front sheet - kmpt · 2019. 2. 7. · notes, with canterbury and swale achieving 100% compliance in...

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Front Sheet

Title of Meeting Trust Board Date 26 July 2018

Title of Paper: CMHT CQC Inspection report update

Author: Mary Mumvuri

Executive Director:

Mary Mumvuri, Executive Director of Nursing & Quality

Purpose: the paper is for: Delete as applicable

Discussion:

Recommendation: This paper provides assurance to the Board on the improvements made to safety and governance in the CMHTs following the Warning Notice from CQC in January 2018. Performance in this report and the associated action plan has already been scrutinised at Care Group meetings, Executive Assurance Committee and most recently Quality Committee. The Board is asked to discuss the report and to provide feedback on areas requiring further assurance. The CQC report following the re-inspection on 15-16 May has now been published and is available on Trust website and appended to this report. Summary of Key Issues: No more than five bullet points Key improvements are in:

A detailed analysis has been completed on reasons for caseloads over 40 and there are robust plans to reduce these via the Active Review process and further recruitment.

All patients waiting for assessment or treatment have a point of contact in the team and have a safety plan and are risk RAG rated.

Referral to Treatment performance increased from 70.8% on 12 June to 81.6% on 3 July.

DNA policy implementation has been audited and is 90% compliant in the audit completed in June. Exceptions are understood, have been followed up and no patients have come to harm as a result of DNA being missed.

Mandatory training is on average 89.3% compliant against a target of 85% and all individual teams are above the 85% target

Supervision improvement for all staff continues and significantly for clinicians, from an average of 31% in January 2018 to 78% in May 2018 and 81% in June 2018, set against a 95% internal target

Core, assessments, care plans, risk assessments, CPA and HONOs continue to improve and are monitored each week and fortnightly through the CliQ-Checks.

Overall vacancy rate for community mental health teams was 58.9 WTE in January 2018 to 27.96 WTE in June 2018 however staffing pressures continue in some East Kent teams due to long term absence.

Residual risks are:

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Documentation of Did Not Attend across all CMHTs is still not 100% compliant. The DNA audit and CLiQ checks will continue to challenge teams and support them with adherence to policy standards.

There continues to be recruitment challenges particularly for Medical staff in some East Kent teams. Cover is currently being provided through locum Consultants until substantive appointments can be made.

Compliance with the 28 day referral to assessment target – whilst the recruitment process has been successful, some teams, such as South Kent Coast are awaiting new starters and this, coupled with sickness rates do not allow teams to provide the additional assessment slots required. The trajectories that have been set are reflective of this and are realistic.

The quality of risk assessments is improving however there is still some variability which is being worked through. The refresher team based risk management training and the CLiQ check programme will ensure continuous monitoring and improvement.

Report History:

Monthly Update to the Quality Committee

Strategic Objectives: Select as applicable

☒ Deliver outstanding quality of care across all of our domains

☐ Are an attractive place to work promoting employee recruitment, retention and

development

☒ Deliver and embed continuous improvement in all we do

☐ Promote and deliver an internationally based research programmes

☐ Maximise the use of digital technology to improve service access and quality

☐ Optimise our estate to deliver integrated physical and mental health services

across all communities in Kent and Medway

☐ Deliver financial balance and organisational sustainability

☐ Develop our core business and enter new markets through increased

partnership working.

Implications / Impact:

Patient Safety: The CMHT safe domain has an overall CQC rating of ‘requires improvement’ from the 2017 comprehensive inspection in respect of caseloads, waiting list, mandatory training and supervision, all of which are being addressed through the CMHT action plan Identified Risks and Risk Management Action: Strategic risk 3756.

Resource and Financial Implications: Failure to comply with the regulatory standards has resulted in an enforcement action being taken against the trust which may have financial and resource implications

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Legal/ Regulatory: There is currently non- compliance with the regulatory standards set out in the Health and Social Care Act 2008. Currently CMHT are non- compliance with 2 Regulations, 12 and 17 Engagement and Consultation:

Equality: N/A

Quality Impact Assessment Form Completed:No

1. Background to the CMHT CQC focussed inspection

The Board is cognisant of this report’s history. The Warning Notice remains in place till 16 August 2018. A follow up inspection is expected shortly after to check that the Trust has fully responded to all the safety and governance concerns. Following the two day re-inspection on 15-16 May to Canterbury & Coastal, South Kent Coast (Folkestone site), Medway and additionally Maidstone CMHTs, the CQC published the report on 18 July. The report recognises the systems and processes now in place and the improvements made and areas requiring further improvements and embedding. The report is attached as an appendix to this report, has been shared with the teams and is now available on Trust website.

2. Progress update

Actions the Trust MUST take to improve

2.1 The trust must ensure that staff assess the risks to patients’ health and safety or respond appropriately to meet people’s individual needs to ensure their welfare and safety during any care or treatment.

The key actions detailed below, are been taken to address the above area of concern.

Review of caseloads – there is a continuous review of caseloads through individual supervision of caseloads, MDT forums and through CliQ-Checks undertaken by Quality Managers. The CliQ- Checks are now completed on a two weekly basis. There are a few members of staff in each team who hold a caseload of over 40, all of which have been subject to detailed scrutiny by Service Managers and a review of the clinical risks.

Exceptions for the high caseloads are fully understood and include:

Patients under depot/clozapine clinics

Medication reviews by Doctors

Waiting for the discharge process to be completed on Rio and formal letters to be sent to the patients and their GPs

Patients in specialist placements out of area

Waiting further specialist psychological interventions Where patients are waiting for assessments, all cases have an appointment booked and will be assessed or reviewed and discharged if appropriate. Detailed discussions, challenge and assurances were provided at Quality Committee

DGS, Medway and South West Kent where there are slightly more staff with caseloads over 40 are creating Active Review process, similar to SKC (Shepway) where this way of working has reduced caseload size from 476 in February 2018 to 246 in June. Patients have a plan setting out mutually agreed frequency of contacts and support. It is important to note that this is a process and not a specific team, as all patients waiting to commence treatment are the

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responsibility of the team. All members of the multi- disciplinary team will be undertaking active review work, supported by the newly developed Standard Operating Procedure.

Risk assessments – In March 2018, 64.4% of patients on caseloads had up to date risk assessments. Risk assessments end of June 2018 were 91.8% for 12 months and 75.86% for 6 months, against a target of 95%.The quality of these risk assessments are demonstrating a month on month improvement as noted in the bi-weekly CliQ-Checks audit across all CMHTs. The additional refresher team based training reported in the last report has seen 70 direct care staff trained with a few more days arranged for the remainder of July. The feedback has been very positive and is increasing staff confidence and opportunities for peer challenge and reflection. Health records audit – The robust clinical audit process continues, led by the Quality Managers, via the fortnightly CliQ Check quality assurance system. Improvements have been noted in initial risk assessments; CPA reviews within the last six months and progress notes, with Canterbury and Swale achieving 100% compliance in progress notes. At each CLiQ check, the Quality Manager reviews a random sample of 10% of the team CPA caseload which can range from 90-145 case notes depending on team size. Immediate feedback is provided to the individual clinician and their managers and completion of actions are followed up at the next audit.

