Healthcare Inspectorate Wales
Inspection Report of Conwy and Denbighshire NHS Trust Child and Adolescent Mental Health Services
December 2005
Arolygiaeth Gofal Iechyd Cymru
Healthcare Inspectorate Wales
CCovers_Eng.inddovers_Eng.indd 1 88/12/05/12/05 8:26:328:26:32 pmpm Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road CAERPHILLY CF83 3ED Tel: 029 2092 8850 Fax: 029 2092 8878
www.hiw.wales.gov.uk
G/426/05-06 December Typeset in 12pt ISBN 0 7504 9740 8 CMK-22-12-053 © Crown copyright 2005
CCovers_Eng.inddovers_Eng.indd 2 88/12/05/12/05 8:26:328:26:32 pmpm Contents
Page No
Introduction 1
Background to Conwy and Denbighshire NHS Trust 2
Inspection Objectives 7
The Scope of the Inspection 7
Stages 8
Overall Findings 8
1. The Patients’ Experience 11
2. Patient and Public Involvement 19
3. Use of Information 25
4. Processes for Quality Improvement 33
5. Staff Focus 39
6. Leadership, Strategy and Planning 47 Annex 1: Summary of Recommendations 53
Annex 2: Postscript 57
Annex 3: Healthcare Inspectorate Wales 61
Annex 4: Glossary of Terms 63
Appreciation 69 Introduction
This was the first inspection of Conwy & Denbighshire NHS Trust undertaken by Healthcare Inspectorate Wales (HIW) as part of its 2004-05 programme of inspections. The remit for the inspection was to examine all mental health services provided by the Trust. For reasons related to Trust service structures and also the practicalities of organising the inspection, it was divided into two streams:
1. Mental health services for adult and elderly patients – report issued in October 2005.
2. Child and adolescent mental health services (CAMHS).
A separate report is being issued for each stream of the inspection. This report specifically examines the Trust's CAMHS, however, there may be Trust-wide issues of relevance that have already been reported on in the first report on mental health services for adult and elderly patients. Where this is the case reference is made to the relevant section of that report.
The inspection commenced on 1st December 2004 and information was collated and analysed, including documentary evidence, patient views, staff interviews and site observations, up to May 2005. The review of mental health services for adult and elderly patients was completed in April 2005 and was published in October 2005.
A summary of the recommendations within this report is provided in Annex 1 and a Postscript to the report in Annex 2. In addition, HIW's Terms of Reference and a Glossary of Key Terms used are provided in Annexes 3 and 4 respectively.
Although this report focuses upon Conwy and Denbighshire NHS Trust the findings, conclusions and recommendations are also directed towards the Trust’s partners and stakeholders, and also the commissioners of NHS services. These agencies will be invited to attend and to participate in the development of action plans.
1 Background to Conwy and Denbighshire NHS Trust
Conwy and Denbighshire NHS Trust was created in 1999/2000 following the merger of Glan Clwyd NHS Trust and parts of the Clwydian Community Care Trust and Gwynedd Community Health Trust. The Trust headquarters are at Glan Clwyd Hospital, Bodelwyddan. The Trust is a combined acute, community and mental health Trust located in central North Wales, serving a population of around 200,000 in the two counties of Conwy and Denbighshire.
The Child and Adolescent Mental Health Services Directorate is part of the Trust's Family Services Division. The Clinical Psychology Directorate, based in a Division with Medicine and North Wales Cancer Treatment Centre, provides clinical psychology input into CAMHS. The Therapy Services Directorate of the Clinical Support Division provides Occupational Therapy and Physiotherapy services within the Trust but currently does not have the capacity to provide input to certain patient groups, including those being treated by CAMHS. Substance misuse services in Conwy and Denbighshire are managed from the North East Wales NHS Trust, including for those patients with a dual diagnosis of mental illness and drug or alcohol problems.
The Welsh Assembly Government's strategy document for CAMHS, ‘Everybody's Business’, published in 2001, describes a four tier strategic concept for multi-agency services. An outline of the different tiers is given below:
Tier 1
The frontline of service delivery. Staff are not necessarily trained as specialists in mental health, but by virtue of their first contacts with, and their continuing responsibilities for young people and/or their families, are well placed to recognise, assess and intervene with children's mental health problems. These staff include GPs, many other primary healthcarers, health visitors, school nurses, teachers and other school staff, non-specialist children’s social workers, foster carers and many non-statutory sector workers.
Tier 2
The first-line of specialist services. The staff include members of health-provided specialist CAMHS, the staff of the education support services including educational psychologists and specialist teachers and specialist children's social workers as well as some staff of voluntary organisations.
2 Tier 3
Second-line specialist services provided by teams of staff from within Specialist CAMHS, for example specialised clinics, day-care services, special units in designated schools, specialist fostering and social services-led specialised family intervention centres.
Tier 4
Highly specialised services that may not need to be available in each local area but to which the local specialist CAMHS require predictable access are termed Tier 4 functions. They include very specialised clinics that are only supportable on a regional or national basis, inpatient psychiatric services for children and adolescents, residential schools and very specialised residential social care.
The child and adolescent mental health services Directorate within the Family Services Division consists of three teams. These teams provide differing levels of service broadly aligned to the national definitions of tiers outlined above. They operate independently with separate waiting lists but have close links enabling collaboration and support to each other:-
• Conwy CAMHS
Location: Argyll Road, Llandudno
Type of service: Tiers 2 and 3
Staffing:
Post Sessions per week Child Therapist 5 Clinical Psychologist 10 Community Paediatrician 1 Community Psychiatric Nurse 10 Consultant Clinical Psychologist 10 Consultant in Adolescent Psychiatry 2 Consultant in Child and Adolescent Psychiatry 10 Specialist Social Worker 8 2 Secretaries/Administrators 10
3 Background: Conwy CAMHS was developed in April 2003, following an investment of around £192,000 by the Conwy and Denbighshire NHS Trust. Prior to this date, North West Wales NHS Trust provided services to the Aberconwy area and a single CAMHS service based in Rhyl provided services to the rest of Conwy. The team moved from Rhyl to its current base in 2004. Services to families living in the Kinmel Bay and Pensarn areas, including Llanefydd and Bylchau are still provided by Denbighshire CAMHS, in order to follow natural patient flows.
• Denbighshire CAMHS
Location: Lawnside, Rhyl
Type of service: Tiers 2 and 3
Staffing:
Post Sessions Post Sessions per per week week Child Therapist 2 Psychology Assistant 10 Child Therapist 8 Secretary 4 Clerk/Typist 10 Secretary/Administrator 10 Clinical Psychologist x 2 10 Social work Therapist 10 Community Paediatrician 1 Social work/ 10 Play Therapist Consultant 10 Specialist Nurse x 2 10 Consultant Psychiatrist 3
Background: Historically the Conwy and Denbighshire NHS Trust delivered a service for the two counties from one team based at Lawnside Child and Adolescent Mental Health Service in Denbighshire. In 2002, the North West Wales NHS Trust transferred the Aberconwy area of North Wales to the Conwy and Denbighshire NHS Trust. In 2003, following investment by the Conwy and Denbighshire NHS Trust for a Conwy Service, it was agreed that the Conwy and Denbighshire CAMHS would consist of two multidisciplinary teams. The Denbighshire CAMHS Team agreed to continue to offer a service to families living in the Kinmel Bay and Pensarn areas of Conwy, including Llanefydd and Bylchau, in order to follow the natural patient flows. The Denbighshire Team also receives 10% of its total referrals from Flintshire, due to an historical agreement, whilst the Denbighshire areas of Corwen and Llangollen are covered by the Wrexham CAMHS, part of the North East Wales NHS Trust. 4 • North Wales Adolescent Service
Location: Cedar Court, Colwyn Bay
Type of service: Tier 4
Staffing:
Post Sessions Post Sessions per week per week
Consultant Clinical 5 Acting Head Teacher 10 Psychologist School Secretary 2 Clinical Psychologist 7 Teachers x 3.3 33 Assistant Psychologist 10 School Support 20 Consultant Child & 12 Assistants x 2 Adolescent Psychiatrist x 2 Senior Child Therapist 8 Consultant Nurse 10 Social Worker 10
Ward Manager 10 Student Social Worker 10 when on placement Deputy Ward 20 Managers x 2 Administrative 35 staff x 3.5 Liaison Nurse 10 Domestic x 2 16 Nursing Team x 10.5 105 Health Care Support 55 Workers x 5.5
Background: The Adolescent Service offers a psychiatric inpatient and day- patient facility for the assessment and treatment of adolescents of either sex with serious psychiatric disorders and their families. It provides this service to patients from the whole of North Wales – i.e. the areas covered by Conwy, Denbighshire, Flintshire, Wrexham, Gwynedd and Isle of Anglesey Unitary Authorities – and also parts of North Powys. There is a school on the premises which is an integral part of the service. The usual age range is from twelve to the eighteenth birthday, although eleven year olds may be considered, providing they are attending secondary education.
5 Tier 2 and 3 services provided by Conwy and Denbighshire NHS Trust are commissioned by the region's Local Health Boards (LHBs), who each decide what services to fund for their local population of children and young people. As a result the range of Tier 2 and 3 CAMHS services available to patients varies according to the LHB area in which they live. Tier 4 services for all patients from Wales are commissioned by Health Commission Wales (HCW), an agency of the Welsh Assembly Government. HCW commissions the Trust to provide the Tier 4 service for North Wales at Cedar Court, and also fund individual placements for local patients in other facilities in the United Kingdom when appropriate.
In the 2001 Census the resident population aged 18 and under of Conwy was measured as 24,054, and that of Denbighshire was 21,668. The population of under 18 year olds in North Wales served by the North Wales Adolescent Service was 154,661.
The age distribution, recorded from the 2001 census, is shown below:
0-15 16-18 Conwy 18.4% 3.5% Denbighshire 19.7% 3.6% North Wales 19.6% 3.7% Wales 20.2% 3.8%
The ethnic groups identified by all respondents to the 2001 census are as follows:
White Mixed Asian or Black or Chinese Other Asian Black ethnic British British group
Conwy 98.94% 0.38% 0.30% 0.09% 0.19% 0.09%
Denbigh- 98.85% 0.47% 0.33% 0.12% 0.16% 0.09% shire
Wales 97.88% 0.61% 0.88% 0.25% 0.22% 0.18%
In Denbighshire there are pockets of high indices of social deprivation, particularly in the Rhyl area. Conwy as a whole has high indices of social deprivation and has the highest suicide rate in Wales. There are also some indications that there are greater numbers of young offenders within the Conwy area compared to Denbighshire.
6 Inspection objectives
The aim of the inspection was to ensure that clinical governance arrangements across the Trust:
• Complied with guidance within Welsh Health Circular (2003) 69: Annual Clinical Governance Reports 1st April 2002 to 31st March 2003 and Future Requirements.
• Are leading to continuous improvement of services to patients.
• Are engendering a culture of quality and learning.
• Are safeguarding the safety of patients and staff.
The Scope of the Inspection
The inspection studied six domains of clinical governance, as set out below:
• The patients’ experience.
• Patient and public involvement.
• Use of information.
• Processes for quality improvement.
• Staff focus.
• Leadership, strategy and planning.
For ease of reference, detailed findings and main recommendations have been set out in the main body of this report against the six domain areas identified above. Each criteria within a domain is identified by a HIW reference code. For example E1 is a criterion within Patient Experience, P1, P2 are criteria within Patient and Public Involvement. The criteria are set out at the commencement of the relevant sections of this report. Evidence or findings of note are reported where necessary for each of the CAMHS services provided at Conwy, Denbighshire or Cedar Court.
7 Stages
The stages for the inspection are as follows:
• Notification to the organisation(s).
• Collection of specific information e.g. documentation, site observation, staff interviews.
• Assessment of evidence against HIW framework.
• Publication and presentation of report.
• Action planning and monitoring.
The action planning stage will be taken forward by the Trust following the publication of this report. The Trust’s Action Plan will be agreed with HIW to ensure the actions address the recommendations made as a result of the inspection. Monitoring of the action plan will be undertaken through the routine performance management arrangements for the NHS in Wales.
A detailed description of HIW’s inspection methodology is located at www.hiw.wales.gov.uk/content/publications/ins-method-acute-e.pdf or can be obtained directly from HIW by telephoning 029 2092 8850.
Overall Findings
The inspection identified that CAMHS managed by the Conwy and Denbighshire NHS Trust provide services which are effective in the treatment of young people who have mental health problems. The evidence confirms that the staff are committed, motivated and hard working, despite having limited resources. The service has developed and progressed over recent years as a result of additional investment but still remains restricted in respect of its’ ability to develop further due to resource issues. This situation is, however, reflected in CAMHS across Wales. There are areas identified within the report where improvements can be made and these form the basis of the recommendations.
