trainingand confirmed they were encouraged to report incidentsand “near misses”. Some staff raised concerns about theindividual risk carried on their caseloads. However, we sawrecords that showed us that caseloads were reviewed atmonthly supervision meetings with line managers and atweekly team meetings. Senior staff confirmed that anyspecific risks would be highlighted and documented withinthe person’s care and treatment plans.

The trust provided clear guidance on incident reporting.Staff described their role in the reporting process. Theevidence seen showed us that the trust had effectivesystems in place to learn from untoward incidents and‘near misses’.


We found that individual care and treatment recordsidentified any potential safeguarding concerns. Staff



confirmed that they had received their mandatorysafeguarding training. They were aware of theirresponsibilities to report any concerns to the relevantstatutory agencies.

Staff were aware of the trust’s whistleblowing policy andconfirmed they felt able to raise concerns with theirmanager.

Assessing and monitoring safety and riskWe observed a number of meetings that were taking placeduring our inspection of this service. We saw that the teamwas quick to provide support and guidance to each other.This showed us that the team was working effectivelytogether to meet the individual needs of the people whouse the service.

Staff were aware of the trust’s lone worker policy. Theyconfirmed that they followed this and reported anyconcerns promptly.


We saw that joint visits and other precautions were takenby staff and these were supported by clear riskassessments.

The services had a record of staffs whereabouts and acoded message system to identify any concerns whenvisiting people in the community.

Clear contingency plans were in place and staff were awareof these. For example, contingency plans were in place forthe breakdown of communication systems and for theemergency evacuation of the building.

A local risk register was in place and this identified thecurrent risks to the service. This meant that the trust hadeffectively anticipated and managed any potential orforeseeable risk to the service.

Bristol early intervention teamTrack record on safety

There were mechanisms in place to report and recordsafety incidents, concerns and near misses. Seniormanagers confirmed that clinical and other incidents werereviewed and monitored at weekly allocation meetings anddiscussed at daily ‘mini risk management’ meetings. Wesaw evidence that quality and safety were standard agendaitems on the monthly team managers meeting.

Staff reported that the local risk register was updated andregularly reviewed. Staff also received feedback on localand trust wide incidents at their weekly team meeting.

We saw that individual care and treatment recordsidentified previous risks and behaviours as well as currentassessed concerns and risks. The evidence seendemonstrated to us that the service had a proven trackrecord on safety and had learnt from incidents that hadhappened.



We saw the monthly clinical incident reports which werereviewed and discussed by the management teams. Thereport outlined the impact to the service, any underlyingcauses as well as the risk and governance team’scomments. The trust issued monthly safety bulletins to allstaff. Staff spoken to were aware of these.

The trust provided clear guidance on incident reporting.Staff confirmed they were encouraged to report incidentsand “near misses”. The evidence seen showed us that thetrust had effective systems in place to learn from untowardincidents and ‘near misses’.


We reviewed five individual care and treatment record andall identified any potential safeguarding concerns. Staffconfirmed that they had received their mandatorysafeguarding training and that they had also received theirtrust ‘Prevent’ training. They were aware of theirresponsibilities to report any concerns to the relevantstatutory agencies.


Assessing and monitoring safety and riskStaff told us that their colleagues were supportive and theycould approach senior colleagues or their line manager foradditional support if required.



Staff were aware of the trust’s lone worker policy. Theyconfirmed that they followed this and reported anyconcerns promptly.

Understanding and management of foreseeable risks


The services had a record of staff whereabouts and a codedmessage system to identify any concerns when visitingpeople in the community.

Clear contingency plans were in place and staff were awareof the trust’s emergency contingency policy and linkedprotocols. This meant that the trust had effectivelyanticipated and managed any potential or foreseeable riskto the service.

North Somerset early intervention teamTrack record on safety

There were mechanisms in place to report and recordsafety incidents, concerns and near misses. Seniormanagers confirmed that clinical and other incidents werereviewed and monitored at weekly team meetings. Wenoted that clinical risks rated as ‘red’ by the team wereassessed at daily morning meetings. We were told thatquality and safety were standard agenda items at themonthly team managers meeting.

Staff reported feedback on local and trust wide incidents attheir weekly team meeting.

We saw that individual care and treatment recordsidentified previous risks and behaviours as well as currentassessed concerns and risks. The evidence seendemonstrated to us that the service had a proven trackrecord on safety and had learnt from incidents that hadhappened.



We saw the monthly clinical incident reports which werereviewed and discussed by the management teams. Thereport outlined the impact to the service, any underlyingcauses as well as the risk and governance team’scomments. Staff spoken to were aware of the trust’smonthly safety bulletins

The trust provided clear guidance on incident reporting.Staff confirmed they were encouraged to report incidentsand “near misses”. The evidence seen showed us that thetrust had effective systems in place to learn from untowardincidents and ‘near misses’.


We reviewed five individual care and treatment records.These identified any potential safeguarding concerns. Staffconfirmed that they had received their mandatorysafeguarding training. They were aware of theirresponsibilities to report any concerns to the relevantstatutory agencies.


Assessing and monitoring safety and riskStaff were aware of the trust’s lone worker policy. Theyconfirmed that they followed this and reported anyconcerns promptly.



The services had a record of staff whereabouts and a dutyofficer system for the monitoring of individual concerns.

Clear contingency plans were in place for this service andstaff were aware of the trust’s emergency contingencypolicy and linked protocols. This meant that the trust hadeffectively anticipated and managed any potential orforeseeable risk to the service.



Summary of findingsPeople received effective care and treatment bycompetent staff. Care provided was based on acomprehensive assessment of individual’s needs, usingthe Health of the Nation Outcome Scale (HoNOS)assessment. Staff also used a ‘clustering tool’ to assessindividual risk, which determined the level of supportthey received.

However, some of the care plans that we reviewed werenot detailed enough and did not show evidence ofpeople’s rights being explained under their ‘communitytreatment order’ (CTO). There was also limited evidencethat, where needed, people’s care plans were linked totheir community treatment orders.

Overall, staff received mandatory training. However,mandatory training in health and safety, conflictmanagement, adult safeguarding and infection controlhad not been undertaken by many of the staff in oneteam. We saw that the trust had drawn up a stafflearning needs action plan where issues were identified.Some staff expressed concern that opportunities fortraining and professional development had beenreduced and that there was little on offer in addition tothe core mandatory training provided.

The trust benchmarked people’s outcomes using, forexample, Patient Reported Experience Measures(PREMS) and Patient Reported Outcome Measures(PROMS). We found that the trust worked together withmulti-agency partners, such as police and the localauthority safeguarding teams.

Most staff received monthly clinical supervision. Thesesessions were used to review caseloads and provideadditional clinical support, as required. However, staff inone team had not received their annual appraisal.


Assessment and delivery of care and treatmentThere was evidence of joint working with other teams andservices to meet the needs of people. We found that staffassessed and planned care in line with the needs of the

individual. People were offered a copy of their care plan,and this was confirmed by those people spoken with. Wereviewed care records which contained comprehensiveinformation, and included risk assessments and care plans.

Outcomes for people using servicesThere were systems in place to monitor quality andperformance. The trust had a range of audit systems inplace monitoring team performance, which team managershad access to. The team manager also told us that theywere monitoring quality and performance through regularindividual supervision and care records audit. When aservice user was first allocated, the consent to share formstating their preferences was uploaded onto the electronicrecord system (RiO) and this was monitored.

The team worked closely with the psychological therapyservices department to provide psychologicalinterventions. Skills mapping of staff showed us that therewere a number in the team with specialist skills, such asfamily work, cognitive and dialectical behavioural therapy.

Staff, equipment and facilitiesThe team did not operate a duty system and we were toldthat any disruption to staffing levels, due to annual leave orstaff sickness, was dealt with through cross cover amongstthe team. Staff confirmed that systems were in place tomonitor staff sickness and that they had access tooccupational health support if required.