2.2 The trust must ensure that staff provide safe care and treatment to patients’ receiving, or awaiting to receive, a service from the adult community mental health teams.

28 day referral to assessment – Teams are scheduling all first appointments well within the 28 day window except for teams where slots are unavailable due to short term absence or vacancies. Teams now routinely book within 10 working days of the referral and there are a number of reminder actions taken at regular periods in order to reduce DNAs. These range from reminder texts, telephone contact and letters. The move from individual clinician paper diaries to electronic diaries should support capacity management, job planning and provide accurate DNA data.

The table below shows the improvement in the 28 day referral to assessment target from June 2018 to July 2018 see Table 1 below. This is monitored each week through a performance report which is sent to every service manager.

All teams have developed trajectories for full compliance with the 28 day referral to assessment target. These trajectories are currently being scrutinised internally within the information team and will be reported to the August 2018 Quality Committee.

Table1

12/06/2018 19/06/2018 26/06/2018 03/07/2018 70.8% 78.3% 78.8% 81.6%

To provide further assurance, the Quality Committee reviewed the CliQ-Check audit results of two new systems and processes, namely compliance with the 28 day breach protocol and revised DNA policy. The percentage of patients, waiting longer than 28 days who have received a letter with an appointment and the contact details for the team, SPoA and third sector organisations, should the patient need support prior to the initial appointment had increased from 50% in May to 80% beginning of July. Compliance with the DNA policy, as measured by CliQ Checks audit results also demonstrated a compliance of 90%. All patients who had DNA’d were followed up and are safe. Follow up on DNAs will continue to be a key priority in August, to ensure it is completed and documented accordingly. The audit of a “Day in the life of CMHT” will provide further assurances about how well the practice is embedded.

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2.3 The trust must have systems in place to ensure patients are aware of any changes in their care provision and alternative plans that have been put in place to ensure their safety. This would include long or short term change of care coordinator and discharge.

A system for handover of care during periods of short or long term leave by a Health Care Professional or Care Coordinator has been established, also known as “Buddy System”. The MDT Red Board meeting serves a purpose to review staffing on a daily basis and to allocate tasks accordingly in the event of staff absence. To ensure consistency across the team, Quality Managers attended Red Board meetings throughout July 2018 to audit for consistency and to ensure expected standards of practice are being adhered to. The results of this audit are currently being completed and will report to the Quality Committee. 2.4 The trust must have effective audit and governance systems and/or processes in place that ensure care and treatment is provided in line with their policies. The CliQ-Checks continue to be completed fortnightly by Quality Managers and they are showing an improvement, as demonstrated above.

The Quality Managers are auditing throughout July 2018 all CMHTs to check level of compliance with the newly established policies and procedures, including the ‘day in the life pack’, red board meetings, team meetings etc. This audit results will be reported to the Quality Committee at its next meeting.

3. Action the Trust SHOULD take to improve

3.1 The trust should ensure that sufficient numbers of permanent staff are recruited and retained to enable the CMHTs to operate effectively. Vacancies for all staff groups across Community Recovery Care Group have improved significantly. A number of clinical staff have been appointed and are due to start in July 2018 and August 2018. Overall vacancy rate for community mental health teams was 58.9 WTE in January 2018 to 27.96 WTE in June 2018. It is noteworthy that South Kent Coast and DGS are all fully established with the nursing team which is an improved position against the January figures. Recruitment challenges remain however for medical staff particularly in East Kent and current mitigations include employment of Locum Doctors while recruitment and retention initiatives continue. Review of medical vacancies and impact continues to be a focus at monthly Vacancy Review Panels attended by the Executive Team and senior medical colleagues.

3.2 The trust should ensure that staff meet the trust’s target for completion of their

mandatory training courses. The average compliance for CMHTs mandatory training is 89.3% which is above Trust target of 85%.and all individual teams are above the 85% target. The exceptions are CPR at 74%; Data Security Awareness at 92% and Breakaway at 76%. There are additional training sessions in July 2018 to improve compliance; the impact of this should be seen in the next report. 3.3 The trust should ensure that all have regular access to supervision and that these

sessions are recorded and stored appropriately. This is another aspect of staff support that has seen a big improvement across all staff. Notable improvements are among clinical staff where an increased on average was from 31% in January 2018 to 78% in May 2018 and 81% in June 2018. The quality of the

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supervision continues to be monitored by the Quality Managers and HR Business partners who audit a sample of these records and facilitate HR support through local surgeries and Care Group Performance Meetings. A move to electronic supervision record due to start in the coming months will make the reporting and recording process more efficient. Although the overall compliance has improved it is noted that DGS, SWK, Maidstone and Medway decreased their performance in month. The care group is urgently reviewing the reasons and will closely monitor this performance and implement additional management support if needed.

3.4 The trust should ensure that staff follows consistent criteria for deciding whether

a patient requires care coordination following initial assessment. There is in place a structured MDT/Clinical review meeting that ensures consistency in the approach to allocation of caseloads. The revised and comprehensive CMHT operational policy was approved by Core Operational Group and is due to be ratified by CEOG by end of July. This should now ensure completeness in the systems and processes established to support the improvements to CMHT thus far. System of allocation of Care Coordinator is included in the suite of audits to procedures currently underway and due to be reported to the next Quality Committee. 3.5 The trust should ensure that staffs follow up clients who did not attend

appointments appropriately. The Red Board meetings already alluded to earlier in the report, provides a forum to review and set actions in place for all patients who not attend their appointments. This new system ensures team oversight and responsibility for following up patients in a timely manner. The DNA audit demonstrated that 90% of patients who did not attend their appointment were followed up according to the policy and where it was missed it was rectified and all patients were assessed as safe. This will continue to be an area of focus in the next month.

3.6 The trust should ensure that staff give patients adequate notice when they need to

cancel appointments and have systems in place to ensure that alternative appointments are arranged in a timely manner.

The Care Group Quality Managers will undertake an audit of the reasons why the service cancel appointments and will report to Quality Committee in September 2018. Meanwhile, a target of reducing the staff cancelled appointments has been set at 2% reduction month on month. This, together with the move to electronic diaries should help with monitoring and oversight of cancelled appointments.

3. Conclusion

This report demonstrates the improvement that have been made to quality and safety of care delivery across the teams, the impact that the established systems and processes are beginning to make. The following month will continue to focus on embedding improvements and quality assurance to ensure that standards of care are being adhered to consistently across the teams. Following the publication of the CMHT CQC report from their may inspection; the Care Group will review the enforcement actions and refresh the action plan to ensure any further areas for improvement are addressed.

