Meeting of Bristol Clinical Commissioning Group Governing Body

To be held on Tuesday 29 March 2016 commencing at 1:30pm at the Greenway Centre, Doncaster Road, BS10 5PY

Title: CQC report on the AWP Bristol Community-based mental health services for adults of working age Agenda Item: 16

1 Purpose

This attached Care Quality Commission (CQC) report was published on 25 February 2016 and describes the findings from the unannounced and subsequent return inspections of the Avon & Wiltshire Mental Health Partnership (AWP) Bristol Community-based mental health services for adults of working age. These services are part of the Bristol Mental Health System and are known as Recovery Bristol Partnership i.e. the partnership of organisations that provide the community services including the Crisis service and early intervention in Psychosis services. This partnership is led by AWP as the organisation holding the contract but made up of a number of Voluntary Community Sector (VCS) organisations as well.

2. Background

On 8 th & 9th December 2015 the CQC inspected the mental health crisis, assessment and recovery services in Bristol. The inspection followed discussions with Bristol CCG and the local safeguarding adult’s team regarding concerns about the poor performance of services and that patients may be at risk. These concerns had been raised in an anonymous letter to the CQC and copied to the CCG, but many of these were also known by the CCG and were being discussed in the local contract meetings. Identified pieces of work to support the provider to address these concerns are listed under section 3. During the CQC unannounced inspection the following areas of concerns were identified:

• Processes for referring and assessing patients were not robust, with a large number waiting for assessment, and some not seen in a timely manner.

• Some patients did not have risk assessments linked to their care plans.

• Some patients did not have care plans and others were of poor quality and some were out of date. Care needs were not always met in a timely way.

If you need this document in a different format telephone the CCG on 0117 900 2632

Page 1 of 4

Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP

• Lack of qualified staff for caring for people with complex patients. Recovery Navigators were supporting complex people, often with no experience of working within the NHS and without the understand how to work with such complex patients.

• There were inadequate governance systems in place. The trust was aware of the difficulties within the service, but no effective measures had been put in place to address the issues.

• Systems in place to audit electronic care records had not identified the poor quality of these records.

• In addition to their generic findings the CQC highlighted six safeguarding concerns. Relevant information was shared with AWP and actions were taken immediately to ensure the safety of these patients and that the necessary safeguarding processes were put in place.

As a result of these findings the CQC issued a warning notice to AWP on 31 st December 2015 because of unsafe services. The CQC required the Trust to:

“Undertake an immediate review of the services’ waiting lists and case load ensuring all patients are allocated to a care coordinator. We (CQC) require you to develop a system to ensure all referrals are tracked and followed up to ensure patients are not forgotten. This should be completed by 1 February 2016. ”

The CQC returned to the trust on 17 February 2016 to check that the actions specified in the warning notice due to be completed by 1 st February had been achieved. They found that an effective system had been implemented to monitor referrals, which included a tracking tool and escalation process to monitor the waiting lists and times for referral to assessment and referral to treatment. Extra staff had been found to support and undertake this process.

3. Key Issues

As stated earlier Bristol CCG had already been aware of a range of issues affecting the performance and quality of services provided by Recovery Bristol Partnership (not just AWP) and had been addressing this in a number of different ways, including:

• Recovery Action Plan including specific work streams within an overall programme of work • Chief executive to chief executive level meetings • Monthly performance meetings with the provider • Agreement on changes to model of care where required • Support to the providers via the CCG and System Lead including where appropriate support from the other providers involved in the care pathway. • Development of a forward strategic plan for local mental health services with the 5 other CCGs, as Bristol CCG takes on Lead Commissioner role for the whole of AWP services

Page 2 of 4 Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP Following the initial inspection and knowledge of the poor findings the CCG has worked closely with the providers of the Recovery Bristol Partnership services to support the necessary improvement actions. In addition to the above meetings recovery meetings have been held with the Bristol triumvirate and AWP executives to focus on the remedial actions required. Bristol CCG’s Chief Officer, Chair and Director of Transformation and Quality have also met regularly with the acting Chief Executive of AWP to discuss the report findings and improvement strategies.