There was a training matrix which was clearly laid out foreach role. This was reviewed at team level to monitoroutstanding training. Opportunities for training andprofessional development, other than core mandatorytraining, had been reduced following a freeze on training bythe trust. Staff had been advised to identify training needsin supervision or appraisal.

Staff confirmed that they received regular managementsupervision and we saw some supervision records. Theteam were offered emotional support if a major incidentoccurred, and there was also informal peer supportavailable. Most staff had laptops and mobile telephones tosupport their work in the community. The team had aweekly clinical meeting for case discussion and there wasalso the opportunity for further team related discussions,which included governance information sharing.

Multidisciplinary workingStaff told us that they worked collaboratively with otherprofessionals, for example the wards and community

Are services effective?By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.


mental health teams using the care programme approachprocess. A good relationship was reported between therecovery team, inpatient and other local community teams.The recovery team also demonstrated that they workedcollaboratively with multi-agency partners, such as policeand the local authority safeguarding teams.

Mental Health Act (MHA) 1983Staff told us that they had access to social workers andapproved mental health professionals (AMHP) within theteam to provide guidance on the MHA. We found that staffhad received mandatory training on the MHA.


Assessment and delivery of care and treatmentRecords we sampled included a care plan that showed staffhow to support the person to meet their needs. We weretold that their GPs managed physical aspects of people`scare.

However, it was not always clear how trust staff assessedand monitored people’s physical health needs, particularlyin relation to side effects from some of their mental healthmedication. For example, a young person working with theearly intervention team had a high body mass index (BMI),continued weight gain and was taking antipsychoticmedication. It was documented that they refused aphysical health check but it was not clear how this wouldbe monitored or followed up.

The recovery team had had a number of locum consultantsin post. People and carers told us that this had led to stressand inconsistency in this part of their care. The trust told usthat a permanent consultant had now been appointed. Theearly intervention team did not have dedicated consultanttime, which meant that people could see several differentdoctors.

Outcomes for people using servicesThere were systems in place to monitor quality andperformance. The trust had a range of audit systems andperformance indicators in place which monitored teamperformance. We saw that quality and performance wasmonitored through regular individual supervision and carerecords audit. The psychiatric liaison team were working ona pilot study as part of a wider suicide prevention project.

Staff, equipment and facilitiesThe recovery and psychiatric liaison teams were staffedwith numbers and a skill mix which enabled effectiveworking. However, the early intervention team reportedvacancies, which was having an impact on the team.

Some staff expressed concern that opportunities fortraining and professional development had been reducedand that there was little on offer in addition to the coremandatory training provided. Staff confirmed that theyreceived regular management and caseload supervisionand we saw some supervision records. Staff had laptopsand mobile telephones to support their work in thecommunity.

We found that the clinic room was clean and wellmaintained, with appropriate key access systems in place.

Multidisciplinary workingThere was evidence that staff worked collaboratively withother professionals, using the care programme approachprocess. The psychiatric liaison team reported goodrelationships with colleagues at the Great Western Hospital.

Mental Health Act (MHA) 1983Staff told us that they had access to social workers andapproved mental health professionals within the team toprovide guidance on the MHA. Staff confirmed that theyhad received mandatory training on the MHA.

Chippenham recovery teamAssessment and delivery of care and treatment

The team demonstrated their understanding of the MHAcode of practice and the Mental Capacity Act (MCA). Staffensured that people who used service’s had the capacity toconsent to treatment. We observed three people’s recordswhich had the relevant assessments and signed consentforms in place.

We saw that individual care and treatment recordsreflected the assessed needs of people who use the serviceand how they were being met. We reviewed four care planrecords and found that the information contained wasvague and not person centred. For example, we found thecontent of the care plans did not provide guidance to staffon how to support people who used the service. We alsonoted that of four care plans reviewed only one had beensigned by the person who used the service.



The records showed us that people’s physical healthcareneeds were addressed by the service and that assessmentsof their physical health status were recorded.

The managers confirmed that trust wide monthly auditswere carried out via the internal IQ system and submittedto the head of operations and head of professionalpractice. These findings were cascaded down anddiscussed at the monthly Wiltshire performance meeting.

The caseload for the team was 370 at the time of ourinspection. The manager told us they were in the process ofreviewing the case loads and were allocating the cases to acertain “patch” area based on postcodes. This meant thatstaff caseloads were being reduced to a manageable level.All caseloads were monitored on the trust’s computerisedsystem and we observed that two staff had a caseload ofover 30. We were told that the trust’s guidance is 24 casesper staff member, although the trust told us that this is notcorrect and is weighted to reflect complexity.

We were informed that the team received between eightand thirty referrals a day, predominantly from primary careservices. All new referrals were discussed as a team once aweek. We found that this was a slow process with theaverage referral taking about two weeks.

Outcomes for people using servicesThe records, and other evidence seen, showed us that thetrust was involved in the monitoring and measurements ofquality and outcomes for people who use the service.However, it was noted that outcome measures were notroutinely used to benchmark the outcomes for peopleusing the service.

The managers told us that they were aware of caseloadswhich required reviewing with regard to a step-down intoprimary care services.

Staff, equipment and facilitiesThe records and evidence seen showed us that the trustensured that adequate staffing, equipment and facilitieswere available to promote the effective care and treatmentfor the people who use the service. One of the twoconsultants was leaving but they had recruited a locum toreplace whilst they were recruiting to ensure continuity inthe service. Some staff raised concern about theirindividual work load although agreed this was beingreviewed with a view of reducing them.

We observed that staff had not received dementia training.We observed that some staff with specialist skills werecontinuously asked to address specific areas, for examplesafeguarding. We found that other staff did not have thesame skills. We found no evidence of wider learning toensure that the relevant skills were available and passed onto all staff.

We reviewed the training matrix and noted the currentpercentage of identified staff trained was at 54%. Examplesof outstanding training included manual handling, healthand safety, managing conflict, adult safeguarding andinfection control. We saw that staff had received emailsoutlining the training due which could be completed viathe e-learning system. We were informed that funding forspecific training had been suspended and had only justbeen reintroduced. The manager told us that trainingattendance was not currently monitored and they did nothave information available to address non attendees attraining opportunities.

There was a comprehensive induction programme in placewith staff being mentored for six weeks. We found that thisservice did not have a competency framework in place toassess individual staff competency.

We saw a staff learning needs action plan. This showed usthat the trust was taking steps to address the learningneeds of the staff who worked in this service.

The two interim mangers had only been in post sinceMarch and May 2014 respectively and were in the processof addressing supervision. We reviewed the clinicalsupervision audit on the trust’s IQ system which identifiedthat 75% of the staff had received their supervision. Noneof the staff had received their annual appraisals but themanagers informed they were aware of the shortfall butwished to ensure continuity with regular supervision priorto reviewing the appraisal process.

Staff told us that they had issues with the laptops providedas they were unable to access the trust’s electronic system.We spoke with the manager who confirmed that there wereissues with access to the lap-tops and the internalcomputer system. Staff also said that the system was veryslow and often “freezes” which meant they had to revert topaper based record keeping.

Staff told us there were issues with staffing which wasconfirmed by the managers. We reviewed the staffing rotasfor May 2014 and these showed us that although staffing



levels were sufficient they were using a high number ofbank and agency staff to cover absences within the coreunit staffing. To provide consistency agency staff werecontracted for three months to ensure familiarity withpeople who use the services.

Administration staff told us they were working long hoursto ensure the information provided on people who use theservice was accurately recorded. We were informed that theunit was actively recruiting for two administrative staff.

Multidisciplinary workingWe saw the trust worked effectively with other providersand partners in the provision of the service. Staff told usthey felt integrated and part of a team. We observeddetailed multidisciplinary discussions during handover toensure people’s care and treatment was coordinated in linewith the expected outcome. Staff discussed their caseloadsand the complexities of people’s needs. We saw thatmedical and nursing teams worked well with otherspecialities and therapy services to provide goodmultidisciplinary care. The records identified that peoplewere able to access voluntary organisations to supporttheir needs in the community.