There is evidence that the demands for specialist CAMHS input is greater than the capacity of both the inpatient and community services that are available. This situation often results in young people having to attend placements out of area as well as leading to significantly long waiting lists. As a result of this situation, staff often feel frustrated about their inability to support the needs of more complex and high risk individuals. The teams are faced with difficulties as a
8 result of environmental issues both at Cedar Court and at the community team bases. There is evidence of difficulties with the environment within which CAMHS are provided and that a lack of space and inappropriate design adds to the pressures faced by the service.
It is evident from the information submitted that there is a realisation within the Directorate of the need to seek views from the young people and their families. However the range of areas about which their opinions are sought is limited and does not appear to impact on service or policy development. There is little evidence to demonstrate that any feedback collected brings about change. There is no evidence of a Patient and Public Involvement (PPI) strategy in partnership with key stakeholders.
There is no Trust wide or CAMHS specific information system which results in a lack of a co-ordinated approach to managing information as well as creating difficulties in respect of monitoring waiting lists. Information gathered about the young person’s experience of using services is specific to individual parts of the service rather than co-ordinated across CAMHS. There are, however examples of actions that have been taken in response to specific requests made by young people. There is little evidence of information being routinely made available to the Trust Board but there was evidence of a range of information available for young people and their families.
There is evidence of a risk management programme in place across CAMHS, together with monthly risk management and clinical governance meetings. There is recognition within the Division that the clinical governance process could be strengthened by the appointment of a clinical governance facilitator. A clinical audit schedule is in place at Cedar Court but there is no such programme planned for the community teams and neither is there evidence of a clinical effectiveness programme for CAMHS. Policies on incident reporting, child protection and patient consent are in place and have been reviewed.
There is evidence that staff working within CAMHS are dedicated and experienced. Staff morale is reported as high despite the service being overstretched. This may be partly attributed to the fact staff said they feel listened to. A need for dedicated, specialist strategic and operational management structures has however, been highlighted. There are robust induction arrangements in place for all new staff and staff are supported in their Continued Professional Development. Performance reviews are undertaken and staff receive clinical supervision. A training plan is in place and staff receive
9 mandatory training. Feedback is sought from staff via surveys but there is no evidence of any action taken as a result.
Management and leadership capacity is low within CAMHS and there is a need to review the management arrangements including clinical leadership. It is unlikely that the current management capacity is sufficient to meet the rapid development needed to plan for an effective Tier 4 CAMHS integrated with other agencies working with children. There is a need to agree a multi-agency plan in line with the newly established Partnership Boards as well as a need to develop a comprehensive overarching strategy for CAMHS.
In conclusion, the inspection has identified that there is a great amount of positive activity being undertaken within the service. If action is taken to address the issues contained within the recommendations there are a number of opportunities to support the service to progress further.
10 1. The Patient’s Experience
As part of HIW's assessment of the experience of patients using the services of the Trust, the following elements of patient care were reviewed and evaluated:
• The quality of care should be consistent and good for all groups of patients (E1)
• The patients should be shown respect; there should be equality of treatment for all groups; catering should be varied and of good quality (E2)
• The organisation should ensure it provides information and involves patients or carers in their care and treatment (E3)
• The environment of care should be clean, have clear signage and include facilities for parents and carers (E4)
• The organisation should take steps to improve the physical access and appointments process (E5)
• The organisation should audit the physical access to care (E6)
• The organisation should ensure it supports patients through the whole journey of care (E7)
• The organisation should ensure it reduces the number of untoward outcomes (E8)
• Patients should have successful clinical outcomes, pain control and better quality of life (E9)
11 In relation to the quality of care a range of factors were consideredE1. There is documentary evidence from the Quality Network for Inpatient CAMHS (QNIC) external review of February 2004 that a very positive level of service provision had been maintained at Cedar Court since the review undertaken the previous year. It reported that the service had achieved a consistently high standard across all areas examined and noted that several improvements had been made. There is evidence that all young people of school age admitted to Cedar Court are expected to attend school full time. There is access to the National Curriculum, external examinations and a wide range of subjects are available at the school.
There is interview evidence of a number of concerns regarding out of area placements, used when Cedar Court is unable to provide the service required. The concerns highlighted include the amount of a clinician's time taken up by travelling to review young people in such placements and difficulties arranging the return home of some patients from private facilities. Concerns about the quality of some independent placements were raised by both clinical staff and the patients themselves. There were also problems engaging parents whose children have been placed out of area.
A number of factors were considered in relation to the humanity of careE2. There is documentary evidence of concerns being raised by young people at Cedar Court about a lack of activities during the evening. Concerns were also reported in respect of the food provided at the unit. Food is prepared at the local community hospital and brought in to Cedar Court and it is reported in the documents submitted, that the choice of food is not always ‘child friendly’ and that there were sometimes difficulties in meeting the needs of young people who have eating disorders. There is evidence in the documents of staff and young people having to buy fruit weekly as the kitchen were unable to provide a wide enough variety of fruits. It was reported in the documents submitted that the young people were unhappy with the juice, squash and biscuits provided. They were told that any requirements that were not available from the catering service, such as healthier biscuit brands, would need to be purchased from ‘treat’ money. It is suggested within the documents that the provision of on-site catering would help resolve this issue.
All young people are given the option on admission of having a single room. In addition, it was confirmed that they are able to sleep, bathe and wash in privacy. This has recently been improved with the provision of en-suite bathrooms.
12 There is interview evidence that there are Welsh speaking staff in both of the community teams as well as at Cedar Court. It was reported, however, that even the young people who are Welsh speaking tend to prefer to engage in therapy in English. Many of the documents available were bilingual and a bilingual greeting is made in response to external telephone calls. HIW's reviewers reported that staff were clear how to access translation services and culturally appropriate information from the Trust.
There is documentary evidence of a behaviour management policy that has been implemented at Cedar Court. It was noted in the documents that physical restraint would only be used in specific circumstances and only when there were sufficient staff available. Counselling is also provided for the young person following any situation where restraint had been used. In addition, Cedar Court has an Anti-Bullying and Non-Oppressive Practice Policy (2004), which requires patients and their parents to sign a contract on admission that includes an agreement to adhere to the Unit's House Rules.
The extent to which patients and their parents or carers were involved in their care and treatment was examinedE3. There is documentary evidence that at Cedar Court a treatment planning meeting takes place, involving the young person and their parents, which takes place during the initial two weeks familiarisation period. In addition, care plans are designed to take account of the views of the young person. A family information form has been developed by the Conwy and Denbighshire CAMHS teams which is sent out to parents and the young person when initial contact is made following referral. This records the families’ perspectives on the young person's problems. Families are also asked to confirm they require a service from CAMHS.
The National Youth Advocacy Service (NYAS) provides a service for young people in Cedar Court as well as a service for young people up to the age of 25 who are admitted to the adult inpatient ward at the Ablett Unit of Ysbyty Glan Clwyd. NYAS provides ‘child friendly’ information about the service they provide including posters, credit card sized contact cards and information packs for younger children and adolescents and young adults, which explains the service they provide. The young people reported very positive comments about NYAS and feel that the issues they raise get resolved, often removing the need to formally make a complaint.
13 In respect of the environment of careE4 there is documentary and interview evidence that the current accommodation both for the community teams and the inpatient service is inadequate. The main problem highlighted is that of limited space. There is evidence from the staff interviews that the Conwy CAMHS team's base at Argyll Road has limited office and therapeutic space and staff feel that they are competing with other staff in the building for such space. It was also described that since rooms are not specifically designated for CAMHS, the space available is often not orientated to young people and families, for example rooms used with children and young people can contain family planning equipment and examination couches. These difficulties associated with the availability of space can make it hard for clinicians to organise their working week in advance or find space to respond to an emergency case. At Denbighshire CAMHS team's Lawnside clinic there are no waiting rooms available, which results in families having to wait in their cars prior to their appointment. It has been documented that there would be benefits for the community teams to have therapeutic space and meeting rooms provided at the Tier 4 facility when it is re-located.
There is evidence from both documents and site observations that the environment at Cedar Court is clean, comfortable and has a warm welcoming atmosphere, with the staff describing it as ‘homely’. There is, however, no space for parents or carers and only limited space for recreation and therapy. The QNIC review noted that Cedar Court does not have a specific room for physical examination and minor medical procedures and identified requirements for meeting rooms, quiet rooms and office space. The review commented that the lack of space presented significant problems in terms of young people’s privacy, care, treatment and recreation. It also reported that staff identified that a two-bedded high dependency unit was required in order to meet the needs of acutely disturbed adolescents. Patients such as these are usually accommodated in a Tier 4 facility, but Cedar Court cannot always provide appropriate levels of care. From a safety and security perspective, there is evidence of appropriate observation policies in place as well as sufficient locks and outside lights. It is documented, however, that there is a need for infrastructure work in many of the buildings used by the Directorate.
A number of factors were considered in relation to access to careE5. There is evidence that referrals to Cedar Court are only accepted from the CAMHS community teams. They are entered onto a register and then submitted to the team for consideration and prioritisation. An information pack about the unit is sent out to the family and an initial home visit takes place, following which an
14 assessment is carried out at Cedar Court and if appropriate, the young person is entered onto the waiting list. There is evidence from the stakeholders’ comments that the referral process to specialist Tier 4 services is too rigid.
Cedar Court currently operates five days a week, opening on Monday morning and closing on Friday evenings. There is an out of hours on-call service provided by the Trust's Consultant Child and Adolescent psychiatrists which covers patients under 16 year olds who present to A&E at Ysbyty Glan Clwyd as well as the inpatients at Cedar Court. For a period of several months in 2004, the Unit operated as a day unit only, due to there being insufficient staff to provide a safe environment of care during weekday nights. When the Unit is closed patients are expected to return home. On occasions when this is inappropriate, due to personal or clinical reasons, the Unit tries to organise staffing so that it can remain open for them. If this is not possible, it was reported that patients may be placed on a paediatric ward or in the adult acute mental health unit, Ablett Unit, at Ysbyty Glan Clwyd, with suitable support from Cedar Court staff. Alternatively patients may be placed in the adult mental health units provided by neighbouring trusts or arrangements made for an urgent out of area placement. The funding for such placements has to be agreed by Health Commission Wales (HCW). If young people are placed out of area it often creates both time and financial difficulties for their families.
There is documentary evidence that supports the suggestion that demand for specialist CAMHS input is outstripping the capacity of the community teams and based on local demographics, it is likely that this position will continue. Both community teams spend a significant amount of time dealing with enquiries about young people on the waiting list and providing consultation to Tier 1 and 2 staff supporting the young people who are waiting to access specialist CAMHS. This is often at the expense of time for direct clinical work and can have a negative impact on the waiting list. There is evidence that the processing of referrals to the Denbighshire CAMHS team has been streamlined by the development of a Referrals Group who meet weekly to review referrals and waiting list priorities. The Conwy CAMHS team has a Referrals Co-ordinator whose role is to initially ‘screen’ the referrals for appropriateness.
There is documentary and interview evidence that the waiting lists for specialist CAMHS are managed according to risk, rather than diagnostic category and that intervention is prioritised accordingly. In addition, families are asked to contact the service if a crisis occurs in order that young people can be re-prioritised if necessary. There is however an issue of clinical capacity. Clinical time is being
15 taken up assessing the status of clients on the waiting list in order to manage risks. In addition, there are issues of staff skills and experience that can limit the conditions and numbers of cases they can deal with.
There is evidence from the interviews that indicates that there was pressure from the Trust's Executive Team to keep the waiting list to within 18 months which was the National target at that time. Concerns were expressed by staff about the Executive Team's level of understanding as to why approaches adopted for managing waiting lists for mainstream, routine services, for example, surgery are not appropriate for CAMHS. One example of this is the approach of treating the next child off the list rather than as an assessment of need or risk. There is evidence from the interviews that illustrates a general lack of robust monitoring of the lists which resulted in the discovery of two children who had been waiting over 18 months. In order to address this an additional administration manager was appointed to support the process which has prevented any recurrence of this problem to date.
The physical access to care was examinedE6 and the only issue to emerge was that of car parking. In both Cedar Court and Denbighshire CAMHS team's base at Lawnside base there is no space for cars to be parked and as a result, they have to be parked on the road outside the building, which can cause problems in respect of safety.