Locations inspected

Location ID Name of CQC registeredlocation

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

Postcodeofservice(ward/unit/team)

RXY04 Trust Headquarters Canterbury and CoastalCommunity Mental Health Team CT1 3HH

RXY04 Trust Headquarters South Kent Coast Mental HealthTeam CT19 5HL

RXY04 Trust Headquarters Medway Community MentalHealth Team ME7 4JL

RXY04 Trust Headquarters Maidstone Community MentalHealth Team ME14 5TS

Kent and Medway NHS and Social Care PartnershipTrust

Community-bCommunity-basedased mentmentalalhehealthalth serservicviceses fforor adultsadults ofofworkingworking agageeQuality Report

Trust HeadquartersFarm VillaHermitage LaneMaidstoneKent. ME16 9QQTel: 01622 724100Website: www.kmpt.nhs.uk

Date of inspection visit: 15 - 16 May 2018Date of publication: This is auto-populated when thereport is published

1Community-based mental health services for adults of working age Quality Report This is auto-populated when the report ispublished

This report describes our judgement of the quality of care provided within this core service by Kent and Medway NHSand Social Care Partnership 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 Kent and Medway NHS and Social CarePartnership Trust and these are brought together to inform our overall judgement of Kent and Medway NHS and SocialCare Partnership Trust.

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 4

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

Information about the service 9

Our inspection team 10

Why we carried out this inspection 10

How we carried out this inspection 10

Areas for improvement 11

Detailed findings from this inspectionFindings by our five questions 13

Summary of findings


Overall summaryBetween 15 - 16 May 2018, the Care Quality Commissioncarried out a focused follow-up inspection to look atwhether the trust had made the necessary improvementsas set out in the Warning Noticed issued on the 16February 2018, following the focused inspection of the22-24 January 2018. We went to four community teamsfor adults of working age provided by Kent and MedwayNHS and Social Care Partnership Trust. These were theCanterbury and Coastal CMHT, the South Kent CoastCMHT, the Medway CMHT and the Maidstone CMHT.

The warning notice we served identified actions the trustmust take by 30 March 2018.

• The trust must complete an immediate review ofeach of the community mental health teams forworking age adults case load focusing on newreferrals and case load allocation, risk assessmentsfor all allocated and unallocated patients with safetyplans being put in place where necessary.

It also identified actions the trust must take by 16 August2018.

• The trust should use the caseload review to inform acomprehensive review of the assessment, planningand delivery of care and treatment for all patientsand ensure they have systems and processesembedded into the service that effectively assess,monitor and improve the quality and safety of theirservice.

During this inspection, we found the following issues thetrust needs to improve:

• Staff continued to not always assess the risks topatients’ health and safety or respond appropriatelyto meet their individual needs. Risk assessmentswere not always completed or updated following anincident or reviewed regularly.

• The duty service at most community mental healthteams we visited continued to be pressured and hadto respond to work outside of their emergency remit.However, we saw some continuity had been installedwith teams having regular duty workers who did notcarry an individual caseload.

• Community mental health teams (CMHT) hadrecently put systems in place to ensure caseloadswere formally handed over and monitored due tocare coordinators planned or unplanned absence.However, these were not yet embedded across allteams.

• We found some improvement in the recording andquality of initial assessments on patients’ care records.However, CMHTs were, on occasions, still relying onprevious initial assessments which often did notcontain recent information.

• The service had introduced daily meetings to allowCMHTs to have oversight of immediate risk on theteam caseload. These were seen to be effective,however, they were not approached consistentlyacross the CMHTs we visited.

• Staff continued to not always follow up patients whodid not attend appointments. This was despite thetrust making the did not attend policy simpler tofollow.

• Some staff continued to report they had to completework outside of their working hours and hadconcerns they would have an excessive workload tocatch up on when they returned from annual leave.

However, we also found the following areas of goodpractice or where improvement had been made:

• The service had made improvements to themanagement of individual care coordinators’caseload. However, we found some inconsistenciesaround how psychiatrists and psychologistsaccepted patients onto their caseloads.

• The service had made improvements in how theymonitored the needs and risks of patients who wereawaiting allocation of a care coordinator.

• The service had made some improvements in theirrecording of recent crisis management plans inpatients’ care records. However, we still found somecrisis plans that contained outdated information anda lack of consistency in where they were recorded.

• Staff were not always assessing new patients referredto the service in pairs. This was due to staff shortages

Summary of findings


and, in some cases, staff resistance. However, thetrust felt that staff needed to be available tocare coordinate their patients and had put measuresin place, such as multi-disciplinary reviews of allassessments, to compensate for the assessmentsbeing carried out by lone workers.

• The service had improved on their consistency infollowing the criteria for deciding whether a patientrequired care coordination following initialassessment. This had been supported by themultidisciplinary reviews following assessment.

• The service had carried out an audit which identifiedthe extent of inappropriate referrals from primary care.They were planning to use this information to putprocesses in place to support GPs when makingreferrals.

• The service had introduced clinical quality checks tosupport staff to improve their clinical documentation.Staff had welcomed this initiative and we noted they

had a general positive impact on the quality ofpatients’ care records. These checks were thoroughand we found very few examples where shortfalls hadbeen overlooked or where staff had not updatedidentified shortfalls.

• The service had introduced other systems andprocesses to monitor caseloads, discharges, waitingtimes and follow-up effectively. However, these werestill being embedded and lacked a consistentapproach across the service.

• Staff were hardworking and felt supported by theirlocal line managers and immediate colleagues. Theyhad welcomed recent changes to management andsystems the trust had introduced.

Overall, we found that whilst the trust had made someimprovements, they needed to further implement andembed the improvements required to the safety andquality of care provided if they are to meet to therequirements of the warning notice by 16 August 2018.

Summary of findings


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

Are services safe?We found the following issues the trust needs to improve:

• Staff continued to not always assess the risks to patients’ healthand safety or respond appropriately to meet their individualneeds. Risk assessments were not always completed, updatedfollowing an incident or reviewed regularly.

• The duty service at most community mental health teams wevisited continued to be pressured and had to respond to workoutside of their emergency remit. However, we saw somecontinuity had been installed with teams having regular dutyworkers who did not carry an individual caseload.

• Community mental health teams (CMHT) continued to notalways have systems in place to ensure caseloads were formallyhanded over and monitored in the event of care coordinatorsbeing on annual leave or off sick.

However, we also found the following areas of good practice orwhere improvement had been made:

• The service had made improvements to the management ofindividual care coordinators’ caseload. However, we foundsome inconsistencies around how psychiatrists andpsychologists accepted patients onto their caseloads.

• The service had made improvements in how they monitoredthe needs and risks of patients who were awaiting allocation ofa care coordinator.

• The service had made some improvements in their recording ofrecent crisis management plans in patients’ care records.However, we still found some crisis plans that containedoutdated information and a lack of consistency in where theywere recorded.

Are services effective?We found the following issues the trust needs to improve:

• Staff were not always assessing new patients referred to theservice in pairs. This was due to staff shortages and, in somecases, staff resistance. However, they had put measures inplace, such as multidisciplinary reviews of all assessments, tocompensate for the assessments being carried out by loneworkers.

Summary of findings


• Community mental health teams (CMHT) continued to notalways have systems in place to ensure caseloads were formallyhanded over and monitored in the event of care coordinatorsbeing on annual leave or off sick.