We observed arrangements in place to work with otherhealth and care providers to coordinate the care that metpeople’s needs. The records reviewed showed us thatpeople, and where applicable their relatives, had beeninvolved in their care. We saw good examples of individualinvolvement in the drawing up of community treatmentplans.

We saw good evidence of patient pathways through theirinvolvement with this service.

Mental Health Act (MHA) 1983Staff told us they had good knowledge of the MHA andcode of practice. The interim managers told us that theyhad conducted a review to ensure that staff were able todeliver assessments and care and treatment which wascompliant with the MHA.

Bristol recovery teamAssessment and delivery of care and treatment

The trust was able to demonstrate that people who use thisservice received effective care and treatment by competentstaff. We saw that people received care based on acomprehensive assessment of individual need using the

Health of the Nation Outcome Score (HoNOS) assessment.The extent of support that people received was determinedby the ‘clustering’ tool used by the trust to assess individualrisk.

We reviewed eight individual care and treatment recordswhich had the relevant assessments and care plans inplace. We found that some care plans lacked clearinformation for staff that may be unfamiliar with theperson. This was brought to the attention of senior staffduring our inspection.

The records showed us that people’s physical healthcareneeds were assessed and addressed in partnership withthe person’s general practitioner. People who used theservice confirmed that they had access to emergencynumbers to enable them to access advice and supportwhen required.

Senior staff confirmed that trust wide monthly audits werecarried out via the internal IQ system. We observed thesefindings were cascaded down and discussed at the weeklyteam meeting.

Outcomes for people using servicesThe records and other evidence seen showed us that thetrust was involved in the monitoring and measurements ofquality and outcomes for people who use the service. Forexample, the service used Patient Reported OutcomeMeasures (PROMS) the recovery star model and the‘wellness recovery action plan’ (WRAP) model to assessindividual outcomes for people.

The trust had a range of audit systems and performanceindicators in place which monitored outcomes for peoplewho used the service.

Staff, equipment and facilitiesThe records and evidence seen showed us that the trustensured that adequate staffing, equipment and facilitieswere available to promote the effective delivery ofcommunity recovery care and treatment for people whoused the service. Out of hours cover was provided by theBristol crisis team.

Senior staff informed us that non-attendance at mandatoryand other training opportunities was monitored throughthe trust’s training department.

Staff told us that there was a comprehensive inductionprogramme in place. The supervision and appraisal recordsseen showed us that staff were receiving monthly



supervision and these meetings were used to discusscaseload management and complex care delivery. Staffconfirmed that they received annual appraisals and thesewere used to identify individual training needs andprofessional development opportunities.

Staff had laptops and mobile telephones to support theirwork in the community.

Senior staff told us that there were adequate staff to meetthe needs of the service. We noted that each staff memberhad an average caseload of 25 to 35 depending oncomplexity and assessed need.

Some staff told us that they felt their caseloads were toohigh. This was brought to the attention of senior trust staffwho informed us that caseloads and referrals werediscussed at the weekly caseload allocations meeting. Wewere informed that agency staff had been recruited tocover staffing shortfalls in the triage team - primary careliaison service (PCLS). Staff told us that their colleagueswere supportive and they could approach seniorpractitioners or their manager for additional support ifrequired.

The service we visited was clean. However we noted thatparts of the building were in need of some refurbishmentand redecoration. This was brought to the attention ofsenior trust staff. Staff reported some delays in gettingmaintenance requests actioned.

Multidisciplinary workingWe found that that staff worked collaboratively with otherprofessionals, using the care programme approachprocess. Records seen showed us that joint assessmentswere carried out on between 10 – 20% of admissions to theservice. However medical staff told us that there was a lackof continuity with psychiatric medical cover due to thenumber of part time doctors working in this service. Thiswas brought to the attention of senior trust staff during ourinspection.

Mental Health Act (MHA) 1983Staff told us that they had access to social workers andapproved mental health professionals within the team toprovide guidance on the MHA. However we found thatthere was no evidence of people’s rights being explainedunder their ‘community treatment order’ (CTO). There was

limited evidence of specific care plans linked to individualcommunity treatment orders for people who required this.This was brought to the attention of senior trust staff duringthe inspection.

Bristol early intervention teamAssessment and delivery of care and treatment

The trust was able to demonstrate that people who use thisservice received effective care and treatment by competentstaff. We saw that people received care based on acomprehensive assessment of individual need using theHealth of the Nation Outcome Score (HoNOS) assessment.The extent of support that people received was determinedby the ‘clustering’ tool used by the trust to assess individualrisk.

We reviewed five individual care and treatment recordswhich had the relevant assessments and care plans inplace.

The records showed us that people’s physical healthcareneeds were assessed and addressed in partnership withthe person’s GP. People who used the service confirmedthat they had access to emergency numbers to enablethem to access advice and support when required.

Senior staff confirmed that trust wide monthly audits werecarried out via the internal IQ system. We observed thesefindings were cascaded down and discussed at thefortnightly team meetings

Outcomes for people using servicesRecords and other evidence seen showed us that the trustwas involved in the monitoring and measurements ofquality and outcomes for people who use the service. Forexample, the service used Patient Reported OutcomeMeasures (PROMS) and Patient Reported ExperienceMeasures (PREMS) to assess individual outcomes forpeople.

The trust had a range of audit systems and performanceindicators in place which monitored outcomes for peoplewho used the service.

We saw evidence of good liaison with local third sectorspecialist housing providers. This assisted people whoused services with any accommodation problems that theymight have.



Staff, equipment and facilitiesRecords and evidence seen showed us that the trustensured that adequate staffing, equipment and facilitieswere in place to promote the effective delivery of thisservice.

Staff told us that there was a comprehensive inductionprogramme in place with new staff being mentored for sixweeks. The supervision and appraisal records seen showedus that staff were receiving supervision monthly and thesemeetings were used to discuss caseload management andcomplex care delivery. Staff confirmed that they receivedannual appraisals.

Senior staff informed us that non-attendance at mandatorytraining was monitored through the trust’s trainingdepartment.

We observed a number of informal meetings taking placeduring our inspection of this service. We saw that the teamwas quick to provide support and guidance to each other.This showed us that the team was working effectivelytogether to meet the individual needs of the people whouse the service.

Senior staff told us that there were adequate staff to meetthe needs of the service. We noted that each staff memberhad an average caseload of 20 as opposed to the nationalguidance of 15 for this specialist service. Staff reported thatthe trust was taking action to address these concerns,through planned recruitment and through monthlysupervision and team formulation supervision led by thepsychology service. Short term absences were beingcovered from within the team.

We noted that there were call bells in the consultationrooms for staff to summon assistance if required. Staff hadlaptops and mobile telephones to support their work in thecommunity.

Multidisciplinary workingWe saw the trust worked effectively with other providersand partners in the provision of the service. Staff told usthey felt a part of a team with good leadership.

We found that the team worked well with other specialitiesand therapy services to provide multidisciplinary care.

We observed arrangements in place to work with theperson’s general practitioner to coordinate some of the

care that people required. Close links were in place withthe Bristol recovery team although concerns wereexpressed regarding some delays with care transfers to thisteam.

Records reviewed showed us that people, and whereapplicable their relatives, had been involved in theirmultidisciplinary care.

Mental Health Act (MHA) 1983Staff told us that they had access to social workers andApproved Mental Health Practitioners within the team toprovide guidance on the MHA. Staff confirmed that theyhad received mandatory training on the MHA.

North Somerset early intervention teamAssessment and delivery of care and treatment

The trust was able to demonstrate that people who use thisservice received effective care and treatment by competentstaff. We saw that people received care based on acomprehensive assessment of individual need using theHealth of the Nation Outcome Score (HoNOS) assessment.The extent of support that people received was determinedby the ‘clustering’ tool used by the trust to assess individualrisk.