A number of examples were identified in respect of supporting young people through their journey of care, several issues emerged from the reviewE7:
• There is documentary evidence that a care pathway has been developed for use by the adult inpatient ward at Ablett Unit when a person under 18 is admitted. This care pathway supports the Welsh Assembly Governments policy on services for 16 to 18 year olds.
• There is documentary and interview evidence of a liaison programme between the CAMHS service, within the Child and Family Directorate and the Mental Health Directorate called ‘Bridging the Gap’. One of the key tasks identified as part of this programme is the development of a joint strategy for 16 to 18 year olds. An example of one of the issues that is being tackled as part of this initiative is clarification of the on-call rota in respect of actions that need to be taken by consultant psychiatrists working in adult services should a young person under the age of 16 present to services.
16 • A joint appointment of a liaison nurse between CAMHS, adult mental health services and paediatrics has been established. The purpose of this role is to ensure young people that attend adult mental health services for inpatient treatment remain safe.
• Work is being undertaken to clarify and ‘streamline’ responsibilities and handover between CAMHS and primary care teams.
• Staff at Cedar Court reported feeling frustrated about the inability of the service to meet the needs of more complex and ‘high risk’ clients. As a result, such people often have to be transferred out of the area resulting in a case not being ‘seen through’ as well as a loss of continuity in care for families.
The clinical and patient defined outcomes were examinedE8, E9. There is documentary evidence of a lack of safe, age appropriate psychiatric inpatient facilities for under 18 year olds in North Wales. It was reported that Cedar Court enables adequate management and nursing supervision appropriate to the degree of disturbance of the young person. It was, however, stressed that a young person who could not be managed safely would not be admitted. It was documented that whilst the average length of stay had reduced there were a number indicators of decreased effectiveness of the service in 2003-04. One of these was a reduction in the number of adolescents treated due to bed closures. Another was identified through examination of assessment scores taken on admission and discharge, where increased scores indicate a deterioration. In 50% of patients during the period 2003 – 04 no change or increased scores were observed. Half of the 50% were patients who had been transferred to out of area inpatient units. In previous years some young people would have been able to remain at Cedar Court and benefited from the then available seven day service.
In summary, there is evidence that the demands for specialist CAMHS input is greater than the capacity of both the inpatient and community services that are available. This situation often results in young people having to attend placements out of area as well as leading to significantly long waiting lists. As a result of this situation, staff often feel frustrated about their inability to support the needs of more complex and high risk individuals. The teams are faced with difficulties as a result of environmental issues both at Cedar Court and at the community team bases. There is evidence that a lack of space and inappropriate design adds to the pressures faced by the service.
17 Recommendations:
• The Trust should work with HCW to agree an effective process for repatriating young people from out of area placements.
• The Trust should work with HCW to ensure that the quality of care provided at out of area placements is of an acceptable standard and is monitored on an ongoing basis.
• The Directorate should review the arrangements for providing food at Cedar Court and ensure that a healthy diet is provided for the young people.
• The availability of space at the community team bases should be reviewed.
• The referral process to Tier 4 services should reviewed to ensure the most effective systems are in place, given the limited resources available.
18 2. Patient and Public Involvement
As part of HIW’s assessment of the approach to public and patient involvement in the development of the Trust’s services, the following criteria were reviewed and evaluated:
• The organisation should use appropriate methods to seek and use the views of service users and carers (P1)
• The organisation should ensure there are processes to monitor the planning and organisation of care from the patients' perspective (P2)
• The organisation should document its learning from the planning and organisation of care from the patients’ perspective (P3)
• The organisation should document the improvement in the planning and organisation of care from the patients’ perspective (P4)
• The organisation should document the steps and monitoring taken to improve the environment of care (P5)
• The organisation should document examples of improvements made to the environment (P6)
• The organisation should identify issues through the patient survey programme, take action and note improvements (P7)
• The organisation should identify the main staff training and development needs to support the work of Clinical Governance and Patient and Public Involvement (P8)
• The organisation should document any training and development undertaken on PPI work (P9)
19 Methods of seeking feedback from service users were examinedP1. There is currently no Patient and Public Involvement (PPI) Strategy that specifically relates to CAMHS. This, however, has been identified by the service as a clinical governance priority area for 2005/06.
At Cedar Court there is documentary and interview evidence of a process being in place to enable young people to contribute to the day to day running of the Unit. This consists of a ‘Pre-Policy/User Feedback Meeting’ which is held monthly and is attended by all available young people and staff representatives. Its purpose is to provide a forum for feedback, to discuss issues the young people wish to be considered further and to select and prepare two young people to attend a second meeting, called the ‘Policy Meeting’ which is also held monthly. This is attended by a consultant psychiatrist, psychologist, ward manager, head teacher, child therapist, social worker and the two young people representatives identified at the ‘Pre-Policy/User Feedback Meeting’. The purpose of the ‘Policy Meeting’ is to discuss the day to day running of the Unit and review current policies and rules that affect the Unit. Formal minutes are taken of both meetings. The young people felt they were not involved in developing policy but they do have the opportunity to contribute to day to day matters at the Unit and as such the name of the Policy Meeting has recently changed to the ‘Young People’s Management Group’.
The outcomes from the involvement of young people in the meetings are variable. There is documentary evidence that a range of issues and requests are discussed at these meetings and feedback is provided about actions taken following previous meetings. There are, however, examples of unresolved issues or requests being raised at several consecutive meetings with no feedback to report. In addition, low levels of staff attendance at Policy Meetings has been raised on several occasions during the last year.
Questionnaires are sent on a patient's discharge from Cedar Court asking whether the patient felt the treatment received had been helpful to both themselves and their family. A follow up questionnaire is also sent six months after discharge enquiring whether things are better or worse since leaving the Unit. Whilst these post discharge questionnaires are proactive initiatives, it is unclear whether they are sent to the young person or to their parents and they do not seek feedback about other aspects such as the patient’s opinions of the quality or environment of care.
20 The Denbighshire CAMHS team has involved families in reviewing the assessment process for autistic spectrum disorder through the establishment of a parents' group. It is intended that this group could be used as a discussion group to canvass views about service provision as well as a way of communicating with families about future service developments.
There is documentary evidence that the Directorate's Emotional Family Support Team have designed a questionnaire that is used by children and young people to report their experiences of the service. There is also evidence of positive feedback from a parenting course held called, ‘Incredible Years’. In addition, it was reported that feedback had influenced the development across the county of the ‘Seasons for Growth’, a pilot bereavement and loss programme taking place at Prestatyn High School.
The Trust has established a young people's forum to engage with children and young people who are inpatients on the paediatric wards, or who regularly attend departments across the Trust. However, HIW have not seen evidence of any involvement by CAMHS patients with this work.
A range of information was considered to determine the extent to which the planning and organisation of care was monitored from the patient’s perspectiveP2, P7. There is documentary evidence of an evaluation having been undertaken of a ‘drop in’ held by primary mental health workers at a primary school for parents and carers. The evaluation considered whether the objectives originally set had been achieved, taking account of user views. The response to this exercise from the feedback gathered was to abandon the initiative and revert to the original methods of communication through the use of mailshots, newsletters, provision of contact details of staff and displays. In making this response there was no evidence that consideration had been given to modifying the approach or implementing alternative ways of achieving the same objectives.
Evidence of what has been learned from the planning and organisation of care from the patient’s perspective was examinedP3. An audit of the referral systems in Tier 3 CAMHS had been undertaken that determined that only 45% of inappropriate referrals were responded to and ‘signposted’ to more appropriate agencies within 21 days. In order to help resolve this issue practical action was taken by administrative staff to change the way referrals were dealt with. Some of the difficulties identified remain unresolved due to a lack of available Tier 1 and 2 services to which the young people should be referred.
21 There is documentary evidence of work undertaken with a school to develop a framework for accessing emotional support within the school entitled, ‘Emotional Pathways’. Comments were sought from teaching staff about the approach at a presentation given to a staff meeting. As a result of the feedback, additions were made to the original framework to enable the smooth running and integration of the framework into the school calendar.
A range of information was examined to determine the extent to which the planning and organisation of care had been improved over the last year,P4 several initiatives were examined as evidence. There is documentary and interview evidence that CAMHS services have expanded with the appointment of two additional consultant psychiatrists as well as the appointment of a Professor of Adolescent Forensic Psychiatry in partnership with the University of Central Lancashire. These together with associated nursing posts have improved access to all areas of CAMHS.
It was generally accepted that Conwy and Denbighshire CAMHS would consist of two multi-disciplinary teams, each providing a service to their respective county. It was planned that each team would operate independently with separate waiting lists but with close links enabling them to collaborate and be supportive of each other. Initially the team members of the Conwy team were based at Lawnside in Rhyl, together with their Denbighshire colleagues until the Argyll Road offices were re-configured and occupied in May 2004.
There is documentary evidence that both CAMHS teams have begun undertaking assessments of children and adolescents with complex developmental disorders, including Autistic Spectrum Disorder. This is a re-instatement of a service that had been suspended since the retirement of a consultant psychiatrist in November 2002.
There is evidence that the frequency of the CAMHS community teams' joint business meeting had been discussed. The meeting currently takes place monthly and the possibility of it becoming bi-monthly was pursued. Due to the varying stages in development of the two community CAMHS teams and the pressure of work they were both facing, it was agreed that the current programme of monthly meetings continue and be reviewed at a later date.
There is evidence too, that the Conwy CAMHS team has made changes to the way that referrals are managed. The team felt that the current referral meeting was too long and was, therefore, not a good use of team member’s time. As a result the acceptance and priority of referrals is decided by three core members.
22 The subsequent team meeting then reviews the waiting list, identifies the young people most at risk and those waiting the longest, allocates young people to the emergency slots as appropriate and provides time for team members to discuss concerns or seek advice on patient care matters.
Four members of the Denbighshire CAMHS team and three members of the Conwy CAMHS team have extended their skills in Dialectical Behaviour Therapy (DBT) in order to provide a service to young people assessed as having a ‘borderline personality disorder’. The Denbighshire team meets monthly with primary mental health clinicians to offer support, consultation and discussion of individual cases whilst the Conwy CAMHS team started an initiative where the adult community mental health team is offered a consultation and training ‘slot’ on a monthly basis, as a way of raising awareness and increasing skills in meeting the mental health needs of their younger patients.
As there has been a reduction in the number of residents at Cedar Court due to nurse staffing problems it has resulted in a reduction in the number of pupils attending the school at the Unit. During this time the school took advantage of the situation to trial new policies and refine curriculum planning.
Evidence was considered to determine the steps taken to improve the environment of careP5. There is documentary evidence that confirms the lease on Cedar Court expires in 2008. Staff interviews stated that there was concern over accommodation pressures and the suitability of buildings for CAMHS. It was reported that the Trust is currently developing a Service and Estates Strategy and that CAMHS has a direct input into this. Staff reported that they were pleased progress is now being made with a replacement inpatient unit. An agreement had been reached on developing a Strategic Outline Case (SOC) for the unit to be sited in Conwy due to existing education and social work links and accessibility of the A55 corridor. It was reported that viable sites are being explored with regard to planning and a multi-agency group has been developed which links into the Trust’s planning process.
Documentary information was examined to determine examples of improvements made to the environmentP6. There is documentary evidence that Argyll Road clinic has been refurbished and that the car park tarmacked prior to the team moving in. There is evidence of a portakabin having been sited at Cedar Court to provide additional office accommodation for staff members. In Cedar Court, school computer equipment has been upgraded, including provision of an interactive whiteboard and a laptop computer to ensure the privacy of the young
23 people’s work. There is also documentary evidence of equipment being purchased as a result of requests from young people raised at Policy Meetings.
The staff training and development needs to support the work of clinical governance and patient and public involvement were examinedP8, P9. Staff interview evidence states that clinical governance is currently embryonic in community CAMHS, given that two new consultants have been appointed and the new teams established. It was reported that there needed to be a period of ‘bedding down’ and the work needed to be better co-ordinated. It was envisaged that the clinical governance programme would develop along the lines of the public health and social care teams of the Child and Family Division, who have identified their responsibilities and priorities for development.
In summary, it is evident from the information submitted that there is a realisation within the Directorate of the need to seek views from the young people and their families. However the range of areas about which their opinions are sought is limited and does not appear to impact on service or policy development. There is little evidence to demonstrate that any feedback collected brings about change. There is no evidence of a PPI strategy for CAMHS developed in partnership with key stakeholders. There is evidence too of clear difficulties with the environment in which CAMHS services are provided.
Recommendations:
• The service should ensure that issues raised at the ‘Young People’s Management Group’ are listened to, explored and feedback provided as to any action taken. Where action is not possible in response to an issue, this too should be explained.