However, we also found the following areas of good practice orwhere improvement had been made:

• We found some improvement in the recording and quality ofinitial assessments on patients’ care records. However, CMHTswere, on occasions, still relying on previous initial assessmentswhich often did not contain recent information.

• The service had introduced daily meetings to allow CMHTs tohave oversight of immediate risk on the team caseload. Thesewere seen to be effective, however, they were not approachedconsistently across the CMHTs we visited.

Are services responsive to people's needs?We found the following areas of good practice or whereimprovement had been made:

• The service had improved on their consistency in following thecriteria for deciding whether a patient required carecoordination following initial assessment. This had beensupported by the multidisciplinary reviews followingassessment.

• The service had carried out an audit which identified the extentof inappropriate referrals from primary care. They wereplanning to use this information to put processes in place tosupport GPs when making referrals.

However, we also found the following issues the trust needs toimprove:

• Staff continued to not always follow up patients who did notattend appointments. This was despite the trust making the didnot attend policy simpler to follow.

Are services well-led?We found the following areas of good practice or whereimprovement had been made:

• The service had introduced clinical quality checks to supportstaff to improve their clinical documentation. Staff hadwelcomed this initiative and we noted they had a generalpositive impact on the quality of patients’ care records.However, these checks sometimes overlooked shortfalls and,when identified, staff did not always update in a timely manner.

Summary of findings


• The service had introduced other systems and processes tomonitor caseloads, discharges, waiting times and follow-upeffectively. However, these were still being embedded andlacked a consistent approach across the service.

• Staff were hardworking and felt supported by their local linemanagers and immediate colleagues. They had welcomedrecent changes to management and systems the trust hadintroduced.

However, we also found the following issues the trust needs toimprove:

• Some staff continued to report they had to complete workoutside of their working hours and had concerns they wouldhave an excessive workload to catch up on when they returnedfrom annual leave.

Summary of findings


Information about the serviceKent and Medway NHS and Social Care Partnership Trustprovide community-based mental health services(CMHTs) for working age adults, age 18-65. This includescontinued support for people, who are already within theservice, over the age of 65 if they have a functionalpsychiatric disorder. They operate from 9-5 Monday toFriday. The CMHTs are made up of health and social careprofessionals (excluding Medway which is no longerintegrated with Medway council and so only provideshealth services) including psychiatrists, social workers,psychiatric nurses, occupational therapists, psychologistsand support workers. The Single Point of Access (SPOA)team manages urgent referrals for the CMHTs andoperates 24hrs a day to receive referrals.

The trust operates nine CMHTs for adults of working ageacross 12 locations. During our comprehensiveinspection in January 2017, we inspected five CMHTs andthe SPOA. We rated the community-based mental healthservices for adults of working age as requiresimprovement overall. We rated the key questions of safe,responsive and well-led as requires improvement withthe key questions of effective and caring rated as good.

Following the comprehensive inspection in January 2017,the Care Quality Commission told the trust that:

• The trust must address the high caseload numbersallocated to individual staff to ensure that all patientsare monitored appropriately.

• The trust must review the waiting lists for thosepatients waiting for initial assessment and thosepatients waiting for allocation to a named worker toensure patients receive a service in a timely way.

• The trust must ensure that staff meet its targets forcompliance with mandatory training, personal safety,conflict management and cardiopulmonaryresuscitation.

We also informed the trust that:

• The trust should ensure that sufficient numbers ofpermanent staff are recruited and retained to enablethe teams to operate effectively.

• The trust should ensure that all staff receive individualsupervision at regular intervals as per the trust’ssupervision policy.

• The trust should ensure that its target for staff toreceive an annual appraisal is met in all communitymental health teams.

• The trust should address the waiting times for accessto psychological therapies for patients at the SouthKent Coast CMHT.

• The trust should implement the new operationalpolicy for the community mental health teams andmonitor its impact on the effective operation of theteams in relation to access criteria, caseloads andappropriate discharges of patients.

We issued the trust with one requirement notice whichrelated to the following regulation under the Health andSocial Care Act (Regulated Activities) Regulations 2014:

• Regulation 18 HSCA (RA) Regulations 2014 - Staffing.

We carried out a focused responsive inspection inJanuary 2018, due to concerns being raised with usaround insufficient staffing levels leading to highcaseloads which were not being managed safely.Following this inspection, the Care Quality Commissiontook enforcement action and issued the trust with awarning notice on 16 February 2018. The warning noticewe served notified the trust that the Care QualityCommission had judged the quality of healthcare beingprovided required significant improvement. We told thetrust they must complete an immediate review of each ofthe community mental health teams for working ageadults’ caseload focusing on new referrals and caseloadallocation, risk assessments for all allocated andunallocated patients with safety plans being put in placewhere necessary, by 30 March 2018.

• The trust must ensure that staff assess the risks topatients’ health and safety or respond appropriately tomeet people’s individual needs to ensure their welfareand safety during any care or treatment.

Summary of findings


• The trust must ensure that staff provide safe care andtreatment to patients’ receiving, or awaiting to receive,a service from the adult community mental healthteams.

• The trust must have systems in place to ensurepatients are aware of any changes in their careprovision and alternative plans that have been put inplace to ensure their safety. This would include long orshort-term change of care coordinator and dischargeto primary care.

We also told the trust they should use the caseloadreview to inform a comprehensive review of theassessment, planning and delivery of care and treatmentfor all patients and ensure they have systems andprocesses embedded into the service that effectivelyassess, monitor and improve the quality and safety oftheir service. We told the trust this should be completedby 16 August 2018.

• The trust must have effective audit and governancesystems and/or processes in place that ensure careand treatment is provided in line with their policies.

Our inspection teamThe team comprised five CQC inspectors, one assistantinspector and two mental health nurse specialistadvisors.

Why we carried out this inspectionWe inspected the trust’s community-based mental healthservices for adults of working age to follow up onconcerns identified during a focused inspection inJanuary 2018.

Following the inspection in January 2018, we tookenforcement action and issued the trust with a WarningNotice on 16 February 2018. The Warning Notice weserved notified the trust that the Care QualityCommission had judged the quality of healthcare beingprovided required significant improvement. We told thetrust they must complete an immediate review of each ofthe community mental health teams for working ageadults’ caseload focusing on new referrals and caseloadallocation, risk assessments for all allocated andunallocated patients with safety plans being put in placewhere necessary, by 30 March 2018.

We also told the trust that they should use the caseloadreview to inform a comprehensive review of theassessment, planning and delivery of care and treatmentfor all patients and ensure they have systems and

processes embedded into the service that assess,monitor and improve the quality and safety of theirservice effectively. We told the trust this should becompleted by 16 August 2018.

Therefore, the purpose of this focused inspection was tomake a judgement on whether the trust had carried outan appropriate review of the community mental healthteams for working age adults’ caseload and whether thishad led to improvements to the quality of healthcareprovided.

As this was not a comprehensive inspection, we did notpursue all key lines of enquiry. We visited four of thetrust’s community-based mental health services foradults of working age. Because we only focused on theissues of concern, we have not reconsidered the rating ofthis service.