We saw that individual care and treatment recordsreflected the assessed needs of people who use the serviceand how they were being met. We reviewed three care andtreatment records and found that the informationcontained was person centred. For example, we found thecontent of the care plans provided guidance to staff on howto support people.

The records showed us that people’s physical healthcareneeds were assessed and addressed in partnership withthe person’s GP. People who used the service confirmedthat they had access to emergency numbers to enablethem to access advice and support when required.

Senior staff confirmed that trust wide monthly audits werecarried out via the internal IQ system. We observed thesefindings were cascaded down and discussed at thefortnightly team meetings.

Outcomes for people using servicesThe trust had systems in place to monitor outcomes forpeople. For example, by the use of Patient ReportedExperience Measures (PREMS) and Patient ReportedOutcome Measures (PROMS).



There were systems in place to monitor quality andperformance. The trust had a range of audit systems inplace which monitored team performance, which teammanagers had access to. The team manager also told usthat they were monitoring quality and performancethrough regular individual supervision and care recordsaudit.

Staff, equipment and facilitiesThe records and evidence seen showed us that the trustensured that adequate staffing, equipment and facilitieswere available to promote the effective delivery of care andtreatment for people who used the service

Senior staff told us that there were adequate staff to meetthe needs of the service. Staff received monthly case loadsupervisions. Short term absences were being coveredfrom within the team.

Senior staff informed us that non-attendance at mandatoryor other training was monitored through the trust’s trainingdepartment.

Staff told us that there was a comprehensive inductionprogramme in place with new staff being mentored for sixweeks. The supervision and appraisal records seen showedus that staff were receiving supervision monthly and thesemeetings were used to discuss caseload management andcomplex care delivery. Staff confirmed that they receivedannual appraisals.

Some staff told us that there were limited opportunities fornurses to develop extended roles, for example nurseprescribing.

Multidisciplinary workingWe saw the trust worked effectively with other providersand partners in the provision of the service. Staff told usthey felt a part of a team with good leadership.

We observed detailed multidisciplinary discussions duringhandover to ensure people’s care and treatment waseffectively coordinated. Areas covered included referralsand complex care requirements. Staff discussed theircaseloads. We found that the team worked well with otherspecialities and therapy services to provide goodmultidisciplinary care.

We observed arrangements in place to work with theperson’s general practitioner to co-ordinate some of thecare that people needed. The records reviewed showed usthat people, and where applicable, their relatives had beeninvolved in their multidisciplinary care.

Mental Health Act (MHA) 1983Staff told us that they had access to social workers andApproved Mental Health Practitioners within the team toprovide guidance on the MHA. Staff confirmed that theyhad received mandatory training on the MHA.



Summary of findingsServices were delivered by caring and compassionatestaff. We found that staff demonstrated confidentialitywhen discussing people’s care and treatment needs.

People were treated with dignity and respect. Weobserved, and saw in our detailed review of 25 care andtreatment records, that people’s and their carers’ wisheswere taken into account in the planning and delivery oftheir care.

Most people told us that staff were supportive and hadinvolved them directly in their care. They were alsosatisfied with the care and support they received fromstaff.

Staff told us that they provided emotional support topeople to help them cope with their care and treatment.They said that this support was available when peopleneeded it. Wherever possible, people were alsosupported to manage their own health and care needsto maintain their independence.


Kindness, dignity and respectPeople who used this service told us they were treated withdignity and respect and did not raise concerns about howstaff treated them. We observed staff interacting withpeople in a caring and respectful manner. People who usethe service and their representatives were asked for theirviews about their care and treatment by the trust. Forexample, we were told that surveys were sent out to allpeople who use the service. We found that whilst there wasnot a good level of response from these surveys, thefeedback received was largely positive.

People using services involvementService user feedback forms were generally positive andpeople said that they received the support they needed.However, some people had raised concerns about therecovery team relating to access time, poor dischargeplanning and being able to access timely help outside of

office hours. Staff we met with told us that people’s carerswere involved in their assessment and care planning. Theservice user involvement coordinator worked with theteam and attended team meetings.

Emotional support for care and treatmentThe team had information packs which were given toservice users and carers. They also contained contactdetails for advocacy services and the patient advice andliaison service (PALS). Staff told us that people’s carers wereinvolved in their assessment and care planning. Carers wespoke with confirmed that this had happened.


Kindness, dignity and respectMost people we spoke with had good experiences of careand did not raise concerns about how staff treated them.We observed staff interacting with people in a caring andrespectful manner.

People using services involvementService user feedback was largely positive for all the teamsand reflected that people who use the service felt theywere involved in planning their care. Some people wespoke with raised concerns about the recovery teamrelating to frequent change of consultants, poor dischargeplanning with primary care services and not always beingable to access timely help outside of office hours.

Care records we looked at reflected that assessment andinitial planning involved the individual. Staff told us thatwhere possible they also supported people to access theirlocal community facilities which may help their recovery. Aservice user involvement coordinator worked within thelocality and was working with service users and carers in anumber of projects.

Emotional support for care and treatmentPeople who use the service and their carers generally feltwell supported by the community teams. Some peoplewho use the service reported finding it difficult seeing anumber of different staff, having a change in their carecoordinator and poor support around discharge transitionback to primary care services. The psychiatric liaison teamhad incorporated a number of supportive strategies intotheir assessment, such as follow up contact from theSamaritans.

Are services caring?By caring, we mean that staff involve and treat people with compassion,kindness, dignity and respect.


Chippenham recovery teamKindness, dignity and respect:

We observed clear evidence of respect and dignity whenstaff were speaking about the service users in theircaseloads.

We spoke with five people via the telephone and found thefeedback to be variable. One person said they received aneffective service and another said staff had gone out oftheir way to support them with their disabled relative.However three people were less complimentary about theservice. One said that they were not impressed with theservice and felt that the team were “more bothered abouttargets”; another said that they did not feel people werelistening to them and felt they were not treated withrespect regarding the administration of medicines. Thechange of care coordinators without prior knowledge was acause of concern to people who use the service. Theseindividual concerns were brought to the attention of seniorstaff during our inspection.

People using services involvementThe evidence reviewed during the inspection showed usthat people who used the service were involved as far aspossible in their own care and treatments.

We saw examples of individual involvement in the recordsreviewed and of active participation by people in theirtreatment plans. People were given information regardingthe advocacy service available. However, it was noted thatall literature provided was in English and there was noprovision for written information in accessible formats,although the unit had access to an interpreting servicewhich they informed us was utilised effectively.

People who use the service said that they understood theircare plans and were able to ask questions. We reviewedfour care plans and found that the information containedwas vague and did not provide staff with sufficientinformation to support the care needs of people. Examplesincluded staff knowledge of diabetes care. The trust mightfind it useful to note that of the four records reviewed onlyone had person had an acknowledged and signed careplan.

The trust used the recovery star model and we saw that54% of staff had received training. We were informed theywere considering using other assessment tools to gaugerecovery but these had not yet been introduced.

Emotional support for care and treatmentStaff told us they supported people to cope emotionallywith their care and treatment and the support wasavailable when they needed it. People were supported tomanage their own health and care needs to maintain theirindependence.

We also noted that access to inpatient care close to homewas not always possible with people being nursed in out ofarea services. People told us they found it difficult whenthey were out of the area as they had limited access tofamily and friends.

Bristol recovery teamKindness, dignity and respect

We found that the people who used the service were beingtreated with kindness and respect. Staff demonstratedconfidentiality when discussing the care and treatmentneeds of individual people who used the service.

We spoke with four people on the telephone and receivedpositive feedback about the service being provided. Peopletold us that they received a good service. One person saidthat staff who had visited them had treated them withkindness and been helpful. Someone else that the staffalways had time for them.

Carers told us that staff had involved them in the care andtreatment of their relative.

People using services involvementThe evidence reviewed during the inspection showed usthat people were involved as far as possible in their owncare and treatments.