• The Directorate should ensure the views of patients and carers on all aspects of services provided are collected and influence service and policy developments.
• The Trust should explore all opportunities for improving the physical environment within which CAMHS operates in the short term and ensure that opportunities for greater integration of teams are considered as part of the reprovision of Cedar Court.
• The Trust should encourage the involvement of young people with mental health problems in the ‘Young Person’s Forum’.
• The Trust should develop a PPI strategy for CAMHS in partnership with key stakeholders.
24 3. Use of Information
Healthcare organisations need to assess how they use information to improve care, including the following issues:
• The organisation should routinely gather information about the patients’ experience (U1)
• The organisation should document the improvements made to patient care as a result of information from patient outcomes (U2)
• The organisation should document how it uses information to inform quality improvements (U3)
• The organisation should use information about staffing levels and skill mix to influence the provision of services (U4)
• The organisation should document how it prioritises the development and improvement of clinical information systems; and information about internal processes (U5)
• The organisation should make clinical outcomes information available to clinicians and document its use (U6)
• The organisation should make suitable information available to the Board and Senior Management and documentation (U7)
• The organisation should make suitable information available to the staff and patients (U8)
• The organisation should ensure information is quality assured and updated constantly (U9)
• The organisation should have processes in place to ensure the confidentiality of information (U10)
• The organisation should inform patients of it’s services and changes (U11)
• The organisation should keep stakeholders outside the organisation (U12)
• The organisation should have processes in place to share learning between other organisations (U13)
25 In order to determine how information was gathered about the patient’s experience a range of information was examinedU1. There was documentary evidence that treatment plans and individual therapy treatment/care plans are in place at Cedar Court. The treatment plan identifies who was present at the treatment planning meeting along with targets for individual, group and family therapy and their associated priorities. The individual therapy treatment/care plan notes each target’s symptom, priority, problem and desired outcome along with the treatment strategy, progress and evaluation.
There are monthly Pre-Policy or user feedback meetings that provide input to the monthly Policy Meetings. Both meetings provide a communication forum to obtain and address issues that are raised by the young people. This is referred to in more detail in the section on Patient and Public Involvement.
There is evidence that a number of questionnaires and feedback forms are used to gather information from service users. These includes the Emotional Family Support Team's questionnaire, Cedar Court's discharge questionnaires and the collection of feedback on the ‘Seasons for Growth’ pilot initiative, which are described in more detail in the section on Patient and Public Involvement. Documentary evidence was submitted from the community CAMHS business meeting that stated that families were not asked for feedback on their services. There was no further evidence found to determine whether that situation had changed or to determine any action planned to address it. Comments were made during staff interviews that meaningful data was not available about referrals or waiting times as a consequence of a poor IT infrastructure.
Limited evidence was submitted that demonstrated how information gathered about the outcomes of patient care was used to initiate service improvementU2. There are examples of action taken in response to specific requests for such things as equipment from the young people at Cedar Court raised at the Policy Meetings but examples were not located to illustrate improvements to patient care as a result of any information gathered.
A range of information was examined to determine the extent to which information was used to inform quality improvements and a number of examples were identifiedU3. A Bereavement Interest Group is in place that has detailed the services that are available to bereaved children across the two counties. This work was undertaken within the context of the Four Tier System in order to identify gaps in service provision. There was documentary evidence of a CAMHS ‘costed’ plan having been developed in line with the SaFF target for 2003/04 for meeting waiting list targets. There is also documentary evidence that NICE guidelines and the draft National Service Framework (NSF) for Children and Young People had 26 been distributed to staff and had been used to inform the Division's Operational Plan for 2005-2006. There is documentary evidence that a post as a Senior Mental Health Specialist for Looked After Children had been created. This was initiated as a result of national concerns about the unmet health needs of Looked After Children as well as the outcomes of a local audit which reflected this situation, showing that few looked after children accessed the existing CAMHS.
There is documentary evidence of the ‘Where Next’ reports, produced collaboratively between the Trust and Young Minds being used to inform quality improvements. Issues highlighted in these reports include the importance of considering the views of young people and young people requesting more information about their own or their relative’s mental health problems. This has influenced the Trust to include young people within various meeting groups and involve them and their families in the production of information leaflets about the different psychological therapies available at Cedar Court.
Evidence of how information about staffing levels and skills have been used to influence service provision was examinedU4. There is documentary evidence of a specialist CAMHS duty system whereby a member of the team is allocated a ‘duty slot’ for an hour a day. Administrative staff are informed in advance who is on duty throughout each day of the week so that they are able to pass on appropriate information to families or professionals. The person on duty deals with any emergency calls and responds to families or professionals seeking help or advice.
The evidence demonstrates that work undertaken by the Denbighshire community team identified that four extra full time staff are required in order to reduce the waiting times to below 12 months. Even with this enhancement, it was reported that the staffing numbers would still be below those recommended by "Building and Sustaining specialist CAMHS: a consultation paper on workforce, capacity and functions of Tiers 2, 3 and 4 child and adolescent mental health services" issued by the Royal College of Psychiatrists in January 2005. Similar development work has also been undertaken by the Conwy CAMHS team that identifies a requirement for five to six extra full time staff to meet the waiting list target. In addition, this work identifies that when the team was established in 2003 it had a significant proportion of relatively inexperienced staff, who required more intensive supervision. At that time the expertise and capacity was not available to work with the most complex cases and neither was the experience to manage a rapid turnover of cases.
27 Development papers prepared by the two community teams identify that a lack of a senior manager dedicated to CAMHS has resulted in much of the managerial work, such as health and safety and organising clinical supervision and training for all disciplines in the team, being undertaken by the team co-ordinator. This role is taken in turn by a member of each team and has no designated management time or accountability. This situation is reported to have impacted on the amount of clinical work that can be carried out by the senior member of the team currently holding the role. These development plans have fed into the CAMHS ‘costed’ plan for sustainable Tier 2 and 3 services that was submitted to the Welsh Assembly Government in October 2004.
There is interview evidence that states there are so few staff, ‘high risk’ cases have to be prioritised, which militates against the pursuit of specific interests and makes the service feel pressured. In addition, there are no staff available for input into Youth Offending Teams (YOTs) or special schools.
Staffing difficulties at Cedar Court were reported in the documents and at the staff interviews. This evidence stated that the inpatient unit was a high risk area as a result of staffing problems, with three staff nurses on long term sick and one on maternity leave. A key frustration reported was the current inability to meet the needs of more complex and high risk clients who have to transfer out of the area. This is reported as resulting in a loss of continuity of care for both the young person and the families. It is documented that the expansion to the community nursing service has impacted on the ability to recruit and retain staff at Cedar Court. There was interview evidence that confirmed two staff work at Cedar Court during the night, which was reported as ‘feeling unsafe’ on occasions.
The processes for identifying and developing clinical information systems as well as the information available to clinicians was examinedU5, U6. The current situation of multiple incompatible information systems in use across the Trust, described in more detail in the report on adult and elderly mental health services, has the same impact on CAMHS services. There is documentary evidence of a capital bid being submitted for funding of CHAINS, a CAMHS information system developed by one of the consultant psychiatrists based at Cedar Court. This system assists with the administration of CAMHS clinics, including those with attached adolescent inpatient units.
Both the documents and the interview evidence confirms that there was no robust system in place for monitoring such things as waiting list information. As a result it was discovered that two young people had been waiting over 18 months. An additional administration manager has been appointed to support this process. There is interview evidence also, that the lack of any tracking process for 28 particular disorders or numbers with particular diagnoses inhibits data collection for audit.
With regard to staff liaison regarding individual patients and caseloads, the Conwy CAMHS team have established a Case Discussion Form to allow information to be easily recorded and presented to the team following initial assessment, or for review of cases that have been given immediate priority. There is evidence of a ‘hand over’ meeting every morning at Cedar Court that is attended by all available members of the team, to ensure that information about each of the young people in the unit is shared. There is evidence of monthly Journal Clubs that updates each community CAMHS team on new research evidence related to clinical work, reviews any academic or clinical articles and allows team members to feed back on any workshops or study days attended.
Information routinely made available to the Board was examinedU7 but there was little evidence submitted either in documents or during staff interviews on this matter. There is evidence, however, of a presentation to the Board by CAMHS staff being planned for 2005. Amongst the evidence submitted were comments recorded at a CAMHS meeting that this inspection was seen as an opportunity to ensure the Trust were made aware of the strengths and weaknesses of CAMHS.
Details of how information is made available to patients and staff was consideredU8. There is evidence that copies of the minutes of clinical governance meetings are placed on the young people’s noticeboard at Cedar Court. An information booklet about Cedar Court has been developed for parents and young people and a booklet about the function and aims of the school is sent to the family prior to the initial home visit. Information explaining the rules at Cedar Court is provided to the young person prior to admission and information on complaints, advocacy and fire procedures is given to the young person on admission. An information file is located in each of the bedrooms and contains information about rights and expectations, such as details of the complaints procedure and the house rules. A ‘team box’ is available at Cedar Court for documents or information that may be of interest to staff.
There is documentary evidence that both the community teams have information leaflets describing their remit as well as leaflets about how to make a complaint. These are sent out to families when a referral is placed on the waiting list. A range of patient information about particular problems, for example, panic attacks, anxiety, depression and stress are also available.
No evidence was submitted that illustrated how information is quality assured or updatedU9. 29 CAMHS services work within the context of the Trust policy on confidentialityU10 that has been reviewed and updated in January 2005. In addition, there are specific references to confidentiality within the local operational policies for both Cedar Court and the community teams. The safeguarding of information and issues around sharing information are covered in such policy documents. It is documented that the issues and rules on confidentiality and their rights of access to their medical files are discussed with the young person on admission to Cedar Court. There is a clear policy on a young person's access to their treatment files. There is documentary evidence that at Cedar Court, improvements had been made relating to information, consent and confidentiality.
There was evidence from staff interviews that the lack of space and the need to ‘double up’ in offices has an impact on the ability to discuss sensitive issues whilst ensuring confidentiality. This related to both community teams as well as at Cedar Court.
Information was gathered about how the service informs both patients and stakeholders about the services it provides and any changes plannedU11, U12. There is evidence, referred to previously, of a range of information leaflets and packs that are available about the services provided by the community CAMHS teams and Cedar Court.
There is interview evidence that highlights the need to improve joint working and agreeing services priorities with social services and education at a strategic level. There are, however, meetings across North Wales involving all Trusts to discuss the development of the Tier 4 service including the shape of the service to replace Cedar Court. There is a Children’s Partnership and a Young Person’s Partnership in both Conwy and Denbighshire which meet monthly. The documents submitted confirm that these forums are, however, for all children’s issues and it is difficult to ensure that CAMHS has the priority on the agenda that is necessary.
There is evidence of meetings held with schools that were attended by a range of agencies and professions. These provided an opportunity for understanding each other's roles and their input into school, whilst identifying areas of concern and perceived gaps. The meetings also provided an opportunity to discuss new ways of joint working and to share learning.
With regards to sharing learning with other organisationsU13 there is evidence of sessions held as an introduction to specialist CAMHS. Eight sessions are put on every year for staff from other agencies, students and trainees to increase the
30 knowledge of the service, provide an informal opportunity to meet new colleagues, improve the quality of referrals and to establish effective community networks. Presentations have been given by staff to the all Wales Eating Disorders Special Interest Group and the Conwy Social Inclusion Training Day. There is also evidence of staff involvement in an all Wales development forum that is looking at frameworks for nursing across Wales. A number of training events on the mental health needs of ‘Looked After Children’ have been provided by staff from the Emotional Health Service, as well as workshops and displays. Regular input has also been agreed to the Denbighshire National Vocational Qualification (NVQ) Training Programme.
Over the last twelve months one of the staff at Cedar Court has been involved with the University of Bangor in both interviewing candidates for training and in reading Diploma in Social Work Portfolios. A member of staff is the Director of the National Training Team for Dialectic Behavioural Therapy, which involves training 70 professionals over a 10 day period as well as running introductory workshops and consultations with teams. This person also offers supervision and input into DBT programmes running within the women’s prison system.
In summary, there is no Trust wide or CAMHS specific information system which results in a lack of a co-ordinated approach to managing information as well as creating difficulties in respect of monitoring waiting lists. Information gathered about the young person’s experience of using services is specific to individual parts of the service rather than co-ordinated across CAMHS. There are, however examples of actions that have been taken in response to specific requests made by young people. There is little evidence of information being routinely made available to the Trust Board but there was evidence of a range of information available for young people and their families.
Recommendations
• The Trust should ensure that CAMHS are considered as an integral part of developing their IT strategy.