We will inspect again after the final timescale of the 16August to assess whether overall the requirements of thewarning have been met.

How we carried out this inspectionDuring this unannounced, focused inspection, weconsidered aspects of the following key questions:

• Is it safe?• Is it effective?

Summary of findings


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

Before the inspection visit, we reviewed information thatwe held about these services. This included an actionplan the trust had formulated in response to our findings,following the unannounced focused inspection inJanuary 2018.

During the inspection visit, the inspection team:

• visited four community-based mental health teamsand reviewed how staff were caring for patients;

• spoke with the service managers and/or team leadersfor each of the teams;

• spoke with 28 other staff members; including nurses,occupational therapists, psychologists, social workers,senior managers and administration staff.

• attended and observed three risk managementmeetings and one multi-disciplinary meeting.

• looked at 75 care and treatment records of patients;• looked at a range of policies, procedures and other

documents relating to the running of the service.

Areas for improvementAction the provider MUST take to improve

• The trust must ensure that staff assess the risks topatients’ health and safety or respond appropriatelyto meet people’s individual needs to ensure theirwelfare and safety during any care or treatment.

• The trust must ensure that community mental healthteams use the systems in place to ensure caseloadsare appropriately monitored in the event of carecoordinators being absent from work. This shouldinclude patients being made aware of any changesin their care provision.

• The trust must ensure that staff follow up clients whodid not attend appointments appropriately.

Action the provider SHOULD take to improve

• The trust should identify best practice being usedwithin new assessment models, meeting structuresand caseload management initiatives and ensure it isimplemented consistently across all communitymental health teams.

Summary of findings


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

Canterbury and Coastal Community Mental Health Team Trust HQ

South Kent Coast Mental Health Team Trust HQ

Medway Community Mental Health Team Trust HQ

Maidstone Community Mental Health Team Trust HQ

Kent and Medway NHS and Social Care PartnershipTrust

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

Our findingsSafe staffing

• Following our inspection in January 2018, we hadconcerns that staff caseloads were higher than reportedas they did not take into consideration coverrequirements for staff on long term absence. We alsohad concerns that patients on caseloads of staff on longterm absence were not reallocated in a timely manner.This meant that caseloads, which contained patientswith high risks, were not monitored appropriately.During this inspection, we found staff caseloads werearound 40 for full-time staff and adjusted appropriatelyfor part-time staff and newly appointed staff. We sawevidence at the Medway CMHT that caseload numbersincluded patients that had been shared from caseloadsof staff on long term absence. We found there had beensignificant improvement in this area.

• Following our inspection in January 2018, we hadsignificant concerns that the CMHTs did not effectivelymanage their caseloads. We found patients were oftenduplicated on caseloads; patients were moved betweenstaff caseloads without appropriate handover orcommunication and patients were not distributedevenly to ensure staff had similar and manageableworkloads. This was despite staff attending meetings toreview their caseloads. This meant patients, some ofwhom were high risk, may be overlooked and notoffered the support they required. During thisinspection, staff told us their line managers supportedtheir caseload management through supervision andcaseload reviews were more structured and had a multi-disciplinary approach. However, they could be cancelledor not always attended by a psychiatrist or psychologistdue to availability. Most staff felt their caseloads weremanaged safely and that patients allocated to themmatched their discipline, whether it be a nurse,occupational therapist or social worker. They were alsoaware of patients that had been added to theircaseloads due to colleagues being on long termabsence. However, within the Canterbury and CoastalCMHT and South Kent Coast CMHT the businessintelligence reports showed a variation in patient

contacts made by care coordinators across the workingweek. Furthermore, at the Canterbury and CoastalCMHT, we found some care coordinators had caseloadscontaining many patients who were appropriate to beon a psychiatrist’s caseloads as they only requiredmedical reviews. This would have given staff morecapacity to allocate more patients to their caseload.Also within this team, a team leader was holding a largecaseload of patients who were accessing psychologicalservices. They had no contact with them and had nohandover from psychology regarding any risks theypresented with. We were told that psychologists couldnot be allocated as care coordinators and would notroutinely update risk assessments as part of theirintervention with patients.

• Within the South Kent Coast CMHT, there was only onecare coordinator with a nursing qualification. We foundthat patients on their caseload were not beingmonitored appropriately. For example, a patient with aforensic background and high risks had not had regularcontact and it was difficult to find assurance that therisks were being managed. Their progress notescontained entries made retrospectively whichcontradicted information recorded in team meetingswhere the patient’s risk had been discussed. We boughtthis to the attention of senior managers who agreed todo a full review of this caseload and follow up any areasof concern. We felt there had been some progress in thisarea but improvements could still be made.

• Following our inspection in January 2018, we hadconcerns there was no system in place to ensure staffcaseloads were managed when they were required tocover the duty service or depot clinic. Furthermore, staffwere often asked to cover duty at the last minutemeaning they had to cancel pre- scheduledappointments for patients on their caseload. During thisinspection, we found that all CMHTs had dedicated dutyworkers who did not carry an individual caseload. Thismeant staff with caseloads had to cover the duty serviceless frequently. In these instances, the Maidstone CMHTused their buddy system. In the other CMHTs, the

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


expectation was for staff to respond to urgent situationsconcerning patients on their caseload whilst otheravailable staff covered duty. We felt there hadbeen significant progress in this area.

• We spoke with duty workers from the Canterbury andCoastal CMHT, Medway CMHT and South Kent CoastCMHT. They felt that the role was pressured andrequired two staff to fulfil the role effectively. Withinthese three CMHTs there was often an expectation forduty to respond to patients who were on caseloads ofabsent staff. Furthermore, when a second worker wasavailable they often had to cover choice and partnershipapproach (CAPA) assessments for absent staff. A seniormanager was allocated to oversee the duty service toprovide advice and escalation situations if required.However, they were not available to support with otherclinical tasks. Due to staff resources, the Canterbury andCoastal CMHT had reduced the amount of assessmentslots available for referrals from the single point ofaccess from six to three per week. Furthermore, theseassessments slots were often filled up to three days inadvance meaning the service could not respond tourgent risk and assessment needs. Senior managerswere aware of this issue and were looking at ways toaddress it.