We saw examples of individual involvement in the recordsreviewed and of active participation by some people intheir treatment plans. People were given informationregarding the advocacy service available. Trust staff hadaccess to an interpreting service.

People told us that they understood their care plans andwere able to ask questions. We reviewed eight care andtreatment plans and found sufficient informationcontained to enable staff to provide the support and carethat met people’s needs.

Emotional support for care and treatmentThe team had information packs which were given toservice users and carers. They also contained contact



details for advocacy services and the patient advice andliaison service (PALS). Staff told us that people’s carers wereinvolved in their assessment and care planning and thiswas supported by those people spoken with.

Bristol early intervention teamKindness, dignity and respect

We found that the people who used the service were beingtreated with kindness and respect. Staff demonstratedconfidentiality when discussing the care and treatmentneeds of individual people who used the service.

We spoke with four people on the telephone and receivedpositive feedback about the service being provided. Peopletold us that they received a good service. One person saidthat staff who had visited them had treated them withkindness and been helpful. Someone else that the staffalways had time for them.

Carers told us that staff had involved them in the care andtreatment of their relative.

People using services involvementThe evidence reviewed during the inspection showed usthat people were involved as far as possible in their owncare and treatment.

We saw examples of individual involvement in the recordsreviewed and of active participation by some people intheir treatment plans. People were given informationregarding the advocacy service available. Trust staff hadaccess to an interpreting service.

People told us that they understood their care plans andwere able to ask questions. We reviewed four care andtreatment plans and found sufficient informationcontained to enable staff to provide the support and carethat met people’s needs.

Emotional support for care and treatmentStaff told us they supported people to cope emotionallywith their care and treatment and the support wasavailable when they needed it. This was supported bythose people that we spoke with. The records seen showedus that people were supported to manage their own healthand care needs wherever possible.

We also noted that access to inpatient care close to homewas not always possible with people being treated out ofthe area. People told us they found it difficult when thishappened as they had limited access to family and friends.

North Somerset early intervention teamKindness, dignity and respect

We found that the people who use the service were beingtreated with respect and empathy. Staff demonstratedconfidentiality when discussing the care and treatmentneeds of individual people who used the service.

We spoke with three people on the telephone attendedthree initial consultations and visited one person and theircarer with their prior permission and accompanied by truststaff.

People told us that they received a good service. Oneperson said that staff who had visited them had treatedthem with respect. Another person said that nothing wastoo much trouble for staff.

Staff told us that people’s carers were involved in theirassessment and care planning. This was supported bythose carers spoken with.

People using services involvementThe evidence provided by the trust showed us that peoplewere involved as far as possible in their own care andtreatments.

We saw examples of individual involvement in most ofrecords reviewed and of active participation by somepeople in their treatment plans. People were giveninformation regarding the availability of an independentadvocacy service.

People said they understood their care plans and were ableto ask questions. We reviewed three care plans and foundthat the information contained enabled staff to provide thesupport and care that met people’s needs. All the careplans reviewed had been regularly reviewed and signed bypeople. Evidence was seen of appropriate outcomemeasures being used by the service.

Emotional support for care and treatmentStaff told us they supported people to cope emotionallywith their care and treatment and that support wasavailable when they needed it. This was supported bythose people that we spoke with and by our directobservations of initial consultation episodes and caredelivery. The records seen showed us that people weresupported to manage their own health and care needswherever possible.



Summary of findingsWe found that people’s needs and wishes were metwhen assessing, planning and delivering care andtreatment. There was also an emphasis on avoidingadmission to hospital wherever possible.

Referrals were managed well and there were effectiveassessment protocols in place. However, staff told usthat there was a shortage of mental health inpatientbeds across the trust. This meant that some peoplewere being accommodated in hospital beds that were along distance away from their home.

Where possible, appointments were made to fit in withpeople’s lives, for example, school and familycommitments. We saw that the service had goodworking arrangements in place with primary care andthird sector providers, and there was evidence that thetrust was reaching out to ‘hard to reach’ groups. Forexample some staff had a special interest in black andminority ethnic (BME) work and there were clear linkswith a BME support group.

People knew how to raise concerns and complaints, andwere supported by staff to raise any concerns abouttheir care. We also saw that the trust had a good systemin place for managing any formal complaints.


Planning and delivering servicesThe team did not operate a duty system, although themanager stated that there was always capacity forsomeone to oversee urgent contact to the team. Weobserved a team meeting and saw capacity and allocationsbeing discussed.

Referrals were taken from the other teams within themental health service, such as primary care liaison or theintensive team. This meant that appropriate systems toshare information with other services were established.

Staff reported it was very difficult to find a local bed if aperson required admission to hospital, particularly apsychiatric intensive care unit (PICU) bed. There were no

crisis or respite bed facilities available in SouthGloucestershire. This meant that people sometimes had tobe admitted to a hospital which was not close to theirhome or family.

Right care at the right timeThe community service used a single point of accesssystem, ensuring that people were seen in a timely mannerand the most appropriate care pathway was agreed. Therewas no waiting list at the time of inspection. Cases wereprioritised and allocated by the multidisciplinary team intwice weekly meetings. We found no evidence ofassessment or treatment being cancelled or delayed due tocapacity issues.

The team had some flexibility in the times they saw people,potentially working from 8am to 8pm. Some people whouse the service have told us that it could be difficult to getsupport outside of working hours.

Care pathwayTransfer of care between teams, and shared care withinteam, was generally effectively managed. Although, someservice users told us that their experience of transferbetween services was not always well planned. We sawthat there were weekly care pathway meetings, which themanagers of all community teams and inpatient teamsattended. This was an opportunity to discuss a person’saccess to the correct care pathway.

Staff told us that there was a significant challenge in findingappropriate beds for people and they were sometimesadmitted out of area, making it difficult for carecoordinators to visit them in hospital and be as involved asthey would like.

Learning from concerns and complaintsPeople who use the service were given information abouthow to make a complaint in the information pack theyreceived. Complaints were received directly and passed tothe team manager or from the patient advice and liaisonservice (PALS). Investigations of complaints wereundertaken by the service manager in the first instance andescalated where necessary.


Planning and delivering servicesInformation was accessible on the trust’s website about thepurpose of the different community services and how to

Are services responsive topeople’s needs?By responsive, we mean that services are organised so that they meet people’s needs.


access them. Staff told us that they prioritised workaccording to risk and identified need. We saw thatappropriate systems to share information with otherservices were established.

No examples were shared of assessment or treatmentbeing cancelled or delayed due to capacity issues bypeople we spoke with, staff or other teams that they workwith. Staff reported it was very difficult to find a local bed ifa person needed to be admitted to hospital.

Right care at the right timeThere were clear care pathways and referral processes forthe community teams. The psychiatric liaison team hadworked with the general hospital in developing a mentalhealth assessment matrix, to assist hospital colleagueswhen and where to make referrals for a mental healthassessment.

The teams had systems and capacity to respond effectivelyto routine and urgent referrals. For example, the recoveryteam operated a duty system and the psychiatric liaisonteam had a daily urgent assessment appointment slot. Theteams were aware of systems in place regarding peoplewho may present out of hours or at weekends due todeterioration in their mental health. Some people wespoke with told us that they had raised concerns about notbeing able to access timely help outside of office hours.

Care pathwayThere were weekly care pathway meetings, which themanagers of all community teams and inpatient teamsattended. This was an opportunity to discuss a person’saccess to the correct care pathway. The recovery team waspart of a `wellbeing` pilot to improve transition frommental health services to primary care.

Staff were able to describe the other services involved inpeople’s care pathways and how their teams fitted intothese. Transfer of care between teams and shared carewithin teams was overall effectively managed. However, thetrust may find it useful to note that some people told usthat their experience of transfer between services was notalways well planned.

Learning from concerns and complaintsStaff were generally aware of the process for managingcomplaints and learning took place in team meetings orindividual supervision. We saw that the trust had recently

introduced a `learning from complaint’s’ bulletin. Somepeople had made complaints directly with the service andothers had contacted the patient advice and liaison service(PALS).