• Staffing levels at Cedar Court should be reviewed to ensure the appropriate staff numbers and skills are in place.
• The service should put processes in place to ensure that the Trust Board receive appropriate and timely information relating to CAMHS, in order that difficulties experienced by the service are understood by the Board.
31 32 4. Processes for Quality Improvement
Healthcare organisations need to understand that the treatments they put in place to care for patients are effective and safe, using the following criteria:
• The organisation should ensure it has a risk management programme that has contributed to clinical quality and continuous improvement (Q1)
• The organisation should ensure it has an up to date patient consent policy, trains staff in the use and audits the use of the policy (Q2)
• The organisation should ensure it has a clinical audit programme that contributes to clinical quality and continuous improvement (Q3)
• The organisation should ensure it has a clinical effectiveness programme that contributes to clinical quality and continuous improvement (Q4)
• The organisation should ensure all incidents are reported, acted on and learned from (Q5)
• The organisation should ensure it captures complaints, compliments and disseminates the lessons learned (Q6)
• The organisation should ensure that it has child protection policies, trains staff and audits their use (Q7)
• The organisation should have processes for sharing learning internally (Q8)
33 The assessment for this domain focuses initially on the risk management programmeQ1. There is evidence that a risk register is in place in CAMHS and that at Cedar Court the risk register has been reviewed. A review of the risk profile at Cedar Court is undertaken regularly at the clinical governance meeting. A risk profile that assessed ligature points at Cedar Court was also submitted to HIW and identified that many had been addressed. It is documented that the Cedar Court Risk Assessment Form is completed for all young people on admission and that a Safety and Security Policy (April 2004) is in place in Cedar Court. The patient safety and risk assessment issues at Cedar Court are confirmed by stakeholder evidence. It is identified that each programme team within the Child and Adolescent Directorate oversees clinical governance activities within their area of service. There is no dedicated clinical governance facilitator within the Family Services Division and it is noted that this will need to be addressed in 2005. One issue raised during staff interviews was staffing levels at night at Cedar Court. The night staffing establishment is recorded as two staff, which it was reported can often feel unsafe. It was commented at the interviews that a bid was being prepared to address this issue. The outcome of this work was not known at the time of the review.
Both CAMHS community teams have a monthly risk management meeting which aims to make the team aware of cases carried by individual team members that present a risk to themselves or others. The meetings also allow discussions about how healthcare professionals are managing the risk. Both community teams each have a Clinical Risk Management File where this information is recorded. The risk register is generated by the team co-ordinator taking into account the risks identified by the team. The risks are then prioritised and assessed using the Trust Risk Category Matrix.
The Trust has a Consent Policy in place that was reviewed in June 2004Q2. CAMHS work within this policy but further evidence relating to specific examples was examined. There is a section within the form for referral to the community CAMHS teams relating to consent which notes whether the young person and their parents or guardians have consented to sharing information with other agencies and the young person’s school. The form also notes what involvement the child has had in discussions and if they are of secondary school age whether they have consented to the referral. As part of the Familiarisation Treatment Strategy at Cedar Court the consent form is discussed with the young person on admission. An Admission Contract is used where the young person and the parent agree to certain rules and give consent for copies to be sent to other
34 professionals. Details are contained within the Research and Development Policy (April 2004) about consent issues. The Policy states that before video or audio recordings are made, informed consent must be obtained in writing from the young person, or their parent or guardian if the young person is a minor. A group video agreement is in place for young people involved in DBT that the young person signs, to agree to group work being video recorded for treatment and supervision purposes. Similarly, milieu therapy and cognitive behavioural therapy (CBT) agreements ensure that the young person understands and agrees to the treatment. There is documentary evidence that Cedar Court achieved an excellent score for consent and confidentiality during its latest QNIC review in February 2004.
There is evidence of a comprehensive clinical audit scheduleQ3 in place for Cedar Court which is linked to monitoring the QNIC standards. The outcomes of these audits are forwarded to Cedar Court's Clinical Governance Group. There is no evidence of instigating audits beyond those required by QNIC to look at local issues, for example examining the effects of recent changes in Cedar Court's opening hours, nor is there is evidence of a planned audit programme in place in the community teams. Interview evidence states that systems are not in place to audit their practice, this was reported as due to capacity difficulties as a result of clinical demand and also lack of an IT infrastructure to provide valid data. Ideas for audits are, however, raised within the joint business meetings and some are undertaken. An example of this is an audit of response times to referral in Denbighshire.
No evidence was submitted to demonstrate that a clinical effectiveness programme is in place specifically for the Conwy and Denbighshire CAMHS teamsQ4. Documentary evidence does, however, state that the routine evaluation of the effectiveness of treatment delivered at Cedar Court is of vital importance. There is evidence that there is an item included in the regular monthly clinical governance meeting for Cedar Court to discuss documents or reports that have been reviewed and discuss the implications for the service.
There is evidence that a Trust-wide incident reporting policy is in placeQ5. The completion of incident report forms and serious clinical incidents was included on the agenda for each CAMHS business meeting and Cedar Court's clinical governance meetings. There is both documentary and interview evidence that a review process is in place for investigating all serious and untoward incidents. Examples of incidents were submitted which outlined the incident, the immediate action taken as well as any longer term action that needed to happen.
35 Incident reports for a range of safety issues for both patients and staff are submitted, for example, after the use of restraint on a patient, verbal or physical aggression against staff and cases of self harm if a patient is on a waiting list. There is documentary evidence that all ‘red’ incident reports are submitted to the Trust's Risk Committee. If an incident occurs relating to child protection issues, then the incident is also reported to the Trust Child Protection Committee. Incidents related to child protection are co-ordinated across North Wales by the Designated Doctor in the National Public Health Service (NPHS). It is documented that following any serious incident there is a debriefing meeting which is attended by the members of staff involved in the incident together with at least one of the Case Managers and where appropriate, a representative from the school.
There is evidence to confirm that families are made aware of the Trust Complaints Procedure (January 2004) when a referral is placed on the waiting listQ6. Information leaflets about how to make a complaint are available in the reception areas of all CAMHS services and on request. There is evidence that the service has recognised that young people may find it difficult at times to make complaints and so ‘child friendly’ information on how to make a complaint has been developed and is given to the young people. Information is displayed about the independent advocacy service, the National Youth Advocacy Service. Information for the Division is produced quarterly, identifying the number of complaints and compliments received, but this information is not available specifically for CAMHS. Complaints are regularly discussed in Cedar Court clinical governance meetings. The main issues identified appear to be difficulties with transport arrangements and an problem following up a complaint from a patient about the quality of their out of area placement. CAMHS does, however, have a representative on the Trust Complaints Committee.
There is documentary evidence that the Trust has an up to date Child Protection Policy (December 2003) in placeQ7. There is also a Trust-wide Policy on the Care of Children Admitted to Wards Outside Specific Paediatric Areas (March 2004) and there has been development work on a care pathway for CAMHS admissions to the adult inpatient mental health unit. The Trust has a clear structure in place for managing child protection issues which sits firmly within the clinical governance responsibilities of the Director of Nursing who has the executive lead role. There is a Non Executive Director with responsibility for children's issues.
In order to ensure specialist CAMHS staff follow the child protection procedure, mandatory training events, regular supervision of staff in relation to child protection issues, case consultation and an audit of staff’s knowledge all take
36 place. In addition, child protection is a standing agenda item on the Tier 3 CAMHS business meetings. Both community CAMHS teams have representatives on their local Area Child Protection Committees, which allows them to keep up with and contribute to developments within child protection, to make links with other agencies and to contribute to any Part 8 enquiries. It was reported at one of the CAMHS teams joint meetings that not all of the staff who may have been employed in the longer term will necessarily have had CRB checks completed. It was agreed that CRB checking for all staff in contact with children would be undertaken.
There is evidence of a Child Protection Induction Pack that has been developed at Cedar Court. This pack is made available to all new members of staff and professional trainees. There is a rolling programme of Level 1 child protection training within the Trust that is attended by all new staff. There is additional in-service training that is planned alongside the induction training. Those staff working with children and families will be required to undertake Level 2 child protection training provided by the Trust. Staff requiring Level 3 training must first attend Level 2 training on appointment to their post. It is the responsibility of the individual member of staff to identify if they require Level 3 training at their Personal Review. Staff requiring Level 4 training need to access it externally to the Trust. There is evidence that at Cedar Court the Child Protection Policy and the process of Child Protection Induction Training are audited regularly with good results. There is stakeholder evidence that confirms that Cedar Court takes Child Protection standards very seriously and that staff attend the appropriate training. It was felt that robust systems were evident both in the Trust and specifically within CAMHS.
Evidence of sharing learning internally was examinedQ8. There is documentary evidence of a monthly journal club within CAMHS. The purpose of this club is to update colleagues on new research evidence relating to clinical work, to review any relevant articles and to allow team members to feedback on any workshops or study days attended. Links have been established between CAMHS and the paediatric wards at Glan Clwyd Hospital and a programme has been introduced for qualified paediatric nurses and support workers. This includes teaching on the nature of adolescence, mental health disorders in adolescence, an overview of CAMHS and referral pathways for self-harm, suicide and eating disorders. Teaching sessions are also held for Accident and Emergency (A&E) doctors on CAMHS and includes particular suicidal and para-suicidal behaviours. This focuses on providing advice and information on assessment and management and referral pathways. 37 Support and training is provided by one of the CAMHS consultant psychiatrists to adult community mental health teams in order to support them in their work with older adolescents. A training and support role is provided to primary care professionals and carers by the Emotional Health Service to Looked After Children. This aims to increase the level of understanding of children's mental health issues to enable the recognition and management of mental health problems at an early stage. In addition, both community teams offer teaching sessions or workshops on mental health problems to a wide variety of professionals.
In summary, there is evidence of a risk management programme in place across CAMHS together with monthly risk management and clinical governance meetings. There is recognition within the Division that the clinical governance process could be strengthened by the appointment of a clinical governance facilitator. A clinical audit schedule is in place at Cedar Court but there is no such programme planned for the community teams and neither is there evidence of a clinical effectiveness programme for CAMHS. Policies on incident reporting, child protection and patient consent are in place and have been reviewed.
Recommendations
• The Division should consider how clinical governance can be better facilitated.
• The inpatient service should examine its clinical audit schedule to ensure that audits of significant issues that fall outside the requirements of QNIC are prioritised and undertaken.
• CAMHS community services should to develop a clinical audit programme.
• The CAMHS service should develop and implement a clinical effectiveness programme.
• The Directorate should review staffing levels and establishments at Cedar Court to ensure the effective management of risk.
38 5. Staff Focus
The following criteria were reviewed as part of HIW’s assessment:
• The organisation should have processes in place to enable staff to have continuing personal and professional development (S1)
• The organisation should have processes in place to monitor the performance of all staff (S2)
• The organisation should encourage and enable staff to improve the services they deliver (S3)
• The organisation should seek and use the views and opinions of staff (S4)
• The organisation should ensure the education and training of staff is planned, evaluated and supports clinical strategies (S5)
• The organisation should undertake suitable initiatives to improve communication and evaluate the initiatives (S6)
• The organisation should ensure it has processes to use the correct skill mix and staffing levels (S7)
• The organisation should ensure staff attendance at mandatory training (S8)
• The organisation should ensure it maintains links with external training bodies (S9)
• The organisation should ensure it has appropriate induction arrangements for all staff (S10)
• The organisation should have processes to enable effective teamwork and evaluate its progress (S11)
• What are the staff based indicator outcomes? (S12)
39 Documentary and interview evidence demonstrates that the service supports staff in their Continued Professional Development (CPD) as well as in meeting their broader training and development needsS1. Seven of the CAMHS team members have extended their skills in DBT in order to provide a comprehensive service to young people with a borderline personality disorder and who deliberately self-harm. There is evidence of two staff training days being held at Cedar Court to update the team on the key models of care used at the Unit. There is also evidence that the staff participated in a wide range of workshops and courses. Teaching and nursing staff at the Unit have completed training in Creative Therapies, with two of the nursing staff having completed an introductory course. One nurse has completed a Foundation Course in Family Therapy and another is currently training in Advanced Group Psychotherapy. There is documentary evidence that 75% of the nursing team at the Unit have dual qualifications of Registered Mental Health Nurse and Child and Adolescent Mental Health Training. In addition three members of staff have attended a three-day training course on Eating Disorders.