Assessing and managing risk to patients and staff

• Following our inspection in January 2018, we hadsignificant concerns around the way community mentalhealth teams (CMHT) assessed the risks to patients’health and safety or responded appropriately to meetpeoples’ individual needs to ensure their welfare andsafety during any care or treatment. During thisinspection, we reviewed 18 care records of patientsunder the Canterbury and Coastal CMHT. All had riskassessments, however, three had not been updatedwithin the last six months and two had not beenupdated for more than a year. Of the 13 care recordsthat contained recent risk assessments we found fourthat did not include risks that featured in their progressnotes meaning their risk rating was lower than it shouldhave been. This included a patient’s risk assessmentthat had not been updated after being deemed high riskafter being seen by a psychiatrist. We reviewed the carerecord of one patient with a forensic history and foundthe risk assessment to be comprehensive. We reviewed16 care records of patients under the South Kent Coast

CMHT. All had risk assessments, however, four had notbeen updated within the last six months, including apatient with a forensic background, and one had notbeen updated for more than a year. Of the 11 carerecords that contained recent risk assessments wefound two that did not include risk incidents thatfeatured in progress notes. We also found three riskassessments that had not been updated with rationalewhy the patient had been discharged from the crisisteam back to CMHT. We reviewed 22 care records ofpatients under the Maidstone CMHT. One patient, whohad not engaged with the team and subsequently beendischarged, did not have a risk assessment, althoughsome risk information did feature in their progressnotes. This meant that if this patient presented toservices in the future it would be difficult to locate thishistoric risk information. Nineteen care records hadrecent risk assessments, however, two had not beenupdated within the last six months. This care recordreview included two patients with forensic histories andthree patients with a diagnosis of emotionally unstablepersonality disorder. We found four of these five carerecords contained recent comprehensive riskassessments. The other care record had acomprehensive risk assessment but we found contactwith the patient’s care coordinator was not as regular asthe risk assessment would suggest. We reviewed 17 carerecords of patients under the Medway CMHT. All had riskassessments, however, one had not been updatedwithin the last six months and one had not beenupdated for more than a year. Of the 15 care recordsthat contained recent risk assessments we found onethat did not include risk incidents that featured inprogress notes. We also found one risk assessment thathad not been updated with rationale why the patienthad been discharged from the crisis team back to CMHT.This care record review included two patients withforensic histories and two patients with a diagnosis ofemotionally unstable personality disorder. We foundthree of these four care records contained recentcomprehensive risk assessments, one patient had a verydetailed risk assessment that involved carers and otheragencies, such as probation. The other care record hada risk assessment that was out of date by over sixmonths and showed irregular contact between thepatient and their care coordinator. We felt there hadbeen some progress in this area but improvementscould still be made.



• Following our inspection in January 2018, we hadsignificant concerns around the lack of crisis and riskmanagement plans contained within patients’ carerecords. This was a concern as it meant staff had noconsistent approach to follow in the event of a patientrelapsing and presenting with increased risks. Duringthis inspection, we reviewed 33 patients’ care records,across the four CMHTs, for evidence of crisis and riskmanagement plans and found that 25 contained them.We found a variation in the detail of these plans acrossthe CMHTs. It was encouraging to find that crisis plansthat had been written more recently were specific to thepatient’s needs and contained views from patients andcarers. However, some crisis plans, which were writtenover a year ago, only contained generic contactnumbers to access in emergency. It was also evidentthat staff were not always recording these plans in thesame part of the patients’ care record. This made themdifficult to locate in an emergency. We were also unableto clearly establish, from the care record, whetherpatients had been given copies of their crisis plans torefer to when required. We felt there had been someprogress in this area but improvements could still bemade.

• Following our inspection in January 2018, we hadsignificant concerns around the lack of systems theservice had in place to monitor and manage the risk topatients who were awaiting care coordinator allocation.We found these patients did not routinely have theirrisks recorded and staff did not contact them to monitorany changes in risk or determine whether their need forallocation had become more urgent. During thisinspection, all CMHTs we visited now had an activereview programme in place to ensure they had oversightof all patients awaiting care coordinator allocation. TheMaidstone CMHT allocated patients awaiting carecoordination to the staff member who had carried outthe initial assessment as they had likely formed atherapeutic relationship with them. Staff were thenresponsible for keeping patients updated on treatmenttimeframes and patients had a named contact if theyneeded to access the service. The other three CMHTsplaced patients on the caseload of a team leader afterthey had their initial assessment and were accepted forcare coordination. However, all had active reviewprogrammes in place to monitor these patients. TheCanterbury and Coastal CMHT currently had 132patients awaiting care coordination. The service

manager monitored this group of patients and we saw aspreadsheet which identified their risk rating; the lasttime they were contacted and a brief plan to befollowed. The Medway CMHT currently had 244 patientsawaiting care coordination, psychological treatment ornon-urgent medical reviews. This team assigned twostaff to review this group of patients and they aimed toreview 30 patients in each session twice a week. Again,they recorded action plans on a spreadsheet and,although patients were not risk rated here, staff couldaccess risk information through their care records. TheSouth Kent Coast CMHT had the highest number ofpatients awaiting care coordinator allocation at 374.They had responded appropriately and had formed anactive review team, of six staff, who reviewed andmonitored this group of patients during a recentlyintroduced a Saturday clinic. The teams had found thisprocess beneficial and reassuring as it had identifiedthat many patients awaiting care coordinator allocationwere getting regular contact from psychology groups,medical reviews, the depot clinic or support workers. Wereviewed the care records of two patients who attendedthe service regularly to have blood tests and collectclozapine, and antipsychotic medicine that requirescareful monitoring of physical health. We found thedocumentation around these contacts only recordedattendance and blood test results and did not gauge thepatients’ mental state presentation. They also felt thatthe active review programme identified patients withhigher risks and more urgent needs and assured us thatthey would be allocated immediately. The trust hadrecently introduced standardised letter templates whichincluded a letter to be sent to patients following theirinitial assessment. This informed the patient ofexpected time scales for treatment and includedemergency contact numbers. We saw some of theseletters uploaded in patients care records. We felt therehad been significant progress in this area.

• Following our inspection in January 2018, we hadsignificant concerns that patients who were awaitingcare coordinator allocation or had not been seen formore than six months were being discharged withminimal clinical rationale and often without beinginformed. During this inspection, we found the activereview programme had made significant progress in thisarea. We saw a letter to a patient under the MedwayCMHT, apologising for inappropriately discharging themand subsequently referring them to a psychology group.



Our findingsAssessment of needs and planning of care

• Following our inspection in January 2018, we hadconcerns that the recently introduced choice andpartnership approach (CAPA) model had not beenimplemented by all teams. This model aims to make theinitial assessment more patient centred so they couldmake an informed choice if they would benefit from theservice. A key requirement of this model is that twopeople carried out the assessment so different viewscould be explored. However, we found many exampleswhere the assessments were being carried out by oneperson due to staff shortages. During this inspection, wefound that only the Maidstone CMHT were regularlycarrying out CAPA assessments with two staff. This teamhad a clear buddy system in place which allowed staffpairings to be allocated for CAPA assessments. Theother three CMHTs we visited said that staff shortagesdid not allow the availability of two staff to carry outthese assessments. Furthermore, staff at the MedwayCMHT had shown some resistance to the buddy systemas they were concerned they would be paired withcolleagues who had poor sickness records and felt thiscould increase their own workload. To compensate,psychiatrists at this CMHT were seeing the patients afterthe CAPA assessment to address any urgent prescribingneeds and give an opinion on a diagnosis. However,staff said that this often meant patients had to waitaround for psychiatrists to be available. To furthercompensate, staff at the three CMHTs who carried outlone CAPA assessments could present their cases to themulti-disciplinary team before informing the patient ofthe outcome of the assessment. We were told thatpatients were informed of this during the assessmentand would be informed of the decision by letter ortelephone with three days. Team leaders andpsychologists felt that staff were improving their abilityto present cases through this process. Staff across theCMHTs were generally positive and felt supported withthe implementation and administration surrounding theCAPA model. We felt there had been some progress inthis area but further improvements could still be made.