Chippenham recovery teamPlanning and delivering services

Evidence was seen that showed us that the trustunderstood the different needs of the people who use theservice and acted on plans to design and deliver theservice. The trust actively engaged with local authoritiesand GPs to provide a coordinated and integrated pathwayto meet people’s needs.

Bed management was a major concern within the unit withstaff spending a large percentage of their time “chasing”beds within the trust. The manager informed us that staffcould spend all day looking for a bed to accommodate aperson. We also noted that access to care close to homewas not always possible with people being situated out ofthe area. People told us they found it difficult when theywere out of the area and had limited access to family andfriends.

The psychologists said they had opened a DialecticalBehaviour Therapy (DBT) sessions for anyone who hadpeople that were interested or wished to be referred to thescheme. Avon and Wiltshire partnership had a psychologyservice in place. People who use the service were able toaccess the service for 20 sessions as a step down dischargeto primary care.

We found good communication between the unit and thespecialised deaf service psychologist which they hadutilised for one of the people who use the services.

Right care at the right timePeople knew what to do, how to seek advice and access theservices in an emergency. They told us they were able tophone up the service at any time and during out of hoursthere was a 24 hour service provided by the intensivesupport team. People said they had utilised the service andhad no issues or concerns.

We noted there was an effective approach to managingreferrals and assessments and there were plans in place totackle any identified problems.

We saw that appointments made were flexible to fit in withpeople’s lives where possible for example, school andfamily commitments.



Care pathwayThe care and treatment records reviewed showed us thatthe unit took into account people’s needs and wisheswhenever possible and when care and treatment wasbeing planned and delivered.

Care records showed us that people and their families wereinvolved in multidisciplinary reviews. Two people told usthat with the constant change in care coordinators it hadan effect on their care plan approach (CPA) reviews whichwere not timely. One person told us they had not had a CPAreview for six months.

We noted good care pathways in place which weredesigned to be flexible whilst ensuring that differentservices worked together to meet the person’s changingneeds. Staff worked alongside the people who use theservice for up to three months prior to discharge to ensurethat people’s needs were addressed and that they had thecorrect care or treatment programme. People referred toprimary care receive a Situation, Background, Assessmentand Recommendation (SBAR) letter, a copy of their careplans and risk assessments.

This meant that the trust had processes in place to ensurethat discharge or transition arrangements met the needs ofvulnerable patients.

Learning from concerns and complaintsComplaints were handled in line with trust policy. Staffwould direct people who use the service and/or theirrelatives to the patient advice and liaison services (PALS) ifthey were unable to deal with concerns raised. People and/or their relatives would be advised to make a formalcomplaint if their concerns remained.

There was information on display within the unit visited.People told us that, if necessary, they would not hesitate toraise a concern. Staff told us they were aware of thecomplaints policy on the intranet service and knew theprocess for making a complaint. We reviewed thecomplaints log and identified one complaint submitted forthis year 2014. Staff told us they had not received feedbackfrom those formal complaints received.

Bristol recovery teamPlanning and delivering services

Evidence was seen that showed us that the trustunderstood the different needs of the people who used theservice. The trust actively engaged with the local authorityand general practitioners to provide a co-ordinated andintegrated pathway to meet people’s needs.

We found evidence that demonstrated that this service wasreaching out to ‘hard to reach’ groups. For example somestaff had a special interest in black minority ethnic (BME)work. Clear links were seen with a BME support group.

Staff reported a shortage of local inpatient acute admissionbeds throughout the trust. This meant that some peoplewere being accommodated in hospital beds that weresome distance from their home.

Right care at the right timePeople knew what to do, how to seek advice and access theservices in an emergency. They told us they were able tophone up the service at any time and during out of hoursthere was a 24 hour service provided by the trust’s Bristolcrisis team. People said they had utilised the service andhad no issues or concerns.

We noted that referrals were received from the primary careliaison service (PCLS). This service triage all the referralsreceived and then referred them to the most appropriateservice. Some staff spoken to felt that this system led tosome inappropriate referrals to this service. Senior stafftold us that all referrals to the service were assessed forappropriateness. Any concerns were discussed at themonthly management meeting.

We found that people were seen in a timely manner andthe most appropriate care pathway was agreed. There wasno waiting list at the time of inspection. Six breaches werereported throughout the whole of Bristol with the 28 daysfrom referral to assessment target. We noted that for thisservice 161 out of 162 people had been assessed withinfour weeks of referral since 1 April 2014.

96.7% of people in Bristol were treated within 13 weeks ofassessment. Cases were prioritised and allocated by themultidisciplinary team in allocation meetings. We found noevidence of assessment or treatment being cancelled ordelayed due to capacity issues.

We noted that people received appointment letters orother reminders about their appointment from the service.



Staff informed us that there was flexibility in arrangingappointments and venues for people to fit in with people’slives where possible for example, with work and familycommitments. We noted that appointments were madewith people between 8am and 8pm.

Care pathwayThose care and treatment records reviewed showed us thatthe service took into account people’s needs and wisheswhen care and treatment was being planned anddelivered. This was supported by those people spokenwith.

We noted multidisciplinary care pathways in place whichensured that different services worked together to meet theperson’s changing needs. Senior staff informed us clinicalsupervision was used to review caseloads to ensure thatpeople were supported through the discharge to primarycare services in a supportive approach.

People referred to primary care received a Situation,Background, Assessment and Recommendation (SBAR)letter, a copy of their care plans and risk assessments.

This meant that the trust had processes in place to ensurethat discharge or transition arrangements met the needs ofpeople.

Learning from concerns and complaintsPeople who used the service were given a copy of thepatient advice and liaison service (PALS) leaflet whichoutlined the trust’s complaints procedure together withinformation about the service. People told us they knew ofthe service’s complaints procedure

Staff told us they were aware of the complaints process andwould re-direct people to the PALS service if they felt theywere unable to deal with their query. People also hadaccess to a local independent advocacy service andinformation about this service was given to people oninitial assessment.

We found evidence that seven complaints had beenreceived about the service between January and March2014. Five of these were informal complaints and these hadbeen resolved at local level. Two formal complaints hadbeen received and were being investigated through thePALS service. We noted that responses had been sent tothe complainants in a timely manner.

We found that a complaints audit was available and thisshowed us that the trust were assessing and monitoring

the quality of their complaints process. Senior staffconfirmed that complaints were reviewed at each monthlymanagement meeting and any lessons as a result would beshared with staff.

Bristol early intervention teamPlanning and delivering services

Evidence was seen that showed us that the trustunderstood the different needs of the people who used theservice. The trust actively engaged with the local authority,third sector providers and primary care services to providea coordinated and integrated pathway to meet people’sneeds.

We found evidence that that demonstrated that this servicetrust was reaching out to ‘hard to reach’ groups. Forexample some staff had a special interest in the homelesspopulation. Whilst another person had a specific interest inpeople with a dual diagnosis. Clear links were seen withlocal homeless charities and other third sector providers.


Right care at the right timePeople knew what to do, how to seek advice and access theservices in an emergency. They told us they were able tophone up the service at any time and during out of hoursthere was a 24 hour service provided by the trust’s Bristolcrisis team.

We found that people were seen in a timely manner andthe most appropriate care pathway was agreed. There wasno waiting list at the time of inspection. We found noevidence of assessment or treatment being cancelled ordelayed due to capacity issues. This was supported by thetrust information reviewed.

We noted that people received appointment letters orother reminders about their appointment from the service.Staff informed us that there was flexibility in arrangingappointments and venues for people to fit in with people’slives where possible for example, with work and familycommitments.



Care pathwayThose care and treatment records reviewed showed us thatthe service took into account people’s needs and wisheswhen care and treatment was being planned anddelivered.

The records seen showed us that people and their familieswere involved in multidisciplinary reviews. This wassupported by those people spoken with.