There is evidence that teaching staff at Cedar Court value their CPD and devotes personal time to their improvement. In addition to the routine in-service training opportunities all teaching staff have undertaken extended studies. Training attendance records were submitted for a number of staff that identified a range of courses and training activities that individual staff members had attended. There is staff interview evidence that confirms a range of training opportunities that are usually funded are available to staff.
Evidence was examined to determine the extent to which there are processes in place for managing the performance of staffS2, S12. There is documentary evidence that all staff are required to participate in annual Personal Development Reviews (PDRs). There is also evidence that the performance management process has also been undertaken by the teaching staff at Cedar Court. Staff reported at the interviews that there are robust processes for PDRs, clinical supervision and mandatory training in place, that apply equally to both clinical and non-clinical staff. It was reported that due to the different line management arrangements that are in place for the different professions in CAMHS, team co-ordinator posts have been created to draw together the multi-disciplinary team and co-ordinate clinical supervision from within the team. There is documentary evidence that all students having placements at Cedar Court are attached to a named professional appropriate to their particular discipline. Students are only accepted following a pre-placement meeting to assess their ability. Whilst on placement all students
40 receive regular supervision. On appointment to Cedar Court, new staff are given details of the probationary period, its purpose, a date for review and any details of induction or training. At this time the documentary evidence states that supervision should be more frequent and dates should be set to review performance. At performance reviews the appropriate level of child protection training for the individual staff member is identified. There is evidence that training attendance records are in place for CAMHS staff on which both mandatory and developmental training is recorded.
There are a number of examples where initiatives have been supported and implemented that have enabled staff to improve the services they deliverS3. Staff within the community teams are encouraged to monitor their caseload and case-mix regularly regarding the level of complexity to ensure that the workload remains manageable. There is also a process in place where staff co-work on difficult cases in order to reduce stress, increase skills and improve the clinical outcome.
At Cedar Court a set of house rules are in place which the young people read before signing their attendance contract. Advice is contained within the house rules about how to make best use of time in Cedar Court by participating in treatment and community meetings and talking to staff. It was reported that an in-service training day had been held for staff on domestic violence that was presented by Colwyn Bay Women’s Aid. There is interview evidence that states a process is developing to gather young people’s views about the planned new unit.
There is both documentary and interview evidence to demonstrate that staff receive regular supervision and have access to a staff support system. There is an ongoing research project in clinical supervision and nursing staff receive weekly supervision.
Information about how the views and opinions of staff are sought was examinedS4, however, neither results nor action plans following staff surveys were submitted as evidence. There was evidence that the Chief Executive visited Cedar Court to consult with the team to determine their service requirements and their vision for the future delivery of Tier 4 inpatient care within the objectives of the CAMHS Strategic Outline Case (SOC) plan. It was reported at interview that staff at Cedar Court feel they are kept up to date on what is happening. Concerns have been raised by staff about how they would fit into a new unit but they have been reassured that the new service will continue milieu work as well as additional acute work.
41 With regards to the planning and evaluation of staff trainingS5, S8, a training plan is in place for CAMHS nursing staff. This identifies need, proposed solution, benefits to the service, priority, cost and evaluation methods. Areas included are mandatory training, IT training, managerial skills and mental health practice skills such as Cognitive Behavioural Therapy (CBT). The Trust’s Child Protection Committee has a Training Sub-Group in place. This Group devised a Trust wide Child Protection Training Strategy (December 2003) and takes the lead in this specialist area of training. The purpose of the Strategy is to produce competent and confident staff who are able to recognise a child in need or one in need of protection and to know where to get advice and how to refer to the appropriate agency.
A standard evaluation form was submitted that is used to review training sessions provided for other agencies. Participants can include comments on whether the session was informative, raised awareness and whether further information or sessions were required. There is evidence from the documents and the interviews that overall, excellent training opportunities were available and accessible to the whole team at Cedar Court. Some deficits in training were, however, identified in relation to training in new pharmacological interventions, training on managing the issue of touching and the problem of sexual attraction between staff and young people and training in equality issues and responses to special needs.
Information about courses and other educational opportunities are either placed in the ‘Team Box’ at Cedar Court, which is kept in the consultant’s office and looked at during the weekly staff meeting or displayed on the nurses' noticeboard. A local training plan is in place for administrative staff. There is stakeholder evidence that states careful attention is paid to the needs of the young people and as a result it was decided that further training was required in de-escalation and restrictive physical intervention. It supports the notion that the safety of patients and staff is taken very seriously. Training and education opportunities are also considered within the section on Processes for Quality Improvement.
In respect of staff communication issuesS6, Cedar Court has staff newsletters, which include information on staff changes and achievements, policy updates, meetings, occupational health and human resource issues as well as training and events planned. There is, however, stakeholder evidence that states that Conwy and Denbighshire CAMHS staff working within other organisations have commented about not being kept up to date with relevant developments in the past. This has to a large extent been addressed through the establishment of
42 more robust communication routes such as attendance on programme teams and strategy groups.
The need to ensure that sufficient staff are in place is highlighted within the CAMHS risk registerS7. It states that all evidence of staff shortages and the effect of them need to be recorded. It highlights the need for staff to monitor their caseload mix regarding complexity and to ensure that workload does not increase the risk of staff ‘burnout’. Staff are also encouraged to seek support from occupational health if they are suffering stress.
There is evidence that a team member in each of the community CAMHS team take on the role of team co-ordinator. This role has been rotated annually within the team, but the current co-ordinators have been in this role for two year. The co-ordinators are responsible for the operational management of the teams and ensuring a high standard of service provision. They represent the teams at the appropriate level of management in the Trust and keep the team informed of relevant developments in the organisation and wider in the field of CAMHS. There is both interview and documentary evidence of the need to review the management structure for CAMHS services and consider the need for a designated management post. The evidence states that in the absence of such a role a significant amount of the managerial work falls upon the team co-ordinator, which has a major impact on the amount of clinical work that can be carried out by this senior member of the team.
There is evidence of a shortage of primary mental health workers in Conwy, compared with Denbighshire and the young people’s health advisors in Conwy have higher caseloads compared to their colleagues in Denbighshire. There appears to be a relative lack of therapeutic options available to the Conwy CAMHS team, that has in some cases reduced the effectiveness of interventions and sometimes increased the length of time that cases are seen.
There is documentary evidence that the expansion of the community CAMHS service had an impact on the capacity of Cedar Court to recruit and retain experienced staff who naturally wanted to seek development opportunities. This had a major impact on the staffing levels within the inpatient unit. The number of residential places available at Cedar Court had to be reduced to 10 and at one point the Unit had to cease as an inpatient service and offer only day services. This has been resolved in part, as new staff have been recruited and the Unit currently provides a five-day per week inpatient service. However should a young person require a 7 day per week service they would transfer to an adult
43 environment over the weekend with support from specialist nursing staff. There is evidence, however, that a consequence of this situation is a greatly increased number of severely ill or high risk young people being referred to out of area psychiatric inpatient placements.
Links with external training bodies were examined in the reviewS9. There is documentary evidence that CAMHS offers training, education and consultation with other professionals within the health service, other statutory agencies, education and voluntary agencies. Teaching sessions are provided for the pre-registration nurses in the mental health and child branches of nurse training courses. These are held within the relevant education settings. Teaching sessions are provided for registered nurses undergoing post registration courses, requiring knowledge of CAMHS issues. There is evidence that three staff at Cedar Court have enrolled on an NVQ Level 3 Teaching Assistant Course and the courses leading to Council for Awards in Children’s Care and Education (CACHE) qualifications.
Senior House Officers (SHOs) undergoing training in general psychiatry rotate at six monthly intervals to CAMHS for experience at both Cedar Court and the community teams. Whilst on placement they receive weekly supervision and teaching sessions with the Consultant Psychiatrist. However in February 2004 the SHO at Cedar Court was placed on the adult mental health on call rota at the Ablett Unit resulting in frequent irregular absence from CAMHS. In August 2004 the adult on call rota converted to a shift system, reducing attendance further. This has led to a consequent significant reduction in opportunity for the SHO to receive training and gain experience in working in CAMHS.
The CAMHS service provides placements for ‘Project 2000’ nursing students. CAMHS staff also provide teaching input during the Child Health and Mental Health branches of training at both Wrexham and Bangor Schools of Nursing. Trainees from the Clinical Psychology Doctoral Course at Bangor University regularly spend time in the CAMHS service ‘attached’ to the Clinical Psychologists working within the service. Medical students from Liverpool and Cardiff Universities attend a teaching session with the CAMHS Consultant Psychiatrist during their paediatric attachment at Glan Clwyd Hospital. Social work placements are available for social work students predominantly linked to the Child Therapist and Social Worker.
An induction pack is in place within all CAMHS servicesS10. All newly appointed staff participate in the Trust’s Corporate Induction Programme. There is a rolling
44 programme of induction with new members of staff attending within a month of their commencement. On appointment, staff are also required to participate in the Directorate's local induction programme, which is service specific and is run over a two week period. In Cedar Court new staff have a preceptorship/induction handbook which takes between 6 months to a year to complete. This is then used as evidence of the staff members’ development and forms part of their professional portfolio.
There is interview and documentary evidence that the staff working within CAMHS services are dedicated and experienced and have good team relationshipsS11. Staff demonstrated that they were very appreciative of the other staff with whom they work. Staff morale was high and they stated that this was largely due to the fact they felt listened to despite the services being ‘over stretched’. They did state, however, that specialist, dedicated strategic and operational management would make a big difference. There was interview evidence that an effective multi-disciplinary team was in place. It was suggested that due to the inadequacy of the building at Cedar Court, conditions were very cramped, but this had helped in promoting team work and in establishing a friendly, homely atmosphere. Staff working at the school, attend community team and ‘handover’ meetings and reported feeling valued as part of the multi-disciplinary team as well as the management team.
The Conwy CAMHS team is new and is developing relationships with other agencies. Relationships are reported to be good between the two community teams but they do have different developmental agendas as a result of the difference in the length of time they have been operating. There is evidence of the community teams sharing information and good practice initiatives. One example of this is the work that has been undertaken around the development of supervision standards.
There is stakeholder evidence that the Tier 4 team at Cedar Court works well with the Tier 3 community teams. It is suggested that this could be attributed to the fact that the Consultant Psychiatrists hold responsibilities with both teams and that several of the nursing staff have worked in both settings.
In summary, there is evidence that staff working within CAMHS are dedicated and experienced. Staff morale is reported as high despite the service being overstretched. This may be partly attributed to the fact staff said they feel listened to. A need for dedicated, specialist strategic and operational management structures has however, been highlighted. There are robust induction
45 arrangements in place for all new staff and staff are supported in their CPD. Performance reviews are undertaken and staff receive clinical supervision. A training plan is in place and staff receive mandatory training. Feedback is sought from staff via surveys but there is no evidence of any action taken as a result.
Recommendations
• The Trust should review the existing management structure for CAMHS to ensure appropriate arrangements are in place.
• The Trust should ensure the outcomes of staff surveys are ‘actioned’.
46 6. Leadership, Strategy and Planning
As part of HIW's assessment of the approach to leadership, strategy and planning in the development of the Trust’s services, the following criteria were reviewed and evaluated:
• There should be clear accountability and responsibility for the quality of clinical care (L1)
• The Board should have processes to be assured of sound governance and assured of the delivery of the duty of quality (L2)
• The organisation should contribute to the development of clinical governance within relevant clinical networks; to all domains (L3)
• The Board should ensure the knowledge gained as a result of governance activities influences service and business planning; and vice versa (L4)
• The organisation should have changed services as a result of patient feedback and other outcomes of clinical governance activity (L5)
• The organisation should use appropriate methods to gain user and public opinion when planning services (L6)
• The organisation should use public opinion to influence service planning (L7)
• The organisation should have a process for prioritising service improvements and monitoring their implementation (L8)
• The organisation should develop its leaders and evaluate the initiatives taken to do this (L9)
• The organisation should use appropriate methods to ensure the clinical governance strategy is continually up to date and fit for purpose (L10)
47 The accountability and responsibility for the quality of clinical care was examinedL1. There is evidence from the interviews that there is much respect for the General Manager of Family Services of which CAMHS is a part. It is recognised that the individual is very experienced but as her role is stretched across all family services it is believed that her task is too great. Staff reported that they were very aware of her workload and as such felt unable to ‘push’ for their issues to be resolved. When interviewed a wide range of staff voiced opinions that a service manager exclusive to CAMHS would provide a greater opportunity to understand and better represent the views of the service. There is a belief that the management infrastructure has not kept in pace with service developments and that there is a general lack of acknowledgement of the complexity of the service. It was expressed during the interviews that it was often difficult to understand where decision making takes place in the service and how any decisions made feed into the broader Trust systems.