• Following our inspection in January 2018, we hadconcerns that staff were not always recording initial coreassessments onto the patients’ care records, and in

some cases there was no record the assessment hadtaken place. We also had concerns that patients beingre-referred into the service did not have their coreassessment updated. During this inspection, wereviewed 21 patients’ care records to see the quality ofcore assessments. We found all contained coreassessments and 15 were completed to a goodstandard. However, we found three that neededupdating and three where staff had not updated theformulation and summary of a core assessment afterbeing referred by another service, such as the crisisteam. This meant that recent changes in the patients’presentation and subsequent risks and needs would nothave been recorded in the core assessment. We feltthere had been some progress in this area butimprovements could still be made.

Multi-disciplinary and inter-agency team work

• The trust had recently introduced a daily ‘red board’meeting across all CMHTs to support teams to identifypatients who are presenting with risks. We attended thismeeting at the Canterbury and Coastal CMHT, MedwayCMHT and the South Kent Coast CMHT; and reviewedminutes of the meeting at the Maidstone CMHT. Wefound the meeting to be an effective process to monitorrisk across the caseload. It identified patients who weredue a seven-day follow-up after being discharged backto CMHT from inpatient or crisis team; patients whowere due their depot after not attending the depot clinicand patients who were showing signs of relapse.However, we found a lack of consistency between howteams utilised the meeting. The South Kent Coast CMHTused it to generate a multi-disciplinary discussion onhow best to manage the risks and delegated actions forstaff. Whereas, the Medway CMHT, did not generate thislevel of discussion and staff were observed coming inand out of the meeting and were not wholly engaged.We also found each team recorded minutes of themeeting differently and there was no standard agendaused.

• All CMHTs we visited gave staff opportunities to presentcomplex cases, safeguarding referrals, assessments andreferrals. We observed a multi-disciplinary meeting atthe South Kent Coast CMHT which was attended by allstaff from that locality team including the two teamconsultants. One consultant led the meeting andallowed staff to present cases. Staff gave advice and

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.


suggestions and proactive management plans wereagreed. All teams also held a monthly clinical riskmanagement forum to discuss complex cases. Staffcould pre- book cases into this forum.

• Following our inspection in January 2018, we hadsignificant concerns there was no systems in place toformally handover caseloads to other staff in the eventof staff being on short term absence. This presented arisk to patients and put added pressure on the dutyworkers. During this inspection, we found the MaidstoneCMHT had an established buddy system. Staff members’buddy would then take responsibility for managing theircaseload when they were absent. This systemsupported continuity of care for patients by effectivelyproviding them with a secondary care coordinator. Theother three CMHTs had not adopted the buddy system.Therefore, when staff were absent patients’ needswould be managed by the duty service. In the event oflong term staff absence, apart from the Maidstone CMHTwho used the buddy system, staff caseloads weremonitored by team leaders who would disseminate thecaseload to other staff if the absence was over twoweeks. We were told that letters would be sent to

patients informing them of this change in their careprovision. However, at the Canterbury and CoastalCMHT, we found an example of a patient who had notbeen informed their care coordinator had been absentfor four months and they had not had any contactwithin this time. The trust had provided an action plan,following our inspection in January 2018, which statedthat a ‘handover of care’ model had been embedded inall teams. This was based on the standard operatingprocedure used by the Dartford, Gravesend And SwanleyCMHT to follow up patients when their care coordinatorswere absent. We did not see evidence of this modelbeing used across all CMHTs we visited. We felt therehad been minimal progress in this area and significantimprovements could still be made.

• We found two examples, at the Maidstone CMHT, ofpatients being allowed to their exercise their right tochoose what CMHT they would like to be assessed andsupported by. However, we also found an example of apatient who had experienced a difficult transfer of carefrom the Canterbury and Coastal CMHT to anotherCMHT within the trust.

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.


Our findingsAccess and discharge

• Following our inspection in January 2018, we were toldthat the trust had a target of seeing 95% of patientswithin their target of 28 days for routine assessment and48 hours for urgent assessment. We found that theCanterbury and Coastal CMHT were seeing 85% ofpatients within this target. The South Kent Coast CMHTwere seeing 78% the Medway CMHT were seeing 82%.During this inspection, we found these figures werebeing maintained within the Canterbury and Coastalteam seeing 84% and the Medway CMHT seeing 86%.However, these figures had dropped for the South KentCoast CMHT seeing 54%. The Maidstone CMHT wereseeing 87% of patients within the target.

• The trust had a target of allocating 95% of patients to acare coordinator within 18 weeks of them beingaccepted for treatment. We found that the Canterburyand Coastal CMHT were seeing 90% of patients withinthis target. This figure was 90% for the Medway CMHT;73% for the South Kent Coast CMHT and 87% for theMaidstone CMHT.

• Following our inspection in January 2018, we hadconcerns that staff did not consistently follow thecriteria for deciding whether a patient required carecoordination. During this inspection, we found that theCAPA model had supported staff to make more clinicallyaccurate decision on whether patients requiredsecondary mental health services.

• The trust provided clear referral criteria for both internalteams and external agencies, however, the service wasstill experiencing a high number of inappropriatereferrals, particularly from GPs. This resulted in a lot ofresources being used daily to screen referrals. A teamleader from the Medway CMHT had recently carried outa three-month audit of GP referrals to this team. They

found that only 19% percent were accepted forassessment and, following assessment, only 6%required care coordinator allocation. In response to thisaudit this CMHT had developed a new referral form forGPs to support them making more appropriate referrals.They had shared information on the audit and newreferral form with the mental health lead for GPs, andthey had agreed to present the findings to the local GPs.The CMHT were hoping the new referral form would bein use by July 2018. The service also accepted self-referrals and these often proved to be inappropriate.Senior managers told us they were consideringreviewing the self-referral process.

• Following our inspection in January 2018, we hadsignificant concerns that staff did not appropriatelyfollow up patients who did not attend (DNA)appointments as per the trust’s DNA policy. During thisinspection, we found the DNA policy had beensimplified to guide staff how to respond to DNAdependent on the patient’s risk. Our review of carerecords across the CMHTs visited identified 16 incidentswhere patients had DNA appointments, however onlyfive care records showed evidence that the DNA policyhad been fully followed, with one care record showingpartial adherence to the policy. The incidents where thepolicy had not been followed included patients whowere deemed high risk or had a history of impulsivebehaviour. The trust’s action plan had givenadministration staff the authority to make entries inpatients’ care records as they often received contactfrom patients, or their carers, that they would not beattending or sent letters to patients to inform them ofpending appointments. However, we saw little evidenceof this happening. We felt there had been minimalprogress in this area and significant improvementscould still be made.