We noted multidisciplinary care pathways in place whichensured that different services worked together to meet theperson’s changing needs. Staff identified some concernswith discharging people to the Bristol recovery team.

Staff told us that there was a significant challenge in findingappropriate beds for people and they were sometimesadmitted out of area, making it difficult for carecoordinators to visit them in hospital and be as involved asthey would like.

Learning from concerns and complaintsPeople who used the service were given a copy of thepatient advice and liaison service (PALS) leaflet whichoutlined the trust’s complaints procedure together withinformation about the service. People told us they knew ofthe service’s complaints procedure

Staff told us they were aware of the complaints process andwould re-direct people to the PALS service if they felt theywere unable to deal with their query. People also hadaccess to a local independent advocacy service andinformation about this service was given to people oninitial assessment.

We found evidence that no formal complaints had beenreceived about the service since January 2014. Six formalcomplaints had been received between January 2012 andDecember 2013. We noted that responses had been sent tothe complainants in a timely manner.

Senior staff confirmed that complaints were reviewed ateach monthly management meeting and any lessons as aresult would be shared with staff.

North Somerset early intervention teamPlanning and delivering services

Evidence was seen that showed us that the trustunderstood the different needs of the people who used theservice. The trust actively engaged with the local authorityand general practitioners to provide a co-ordinated andintegrated pathway to meet people’s needs.

Information was accessible on the trust’s website about thepurpose of the different community services and how toaccess them. Staff told us that they prioritised workaccording to risk and identified need. We saw thatappropriate systems to share information with otherservices were established. No examples were identified ofassessments or treatments being cancelled or delayed dueto capacity issues by people and staff spoken with. Thiswas supported by the trust information reviewed.


Right care at the right timePeople knew what to do, how to seek advice and access theservices in an emergency. We found that people were seenin a timely manner and the most appropriate care pathwaywas agreed. There was no waiting list at the time ofinspection.

We noted that people received appointment letters orother reminders about their appointment from the service.Staff informed us that there was flexibility in arrangingappointments and venues for people to fit in with people’slives where possible for example, with work and familycommitments.

Care pathwayThose care and treatment records reviewed showed us thatthe service took into account people’s needs and wisheswhen care and treatment was being planned anddelivered.

The records seen showed us that people and their familieswere involved in multidisciplinary reviews. This wassupported by those people spoken with. For example, wenoted that the trust used the Care Programme Approach(CPA) to ensure the active involvement of all thoseinvolved.

We noted multidisciplinary care pathways in place whichensured that different services worked together to meet theperson’s changing needs. We saw good examples ofinnovative practice to ensure that discharge or transitionarrangements met the needs of people. For example withthe trust’s recovery college and individual placementsupport provided for individuals. The latter enabled andsupported people into paid employment.



Learning from concerns and complaintsWe found that complaints were handled in line with trustpolicy. Staff directed people who used the service to thepatient advice and liaison services (PALS) if they wereunable to deal with concerns raised.

We saw that every person who was referred to the servicereceived an information pack. This included informationabout raising concerns or complaints.

Staff told us they were aware of the complaints policy onthe intranet service and knew the process for making acomplaint. We noted that no formal complaints had beenreceived by this service since January 2014.



Summary of findingsWe saw good examples of local leadership in theservices we visited. Staff told us that they felt wellsupported by their immediate line manager and knewwho the trust’s senior leaders were.

There were monthly management meetings andmanagers told us that they used these as learning anddevelopment opportunities. The services managedpeople’s clinical risk and we saw that feedback frompeople was recorded effectively.

Most staff were aware of the trust’s vision, values andstrategies and of the trust’s local management structure.However, other staff felt undervalued by the trust. Forexample, staff reported that there had not been amedical advisory group for Bristol for 18 months.

The trust had an ‘Information Quality’ (IQ) system inplace. This enabled senior managers to regularly reviewthe service’s quality and records management, with thefindings disseminated to the team. We saw that seniormanagers were using this system effectively.


Vision and strategyMost staff told us that they we were aware of the trust’svision and values and strategic objectives. We foundevidence of the trust’s vision and values on display withinthe service. Some staff were unsure of how the trust’s localmanagement structure worked in practice.

Responsible governanceThe manager reported that the trust IQ governance systemallowed them to monitor quality and assurance at a locallevel. Governance issues were discussed in team meetingsand the locality quality and standards meeting.

Leadership and cultureWe found overall that this team was well-led. There was arelatively new manager in post and they were supported bytwo senior practitioners. Staff told us that they feltsupported and were encouraged to share concerns andideas. They were listened to and told us that any expressedconcerns were acted on.

We were told by most staff that the South Gloucestershiresenior management team were accessible andapproachable.

EngagementThe trust was in the process of establishing a number ofstaff, service user and carer engagement forums and aservice user involvement coordinator was in post tosupport local projects. Senior staff told us that they hadalready been very successful engaging people to sit onrecruitment panels and various trust wide meetings wherecarers and service users could make a difference. Therewere regular interface meetings between the communityteams and the inpatient ward.

Performance improvementWe saw that there were regular team audits undertaken tomonitor quality. Team meeting minutes reflected that teamaudits and performance were discussed. Staff told us thatthey had good support and had opportunities to reflect onany performance or learning outcomes in managementsupervision.


Vision and strategyMost staff told us that they were aware of the trust’s visionand values and strategic objectives. We found someevidence of the trust’s vision and values on display withinthe service.

Responsible governanceThe trust had a comprehensive governance system, whichthe managers used at team level to monitor and supportthe services they provided. Staff told us they felt able toreport incidents and raise concerns and that they would belistened to.

Leadership and cultureWe found overall the community teams were well-led andthere was evidence of clear leadership. Staff generally feltable to raise concerns. There was positive feedback aboutthe service manager and the Swindon senior managementteam being accessible and approachable. Staff felt listenedto and supported.

EngagementThe trust was in the process of improving its engagementwith service users and carers and we saw there were a

Are services well-led?By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.


number of recently established forums to facilitate this. Thecommunity teams were represented on a number offorums to improve engagement with both staff and serviceusers and carers.

There was also strong local servicer user network groupsand voluntary sector input from Mind. Some of the localservice user network groups did not feel that the trusteffectively engaged with them. The Swindon seniormanagement team had recently set up `open forums` tobe held in the community, to hear feedback from peopleand incorporate this into making improvements to servicedelivery.

We saw meeting minutes which showed that the trustsenior management team had met with people who usethe service to discuss some of their concerns about localservices and how they could work together to resolvethese.

Performance improvementWe saw that service developments were being monitoredfor risks, effectiveness and with consideration of localneeds. This was done locally within team meetings and atlocality level through quality and safety meetings.Specialist teams also participated in monthly good practicenetwork meetings to share ideas and concerns.

Chippenham recovery teamVision and strategy

Some staff we spoke with said they were unaware of thetrust’s vision and values and strategic objectives. Theyreported they did not feel listened to by senior trustmanagement. This was brought to the attention of seniorstaff during our inspection.

Senior managers said that they were aware of the strategicobjectives and we saw the action plan in place to achievethis.

Responsible governanceWe saw clear clinical governance arrangements in place ata local level. We saw the trust’s record management reviewand quality review of the service dated May 2014. Staff toldus they knew their responsibilities and the limits of theirauthority. Staff were aware of their particular lead roles andduties.

There was a risk register which identified specific risks. Wefound no benchmarking of national audits to assess theperformance of the service.

The training records reviewed showed us that training wasrequired in certain areas for example, manual handling,infection control and health and safety. We found thatarrangements were in place for staff to attend alloutstanding training.

Leadership and cultureSome staff told us that morale within the staff team waslow due to not having a manager for the past two years.They currently had two interim managers with one leavingat the end of June 2014. They felt that they were back tosquare one again with no manager. Some staff did not feelvalued or well-led although they stated that it was betterthan before with the two new managers currently in situ.One person told us that they felt that the trust was too bigand impersonal and they felt isolated at times.