There is documentary evidence that components of clinical governance were being addressed in the CAMHS monthly joint business meeting and a clinical governance activity schedule had been developed. There is evidence that clinical governance meetings are held at Cedar Court and that they were held weekly between June and December 2004 but there is only evidence of one having been held since then in February 2005. Details of the standards that have been and are due to be audited as well as the outcomes of audits are discussed in theses meetings. It was reported that CAMHS clinical governance activity is currently embryonic given the appointment of new clinical staff.
There was little evidence submitted to demonstrate how the Board was assured of sound governance specifically within the speciality of CAMHSL2, L4. It was reported in a CAMHS business meeting that it was agreed that an annual report for the Conwy and Denbighshire CAMHS teams should not be produced as they were unclear what the requirement is for such a document and for whom it should be written. It was also reported that both teams felt the inspection visit was an opportunity for the Trust to be made aware of CAMHS current strengths and weaknesses.
There was interview evidence suggesting that the Trust Board were now aware of specific issues in relation to the management of waiting lists in CAMHS but that there was still some naivety about capacity issues, the level of unmet need and the complexity of the multi-disciplinary clinical work. It was felt that Trust management is orientated around acute services and as a result they were not fully aware of the issues around CAMHS. It was said to be difficult to
48 communicate the unique responsibilities that come with CAMHS and the need to treat the child in the context of their families and social networks that are often dysfunctional. It was felt, however, by the staff interviewed that there has been support from the Trust Board. It was stated that the Chief Executive is actively involved in CAMHS services and is very interested in discussing and learning about the problems faced by the service and understanding its unique perspective. It was felt that this willingness was very heartening.
Evidence was submitted that demonstrates that CAMHS staff participated in the All Wales CAMHS Primary Mental Health Forum, where topics discussed included developments and training offered in participant areas as well as support and researchL3. CAMHS staff have also delivered presentations to the Paediatric clinical governance meeting as well as to the clinical governance day held by the Trust. There is interview evidence that the commissioners have developed a group to explore the development of clinical networks for CAMHS across North Wales.
Documentary evidence was submitted of actions that were identified as a result of having undertaken clinical governance activitiesL5. For example following the use of the Commission for Health Improvement (CHI) child protection self-assessment tool, child protection issues were incorporated into the induction programme and supervision sessions were planned for staff. Child protection issues are being taken account of as part of planning the replacement for Cedar Court.
There is evidence also that a business case was developed for the extension of the role of the Liaison Nurse having determined the demand for the service at weekends. In addition the number of Primary Mental Health Workers has been increased.
There is documentary evidence of feedback and requests made by the young people at the Policy Meeting at Cedar Court that have had an impact on the way the service is providedL6, L7. These are referred to in more detail in the section on Patient and Public Involvement. Examples include the development of an evening agenda of planned activities and the purchase of additional games. There is also evidence of the Trust having been acknowledged in ‘Patient Centred Care - Improving Patient Experience’ magazine for having designated forums for gaining the views of children and young people and for developing specialist posts to address the needs of socially excluded children, for example the Nurse Consultant. There is interview evidence that demonstrates there is a process in place to gather the views of young people about the development of the new Tier 4 Unit.
49 No evidence was submitted to demonstrate that the service or Division had a Patient and Public Involvement Strategy or Plan in place.
There is documentary evidence of discussions held at the CAMHS business meeting about the identification of priorities for the development of Cedar Court and emergency capacity at Tier 3L8. There is also evidence that a CAMHS ‘costed plan’ has been developed that set out a way forward for delivering sustainable Tier 2/3 CAMHS. A monthly management meeting is held where service development issues are discussed. Within the Child and Adolescent Directorate's Operational Plan for 2005-2006 the key objectives for CAMHS are included. The top three objectives are identified as increasing the capacity of Tier 2/3 services linked to the ‘costed plan’, to improve accommodation for CAMHS for both Conwy and Denbighshire and to improve the infrastructure support, for example, dedicated management time, additional administrative staff and improved IT. There is documentary evidence that both Conwy and Denbighshire CAMHS have away days at least once a year. These days provide the teams with time to review the team’s developments and plan for future clinical developments and workforce planning. Cedar Court also have a Management Team Away Day where current policies and procedures are discussed and reviewed.
There is interview evidence that rapid service development has taken place in the absence of an agreed service and estates strategy. It was reported that the Trust has been active in attracting senior clinicians and are supportive in developing the service, however the management structure does need to be reviewed to ensure it offers support to these increased services whilst also facilitating development of an overarching CAMHS strategy. It is recognised that it would be difficult to develop such a strategy in the absence of a co-ordinated commissioning structure and process led by the organisations responsible for commissioning all tiers of CAMHS.
There is interview evidence of a Children’s Partnership and a Young Person’s Partnership for both Conwy and Denbighshire that meet monthly. These forums are for all children’s issues and it is difficult for CAMHS to attain the priority on the agenda that is required. It has been proposed that a co-ordinated group is needed to look at CAMHS across Conwy and Denbighshire collectively. There is evidence that North Wales meetings, involving all the Trusts, are held to discuss Tier 4 provision, including the shape of the service to replace Cedar Court. Beyond this HIW has seen no evidence of regular engagement by the service with its commissioners to discuss Tier 2 and 3 services.
50 There was no evidence submitted that demonstrates any initiatives undertaken to promote the development and evaluation of leadershipL9. Neither was evidence provided to demonstrate an up to date clinical governance strategy for CAMHSL10. Clinical governance structures were being reviewed across CAMHS but there was evidence that structures and processes needed to be strengthened.
In summary, management and leadership capacity is low within CAMHS and there is a need to review the management arrangements including clinical leadership. It is unlikely that the current management capacity is sufficient to meet the rapid development needed to plan for effective services at all CAMHS tiers which are integrated with other agencies working with children. There is a need to agree a multi-agency plan in line with the newly established partnership boards, as well as a need to develop a comprehensive over-arching strategy for CAMHS.
Recommendations
• The organisations responsible for commissioning all tiers of CAMHS need to undertake a ‘root and branch’ review of how young people’s mental health needs are addressed.
• The Trust should undertake a review of the management arrangements in place for CAMHS to ensure the service has the capacity to facilitate strategic development and provide a clinical service.
• The Trust should incorporate the outcome of the ‘root and branch’ review with other plans in existence, such as the CAMHS ‘costed plan’ and the reprovision for Cedar Court proposals (SOC), in order to develop a comprehensive, overarching strategy for CAMHS.
51 52 ANNEX 1
Summary of Recommendations
The Patients’ Experience – Domain 1
Rec No Recommendation Page
1. The Trust should work with HCW to agree an effective 18 process for repatriating young people from out of area placements. 2. The Trust should work with HCW to ensure that the 18 quality of care provided at out of area placements is of an acceptable standard and is monitored on an ongoing basis. 3. The Directorate should review the arrangements for 18 providing food at Cedar Court and ensure that a healthy diet is provided for the young people. 4. The availability of space at the community team bases 18 should be reviewed.
5. The referral process to Tier 4 services should reviewed to 18 ensure the most effective systems are in place, given the limited resources available.
Patient and Public Involvement – Domain 2
Rec No Recommendation Page
6. The service should ensure that issues raised at the ‘Young 24 People’s Management Group’ are listened to, explored and feedback provided as to any action taken. Where action is not possible in response to an issue, this too should be explained. 7. The Directorate should ensure the views of patients and 24 carers on all aspects of services provided are collected and influence service and policy developments. 8. The Trust should explore all opportunities for improving 24 the physical environment within which CAMHS operates in the short term and ensure that opportunities for greater integration of teams are considered as part of the reprovision of Cedar Court. 9. The Trust should encourage the involvement of young 24 people with mental health problems in the ‘Young Person’s Forum’. 10. The Trust should develop a PPI strategy for CAMHS in 24 partnership with key stakeholders.
53 Use of Information - Domain 3
Rec No Recommendation Page
11. The Trust should ensure that CAMHS are considered as an 31 integral part of developing their IT strategy. 12. Staffing levels at Cedar Court should be reviewed to 31 ensure the appropriate staff numbers and skills are in place. 13. The service should put processes in place to ensure that 31 the Trust Board receive appropriate and timely information relating to CAMHS, in order that difficulties experienced by the service are understood by the Board.
Processes for Quality Improvement – Domain 4
Rec No Recommendation Page
14. The Division should consider how clinical governance can 38 be better facilitated. 15. The inpatient service should examine its clinical audit 38 schedule to ensure that audits of significant issues that fall outside the requirements of QNIC are prioritised and undertaken. 16. CAMHS community services should to develop a clinical 38 audit programme. 17. The CAMHS service should develop and implement a 38 clinical effectiveness programme. 18. The Directorate should review staffing levels and 38 establishments at Cedar Court to ensure the effective management of risk.
Staff Focus – Domain 5
Rec No Recommendation Page
19. The Trust should review the existing management 46 structure for CAMHS to ensure appropriate arrangements are in place. 20. The Trust should ensure the outcomes of staff surveys 46 are ‘actioned’.
54 Leadership, Strategy and Planning – Domain 6
Rec No Recommendation Page
21. The organisations responsible for commissioning all tiers 51 of CAMHS need to undertake a ‘root and branch’ review of how young people’s mental health needs are addressed. 22. The Trust should undertake a review of the management 51 arrangements in place for CAMHS to ensure the service has the capacity to facilitate strategic development and provide a clinical service. 23. The Trust should incorporate the outcome of the ‘root 51 and branch’ review with other plans in existence, such as the CAMHS ‘costed plan’ and the reprovision for Cedar Court proposals (SOC), in order to develop a comprehensive, overarching strategy for CAMHS.
55 56 ANNEX 2
Postscript
The Child and Adolescent Mental Health Service (CAMHS) in Conwy & Denbighshire is a constantly evolving service growing and adapting to meet the needs of the population it serves. Since the HIW Inspection a number of changes have taken place to continue this process.
Clinical Governance planning:
Recognising that the implementation of Clinical Governance is an ongoing process due to new staff appointments, Tier 3 specialist CAMHS have designed a local template of Clinical Governance compliance and have set an agenda of Clinical Governance development for the year ahead. Tier 4 CAMHS at Cedar Court have had formal mechanisms of clinical governance for many years and are linked into the above process.
CAMHS/Adult Interface and services for transition age group (young people aged 16 and 17 years):
In accordance with the Welsh Health Circular relating to the transitional age group (WHC (2002) 125), a cross-divisional CAMHS/Adult Mental Health working group chaired by a CAMHS consultant psychiatrist and consultant nurse has been formed. This group is developing a strategy to bridge the current gaps in service for 16 and 17 year olds and devise an interim solution to the resource issues in this area. The group intends the strategy to describe a future where funding is identified to provide an age appropriate service to all 16 and 17 year olds as part of a comprehensive CAMHS service. In the interim CAMHS and Adult Mental Health services will work jointly to endeavour to meet the needs of this age group.
Information on performance management and clinical effectiveness at Tier 3 CAMHS:
Significant steps have been taken over the past year to improve the performance management and clinical effectiveness information produced by Tier 3 CAMHS such as waiting list management systems, development of supervision policy, review of outcome measures and the introduction of Children’s Global Assessment Scale (Shaffer et al, 1983).
57 Information on performance management and clinical effectiveness at Cedar Court, Tier 4 CAMHS:
The year 2003/2004 was a difficult year due to severe staff shortages and consequent bed closures resulting in a reduction in clinical effectiveness. In 2004/2005 there was an increase in number of cases admitted to Cedar Court and a decrease in average length of stay. Clinical effectiveness improved in 2004/2005 as evidenced by the outcome measures available in the 2004/2005 Cedar Court Annual Report published shortly after the Inspection visit.
Tier 4 CAMHS: Cedar Court Feedback
The feedback from the ‘Young Person’s Management Group’ now has a high priority on the Cedar Court Management Meeting agenda. This is to ensure that young people receive more timely feedback from management on their requests/issues.
Feedback questionnaires are sent separately to both young people and their parents/carers. A consultation process was set up in late Spring 2005 to seek the views of young people on other aspects of Cedar Court including environment and quality of care and is progressing well. This is part of the Patient and Public Involvement contribution to the plans for re-provision of Cedar Court.
Tier 3 CAMHS: Conwy team
In order to ensure optimum management of high-risk cases and allow the team to be kept continually informed, the Conwy CAMHS team has developed a process of discussing these cases weekly at the case discussion meeting, and recording appropriate information in the case file.