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


Our findingsGood governance

• The trust had recently introduced an audit processcalled clinical quality (CLIQ) checks. These were carriedout by three quality leads across the service and theywould each audit 10 care records weekly against TheNational Institute for Health and Care Excellenceguidelines. These CLIQ checks looked areas such as riskassessments, care plans and crisis plans. We found theyhad led to improvement in clinical documentationand found very few examples of where CLIQ checks hadnot picked up incidents of clinical documentation thatneeded updating or more detail. Furthermore, whenactions had been identified, staff were regularlyaddressing them in a timely manner. Staff told us theywelcomed the CLIQ checks as a way of monitoring theirclinical documentation.

• The service had other systems in place to support staffto manage their caseloads. These included the redboard meeting, the active review programme, clinicalrisk management forum, supervision and caseloadreviews. However, we found that these systems wereonly effective when staff bought caseload concerns orsafety issues to these forums. We felt that supervisorsand senior managers could take more responsibility inappropriately challenging staff to identify areas ofconcern.

• The service had access to business intelligence softwarethat allowed them to monitor individual communitymental health teams’ adherence to key performanceindicators. However, at times it was unclear how thisinformation was being used, for example when itidentified a lack of recorded patient contacts.

• All the community mental health teams we visited hadimplemented a different approach to new systems, suchas the red board meeting and active review programme.We felt some approaches were more effective thanothers and that a consistent approach across the servicewould lead to further improvement.

Leadership, morale and staff engagement

• Staff morale had improved since our inspection inJanuary 2018. They were positive about the changessenior managers were implementing and how thesesupported their ability to safely and effectively supporttheir patients and manage their caseloads However,staff were still, on occasions, feeling the need to catchup on work in their own time. Staff still expressedconcerns regarding lack of cover arrangements whenthey were absent from work.

• Staff felt well supported by local management andacknowledged they had been appropriately informedabout recent operational changes. However, some staffwere showing resistance to some of the processes thathad been introduced.

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.


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

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

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Regulation 12 of The Health and Social Care Act 2008(Regulated Activities) Regulations 2014 – Safe care andtreatment.

Whilst we observed some improvements in some areas,our concerns from the January 2018 inspectionremained.

Staff did not always assess the risks to patients’ healthand safety or respond appropriately to meet peoples’individual needs to ensure their welfare and safetyduring any care or treatment.

The trust did not provide care and treatment in a safeway for patients’ receiving, or awaiting to receive, care ortreatment from the adult community mental healthteams.

Staff did not document appropriate information that hadbeen shared to ensure care and treatment remained safefor people using services. When staff were on annualleave or sick leave, a handover to another colleague orduty worker was not recorded. When patients weredischarged back to their GP they were not alwaysinformed.

These were breaches of Regulation 12(1)(2)(a)(b)(i).

Regulated activity

Regulation

Regulation

This section is primarily information for the provider

Enforcement actions


Assessment or medical treatment for persons detainedunder the Mental Health Act 1983

Diagnostic and screening procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation 17 of The Health and Social Care Act 2008(Regulated Activities) Regulations 2014 – Goodgovernance.

Whilst we observed some improvements in some areas,our concerns from the January 2018 inspectionremained.

The trust did not operate effective audit and governancesystems and/or processes to make sure they assessedand monitored the service at all times and in response tothe changing needs of people referred and / or acceptedto the service. There were not robust systems andprocesses in place to monitor and ensure compliancewith trust policy and procedures as outlined in the trust’sCommunity Mental Health Team Operational Policy andTransfer Discharge Policy.

This was a breach of Regulation 17(1)(2)(a)(b)(c),

This section is primarily information for the provider

Enforcement actions


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Front Sheet

Title of Meeting Trust Board Date 26 July 2018

Title of Paper CQC Reports

Author Mary Mumvuri, Executive Director of Nursing and Governance

Executive Director

Mary Mumvuri, Executive Director of Nursing and Governance

Purpose: the paper is for: Delete as applicable

Noting:

Recommendation:

The Board is asked to note the CQC Reports published since the last Board meeting

Summary of Key Issues: No more than five bullet points

Three reports have been published by CQC since the last Board meeting:

Community based service for people of working age -a focused follow-up inspection. This is covered in the CQC CMHT progress report.

2 Focussed inspection reports on Older Adult wards – Orchards and Jasmine

Key findings are noted below and full reports have been circulated separately.

Report History:

Quality Committee CQC Report

Strategic Objectives: Select as applicable

☒ Consistently deliver an outstanding quality of care

☐ Recruit retain and develop the best staff making KMPT a great place to work

☒ Put continuous improvement at the heart of what we do

☐ Develop and extend our research and innovation work

☐ Maximise the use of digital technology

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☐ Meet or exceed requirements set out in the Five Year Forward View

☐ Deliver financial balance and organisational sustainability

☐ Develop our core business and enter new markets through increased

partnership working

☐ Ensure success of our system-wide sustainability plans through active

participation, partnership and leadership

Implications / Impact:

Patient Safety: The safe domain has an overall CQC rating of requires improvement. This domain requires particular focus

Identified Risks and Risk Management Action: Strategic risk 3756

Resource and Financial Implications: Failure to comply with the regulatory standards could result in an enforcement action being taken against the trust which may have financial and resource implications

Legal/ Regulatory: Compliance with the regulatory standards set out in the Health and Social Care Act 2008

Engagement and Consultation:

Equality:

Quality Impact Assessment Form Completed: Yes/ No

Focussed inspection of older adult wards

Following the two day focussed inspection conducted on Jasmine and the Orchards wards

on 17 and 18 April, the trust has now received the reports. The trust responded to request on

factual accuracies and the final report for the Orchards was published on 21 June and for

Jasmine on 12 July.

No Regulatory Notices were issued.

The Orchards had 5 should do actions identified for improvement and updates are provided

in bold as follows:

The trust should ensure that they take immediate action to mitigate risks associated with

urgent ligature points. Planned works have been approved by the care group; tendering

process is in progress and due to complete in August.

The trust should take immediate action to carry out the repair works for the female garden

area. As above, planned works have been approved by the care group; tendering

process is in progress and due to complete in August.

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The trust should take immediate action to ensure that the ward has access to a secure

camera to reduce any risk to patients and ensure timely and appropriate care. Completed.

The trust should ensure that all staff are aware of the decision to keep privacy screens on

patient bedroom doors closed at all times. Completed.

The trust should ensure that patients are able to read menus and that appropriate food, in

line with national guidance, is available for patients. Completed.

Jasmine Ward also had 4 should do’s identified for improvement, as follows:

The trust should review the fitting of an alarm on the main ward door to alert staff if not

secured properly. completed.

The trust should ensure there is a suitable, safe and calming room available on the ward to

de-escalate patients when needed. This is under review and will be completed once the

designation of the ward has been considered.

The trust should support occupational therapists who wish to wear a work uniform.

Consideration is being given by the AHP workforce about whether they wish to wear

uniforms.

The trust should review the provision of physiotherapy for Jasmine ward. There is now

physiotherapy input to the ward.

An overarching action plan to include all 9 should do’s was developed and is monitored via

the care group/CQC Oversight Group.

front sheet - kmpt · 2019. 2. 7. · notes, with canterbury and swale achieving 100% compliance in...

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