We observed there were swift and effective interventionprocedures in place to deal with behaviour andperformance inconsistencies. Staff said that the managershad an open door policy and were able to address anyissues or concerns they may have with them.

One staff member said they would like to see consistencyfrom a higher level and clarification of their expectations offront line staff. They also said that they found that sometrust wide information was not cascaded to front line staff.

EngagementPeople had access to the advocacy service and weresupported to make complaints through the PALS service.

We reviewed the friends and family test for the service. Thisshowed us that most people were happy with the serviceprovided and would recommend the service to their friendsand family.

We found that trust level feedback was not shared acrossthe teams with regard to concern, complaints or incidentsreceived and investigated.

Performance improvementStaff told us they were aware of their professionalobjectives and these were reviewed regularly atsupervision. Due to the interim managers having been inpost for a short time staff had not received any appraisals.The manager informed us they were aware of the shortfallbut wished to concentrate on regular supervision with staffprior to reviewing the appraisal process.



The trust had an IQ system in place to monitor and auditthe care management records and the quality records inline with the outcomes set out by the Care QualityCommission.

Bristol recovery teamVision and strategy

Most staff told us that they we were aware of the trust’svision and values and strategic objectives. We foundevidence of the trust’s vision and values on display withinthe service and there was evidence of this on the trust’sintranet system. Some staff were unsure of how the trust’slocal management structure worked in practice.

Responsible governanceSenior staff reported that the trust IQ governance systemallowed them to monitor quality and assurance at a locallevel. Governance issues were discussed in team meetingsand the service’s monthly quality and standards meeting.

Staff told us they knew their responsibilities and the limitsof their authority. Staff were aware of their particular leadroles and duties.

We noted there was a local risk register in place whichidentified specific risks. The training records reviewedshowed us that mandatory training was up to date and thatspecific training needs had been addressed.

Leadership and cultureSome staff told us that morale within the staff team waslow due to the increased demands on the service. Otherstaff told us that the appointment of a new manager hadled to recent improvements in staff morale.

Some staff told us that they hadn’t been informed of thetrust tendering process and that staff consultation hadbeen ‘lip service’. Another staff member told us that theydidn’t receive some trust wide information. Other staff saidthat senior staff had an open door policy and were able toaddress any issues or concerns they may have with them.

EngagementPeople had access to the advocacy service and weresupported to make complaints through the PALS service.We found that any concerns and complaints received bythe service were discussed at team meetings and duringindividual clinical supervision. Staff told us that they wereaware of the trust’s whistleblowing policy and informed usthey knew the processes to follow should they have anyconcerns.

The records seen and people spoken with were positiveabout the care and treatment given by front line staff. Thetrust was in the process of improving its engagement withservice users and carers and we saw there were a numberof recently established forums to facilitate this. Thecommunity teams were represented on some of these toimprove engagement with people and their carers.

Performance improvementStaff told us they were aware of their professionalobjectives and these were reviewed regularly at monthlysupervision and annual appraisals.

The trust had an IQ system in place which reviewed thequality and record management of the service regularlywith the findings being disseminated to the team. We sawthat this was being effectively used by senior managers.

Bristol early intervention teamVision and strategy

Most staff told us that they we were aware of the trust’svision and values and strategic objectives. We foundevidence of the trust’s vision and values on display withinthe service and there was evidence of this on the trust’sintranet system. Staff were aware of how the trust’s localmanagement structure worked in practice.

Responsible governanceSenior staff reported that the trust IQ governance systemallowed them to monitor quality and assurance at a locallevel. Governance issues were discussed in team meetingsand the service’s monthly quality and standards meeting.

We noted there was a local risk register in place whichidentified specific risks. The records reviewed showed usthat the trust was taking steps to ensure that mandatorytraining for staff was up to date.

Leadership and cultureStaff told us that morale within the team was good and theteam was supportive. We saw that staff worked effectivelytogether with good communication systems within theservice.

We found effective clinical and managerial supervision inplace to manage any concerns about individual practice.Staff confirmed that the manager had an ‘open door’ policyand they felt able to approach them with any concerns.

Some staff told us that they hadn’t been informed of thetrust tendering process and felt that medical staff were



undervalued by the trust. Staff reported that there hadbeen no medical advisory group for Bristol for 18 months.This was brought to the attention of senior staff during ourinspection.

EngagementWe found that any concerns and complaints werediscussed at team meetings and during individual clinicalsupervision. Staff told us that they were aware of the trust’swhistleblowing policy and informed us they knew theprocesses to follow should they have any concerns.

People who used the service were generally positive aboutthe care and treatment given by front line staff. Weobserved some good examples of individual engagementduring our inspection. For example during meetings andtelephone calls made to people.

Performance improvementStaff told us they were aware of their professionalobjectives and these were reviewed regularly at monthlysupervision and annual appraisals.

The trust had an IQ system in place which reviewed thequality and record management of the service regularlywith the findings being disseminated to the team. We sawthat this was being effectively used by senior managers.

North Somerset early intervention teamVision and strategy

Staff we spoke with said they were aware of the trust’svision, values and strategic objectives. We found evidenceof this strategy and vision on display within the service.Staff knew of the trust’s senior management structure andconfirmed that they received regular trust updates via thetrust’s intranet and other bulletins.

Responsible governanceSenior staff reported that the trust IQ governance systemallowed them to monitor quality and assurance at a local

level. Governance issues were discussed in the teammeeting and the service’s monthly quality and standardsmeeting. We noted there was a local risk register in placewhich identified specific risks.

Leadership and cultureStaff told us that morale within the team was good and wesaw staff worked effectively together. There were goodcommunication systems within the service.

We found effective clinical and managerial supervision inplace to manage any concerns about individual practice.Staff told us that the manager had an ‘open door’ policyand they felt able to approach them with any concerns.

Some staff told us that they hadn’t been kept informed ofthe trust tendering process. They felt that they hadn’t beenan effective consultation with front line staff. This wasbrought to the attention of senior staff during ourinspection.

EngagementWe found that any concerns and complaints werediscussed at team meetings and during individual clinicalsupervision. Staff told us that they were aware of the trust’swhistleblowing policy and informed us they knew theprocesses to follow should they have any concerns.

The feedback seen showed us that most people werepositive about the support and treatment provided by thisservice.

Performance ImprovementWe found clear systems in place to monitor and improvethe performance of this service. For example we sawregular multidisciplinary team meetings and clear auditresults with actions identified where applicable.



Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activityAssessment or medical treatment for persons detainedunder the Mental Health Act 1983

Treatment of disease, disorder or injury

The registered person had not taken proper steps toensure that each service user is protected against therisks of receiving care or treatment that is inappropriateor unsafe.

• Not all CTO patients had clear care plans or been giventheir rights under the Mental Health Act 1983

• Care plans did not always reflect all needs and physicalhealth concerns were not always assessed and met

• Some caseloads were higher than the nationalguidance and trust policy

Regulation 9 (1) (b) (i) (ii)



The registered person had not protected service usersagainst the risks associated with the unsafe use andmanagement of medicines, by means of the making ofappropriate arrangements for the obtaining, recording,handling, using, safe keeping, dispensing, safeadministration and disposal of medicines:

How the Regulation was not being met:

• In two teams we found that there was no appropriateprocedures in place for the administration,management, storage, disposal and audit ofmedications

• In one team we found that the fridge was broken and sothe integrity of medications could not be assured

Regulation 13



The trust had not ensured that suitable arrangementswere in place in order to ensure that persons employed

Regulation

Regulation

Regulation

Compliance actions


for the purposes of carrying on the regulated activitywere appropriately supported in relation to theirresponsibilities by receiving appropriate training,professional development, supervision and appraisal;

• Staff at the Chippenham recovery team had notundertaken mandatory training in health and safety,conflict management, infection control and recoverystar assessment

• Some staff had not had supervision meetings orappraisals

Regulation 23

Compliance actions


avon and wiltshire mental health partnership nhs trust

Documents