Performance Management – Tier 3 (Conwy and Denbighshire Waiting Lists)
Significant work has been undertaken by the Divisional Management Team working jointly with the Tier 3 CAMHS teams to address and manage the CAMHS waiting lists. Acute based performance management skills and Guide to Good Practice recommendations have been adapted and applied within both the CAMHS Teams. By adapting these methods and principles of waiting list management both teams are working towards achieving the SaFF target of 12 months by 31 March 2006. An increase in workforce capacity in the Lawnside Team has also benefited this process.
58 Conwy CAMHS Accommodation/Clinic Access
This is currently under review by the Divisional Management Team, working jointly with the CAMHS teams.
Reprovision of Tier 4 services
A multi-agency group chaired by Health Commission Wales (HCW) has developed a proposal to Strategic Outline Case (SOC) stage. Despite leading this process HCW has raised concerns over the affordability of the proposals in the SOC. The Trust has sought urgent clarification from HCW as to the level of service they wish the Trust to provide, and is awaiting a response. The delay in agreeing the business case is a significant cause for concern given that the lease for Cedar Court expires in 2008.
Information Systems
The Management Team is working jointly with the IM&T Department to install the Trust’s Patient Administration System (PAS) in the community bases (Lawnside and Argyll Road). The process has been mapped with the CAMHS Tier 3 Services and IM&T staff. Installation of the PAS information system will provide the CAMHS Service with a stable information system, improve the current administration process, and will greatly assist in the monitoring and management of the CAMHS Tier 3 waiting lists.
59 60 ANNEX 3
Healthcare Inspectorate Wales
Healthcare Inspectorate Wales (HIW) was established on 1 April 2004 by the National Assembly for Wales to discharge the responsibilities specified for the Assembly in the Health and Social care (Community Health and Standards) Act 2003. HIW has been established as a Unit within the Assembly with a formal independence provided through delegations made under the 2003 Act to the Chief Executive of HIW.
HIW’s core responsibility is to undertake reviews and investigations into the provision of NHS funded care either by or for Welsh NHS organisations in order to provide independent assurance about and to support the continuous improvement in the quality and safety of Welsh NHS funded care. In doing so, HIW must play particular regard to:
• the availability of and access to healthcare;
• the quality and effectiveness of healthcare;
• the management of healthcare and the economy and efficiency of its provision;
• the information provided to the public and patients about healthcare; and
• the rights and welfare of children.
The frameworks of Clinical Governance and Healthcare Standards set by the Welsh Assembly Government are central to the way in which HIW assesses Welsh NHS organisations and Welsh NHS funded care.
In this respect, HIW is committed to:
• strengthening the voice of patients and the public in the way health services are reviewed;
• working with others to improve services across sectors and agencies;
• working with other regulators/inspectorates to ensure that the public, NHS organisations and the Assembly receive useful, accessible and relevant information about the quality and safety of Welsh NHS funded care and;
• developing more effective and co-ordinated approaches to the review and regulation of the NHS in Wales.
61 62 ANNEX 4
Glossary of Terms
A&E Accident and Emergency.
Accountability Liability to answer for conduct/performance.
Action plan A timetable of agreed tasks designed to address a specific set of problems; in the context of an inspection, designed to respond to its recommendations.
Adverse Incident Any event or circumstances arising during NHS care that could have or did lead to unintended or unexpected harm, loss or damage.
Advocacy The process of supporting and enabling people to express their views and concerns; access information and services; defend and promote their rights; and, explore choices and options. Advocates support and argue the case for service users and help them put across their point of view.
Appraisal (of staff) An assessment of the extent to which a person's performance meets the standards or objectives required of her/his post.
Audit Originally applied to assessment of the accuracy and probity of financial accounting; now extended to cover any assessment activity which sets out to assess the extent to which a product/outcome matches the criteria set.
Benchmarking Comparison of practice or performance with that of others, with the purpose of identifying and emulating best practice.
Care pathway A defined set of treatment and care steps designed to meet the particular need of each patient.
Carers People who look after their relatives and friends for no pay, often in place of a nurse.
Caseload The group of patients managed by an individual health care professional.
Case mix The mixture of clinical conditions - and severity of condition - found in a particular healthcare setting or in the caseload of a health care professional.
Clinical audit Evaluation and measurement by health professionals of how far they are meeting standards that have been set for their service. Standards may be set by health professionals themselves or others.
63 Clinical director The clinician who is accountable for clinical and sometimes management elements of service delivery.
Clinical effectiveness The degree to which a treatment achieves the health improvement for a patient that it is designed to achieve.
Clinical governance A “framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish” (Welsh Office: ‘Quality Care and Clinical excellence’).
Clinical incident An event which occurs in a hospital or in community health services from which actual or potential harm may have been experienced by patients or the public.
Clinical Information (1) information about treatments given to a patient by a health professional. (2) information about clinical practice collected by an organisation for management purposes
Clinical outcome The impact of a treatment on the health or well being of an individual.
Clinical risk Risks associated with various health care treatments.
Clinical risk management Understanding the various levels of risk attached to each form of treatment and systematically taking steps to ensure that risks are minimised.
Clinical Supervision A formal process of professional support and learning which enables individual practitioners to develop practice and enhance patient protection and safety of care in complex clinical situations.
Clinician/clinical staff A fully trained health professional – doctor, nurse, therapist, technician etc.
Cognitive behaviour therapy (CBT) A number of therapies that all have a similar approach to solving problems, which can range from sleeping difficulties or relationship problems, to drug and alcohol abuse or anxiety and depression. CBT works by changing people's attitudes and their behaviour. The therapies focus on the thoughts, images, beliefs and attitudes that we hold (our cognitive processes) and how this relates to the way we behave, as a way of dealing with emotional problems. CBT is a combination of psychotherapy and behavioural therapy. Psychotherapy emphasises the importance of the personal meaning we
64 place on things and how thinking patterns begin in childhood. Behavioural therapy pays close attention to the relationship between our problems, our behaviour and our thoughts.
Community Health Council (CHC) Not-for-profit, community-based health promotion, advocacy and policy organisations. CHCs were established in 1992. They were set up to strengthen community participation in defining state and local policy that impacts healthcare access and quality. CHCs represent the public interest in the NHS and have a statutory right to be consulted on health service changes in their area.
Community Mental Health Team (CMHT) Multi-disciplinary team made up of psychiatrists, social workers, community psychiatric nurses, psychologists and therapists. Provides assessment, treatment and care in the community, rather than in hospitals, for people with severe long-term mental health problems.
Community Psychiatric Nurse (CPN) A nurse who works in the community seeing patients with psychiatric problems both at home and in clinics.
Consent Permission, granted by a patient (or, in the case of minors, a parent or guardian) to allow a health treatment, examination or investigation to be undertaken.
Continuing Professional Development (CPD) A continuing learning process that complements formal undergraduate and postgraduate education and training.
Data Protection A requirement upon public bodies and others to act responsibly in managing personal data. Such responsibilities are covered by the Data Protection Act 1984 and the Computer Misuse Act 1990, designed to safeguard data held on individuals.
Dialectical behaviour therapy (DBT) A treatment that involves individual therapy and group skills training. DBT is a therapy approach that was originally developed for individuals with borderline personality disorder who engage in self-harm or "parasuicidal behaviours." The treatment is now also used for self-harming individuals with a wide variety of other psychological problems, including eating disorders and substance dependence. DBT teaches clients alternative ways of managing their emotions and tolerating distress.
Health Commission Wales (HCW) An executive agency of the Assembly. It will perform the services previously carried out by the Specialised Health Services Commission for Wales with some additional roles including: specialised services for children and people with complex physical disabilities; specialised cancer
65 services; neurosciences; mental health services; NHS Direct; national population screening programmes; emergency ambulance services; blood transfusion and tissue typing; regional pharmaceutical services; and dental SIFT.
Information Management and Technology (IM&T) The structures and systems through which an organisation manages data, information and knowledge to address the challenges it faces in providing services and ensure high quality outcomes.
Incident reporting system Arrangements through which critical incidents are recorded and brought to the attention of managers responsible for their elimination or reduction.
Informing Healthcare An information strategy commissioned by the Welsh Assembly Government to contribute directly to the achievement of ‘Improving Health in Wales’.
Looked After Children (LAC) Children for whom the Local Authority has responsibility, who may have to live away from their own homes and are cared for by the local authority Social Services Department.
Medical director The term usually used for a doctor at Trust board level responsible for all issues relating to doctors and concerning medical and surgical issues within the Trust.
Milieu therapy Specific help to deal with social and/or emotional problems provided by creating a helping environment rather than by any specific individual or group therapy.
Multidisciplinary team A team or group consisting of representatives from several different professional backgrounds who all have different areas of expertise.
National Assembly for Wales The devolved tier of government in Wales.
National Health Service (NHS) Trusts A self-governing body within the NHS, which provides health care services. Trusts employ a full range of health care professionals including doctors, nurses, dieticians, physiotherapists etc. Acute trusts provide medical and surgical services usually in hospital(s). Community trusts provide local health services, usually in the community, e.g. district nurses, chiropodists etc. Combined trusts provide both community and acute trust services under one management.
66 National Institute for Health and Clinical Excellence (NICE) A special health authority producing guidance for the NHS and patients on medicines, medical equipment and clinical procedures.
National Service Framework (NSF) Guidelines for the health service on how to manage and treat specific types of disease and illness.
Occupational Therapy The use of purposeful activity and meaningful occupation to help people with mental health problems. It plays a key role in helping people overcome problems and gain confidence in themselves.
Outcome The result of a treatment, service or prevention programme.
Paediatric services Medical services for children.
Part 8 review A review conducted by the local Area Child Protection Committee into the death or serious injury of a child where child abuse is confirmed or suspected, or where child protection issues likely to be of major public concern arise. It examines the involvement of all agencies and practitioners with the child and family. Case reviews are not enquiries into how a child died or who is culpable; the purpose of the case review is to establish whether there are any lessons to be learned about the way in which agencies work together to safeguard children and to implement any necessary changes.
Patient Involvement The amount of participation that a patient can have in her/his care or treatment. It is often used to describe how patients can change, or have a say in the way that a service is provided or planned.
Performance Management The use of a review process, focusing on standards and objectives, to assess how well a person, team or service is working.
Performance Monitoring A system which routinely collects and analyses how well a particular service or procedure meets targets or standards.
Primary care Family health services provided by GPs, dentists, pharmacists, opticians, and others such as community nurses, physiotherapists and some social workers.
Quality Network for Inpatient CAMHS (QNIC) QNIC is an initiative from the Royal College of Psychiatrists' Research Unit. The aim is to improve the quality of in-patient psychiatric care.
Risk assessment An examination of the risks associated with a particular service or procedure.
67 Secondary care Specialist care, usually provided in hospital, after a referral from a GP or health professional.
Senior House Officer (SHO) One of the training grade posts a hospital doctor holds after qualifying and before becoming a fully trained specialist (consultant) who accepts total responsibility for patient care in a particular branch of medicine.
Signposts 2 Followed Signposts 1, “a practical guide to public and patient involvement in Wales” published and distributed by the National Assembly for Wales in 2001. Designed principally to help NHS Trusts and local health groups address development of public and patient involvement, (PPI).
Stakeholders A range of people and organisations that are affected by, or have an interest in, the services offered by an organisation, in relation to health services includes, for example: patients, carers, staff, unions, voluntary organisations, Community Health Councils, social services.
Trust Board A group of people who are statutorily responsible for major strategy and policy decisions in each NHS Trust. Typically comprises a lay chairman, five lay members, the Trust chief executive and executive directors.
Waiting lists The number of people waiting for a planned procedure or service provided by the NHS.
Youth Offending Team Multi-agency teams who draw their members from probation, social services, local education authorities, health services and the police. YOTs oversee the outcomes of the criminal justice process in each young offender's case. This includes: deciding on appropriate rehabilitation programmes and accommodation, overseeing reparation orders and community sentences, writing court reports, supervising bail and supporting the young person during and after custodial sentences, as well as setting up youth offender panels.
68 Appreciation
HIW would like to thank the Chairman, Trust Board and in particular Mr Gren Kershaw, Chief Executive of Conwy and Denbighshire NHS Trust for his co-operation. HIW would also like to thank Mrs Cathy Howe, Mrs Tracey Macgillivray and the CAMHS staff for their assistance in undertaking the review.
HIW would like to thank the team of external inspectors that HIW used, who were:
Dr Greg Richardson
Ms Kay Darby
69 Further copies of this document can be obtained from:
Annere Creighton Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road CAERPHILLY CF83 3ED
Tel: 029 2092 8874 Fax: 029 2092 8878 E-mail: [email protected]
www.hiw.wales.gov.uk
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