4 Assurance processes

Monitoring of the actions to address the warning notice requirements will be monthly at the Bristol Recovery Partnership contract meetings. However, assurance from AWP has been requested around their own internal governance arrangements for monitoring compliance against the CQC recommendations. As Bristol CCG will be the co-ordinating commissioner for AWP from April 1 st 2016 a new governance structure has been proposed which will mirror the approach taken with other providers. The six CCGs will continue to hold their own locality performance meetings with AWP, with escalation reports provided to the quality, performance and finance sub groups. Updates on the trust’s compliance with the CQC actions will be escalated through this route to the sub groups and on to the Contract Quality & Performance Management (CQPM) meetings. In addition, the Quality Improvement Group established to monitor the trust’s compliance against the CQC recommendations and actions from the inspection of the whole trust in 2014 will remain. This meeting is chaired jointly by NHS England and the Trust Development Authority. This group will also oversee compliance with the recommendations from the Bristol CQC inspection.

5 How have service users, carers and local people been involved? Service users were not directly involved in the CQC inspection, but views and comments from users groups have been heard and taken into account as part of the improvement strategies.

6 Implications on equalities and health inequalities.

There are no specific health inequalities issues raised in the paper.

Please indicate below the age group/s covered by the service/affected by the issue discussed

Children/Young Adults X People

7 Financial Implications

There are no financial implications for the CCG.

8 Legal implications

Page 3 of 4 Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP There are no legal issues raised in this paper

9 Risk implications, assessment and mitigation

The risks in this paper relate to the specific findings in the CQC report about patient safety and delivery of the services. Improvements were noted at the return visit by the CQC and the CCG will monitor compliance with action plans to ensure the improvements are sustainable. There is an additional risk which relates to the impact on other parts of the Bristol Mental Health system. The community services are central to the system working as a whole and if they are not functioning well this will have a knock on effect to other areas in the system. The CCG is working with Bristol Recovery Partnership to review the model of care, including looking at the skill mix that the community services are operating under.

11 Recommendation(s)

The Quality and Governance Committee is asked to note the CQC findings in the inspection report published on 25 th February 2016.

Bridget James Head of Quality 15 th March 2015

Alison Moon Director of Transformation and Quality 15 th March 2015

Glossary of terms and abbreviations

CQC Care Quality Commission The CQC are an independent regulator of health and adult social care in England. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve.

Page 4 of 4 Avon and Wiltshire Mental Health Partnership NHS Trust Community-based mental health services for adults of working age Quality Report

Head Office, Jenner House Langley Park Chippenham Wiltshire SN15 1GG Tel: 01249468000 Date of inspection visit: 08 and 09 December 2015 Website: www.awp.nhs.uk Date of publication: 25/02/2016

Locations inspected

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

RVN1H North Assessment and Recovery Trust Headquarters BS10 5PY Team

RVN1H Central and East Assessment and Trust Headquarters BS2 9RU Recovery Team

RVN1H South Assessment and Recovery Trust Headquarters BS14 9BP Team

RVN1H Trust Headquarters Bristol Crisis Team BS4 5BJ

1 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

This report describes our judgement of the quality of care provided within this core service by Avon and Wiltshire Mental Health Partnership NHS Trust. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Avon and Wiltshire Mental Health Partnership NHS Trust and these are brought together to inform our overall judgement of Avon and Wiltshire Mental Health Partnership NHS Trust. We do not give a rating for Mental Health Act or Mental Mental Health Act responsibilities and Mental Capacity Act; however we do use our findings to Capacity Act / Deprivation of Liberty Safeguards determine the overall rating for the service. We include our assessment of the provider’s compliance with the Mental Health Act and Mental Capacity Act in our Further information about findings in relation to the overall inspection of the core service. Mental Health Act and Mental Capacity Act can be found later in this report.

2 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

Contents

Summary of this inspection Page Overall summary 4 The five questions we ask about the service and what we found 5 Information about the service 8 Our inspection team 8 Why we carried out this inspection 8 How we carried out this inspection 8 Areas for improvement 9 Detailed findings from this inspection Findings by our five questions 11 Action we have told the provider to take 21

3 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

Overall summary

On 8 and 9 December 2015 we inspected the crisis, difficulties within the service. No effective measures had assessment and recovery services that the trust delivered been put in place to address the issues. The lack of a to adults of working age in response to a number of service manager for the assessment and recovery teams concerns. meant there was nobody with overall responsibility for the systems and processes within these teams. Senior The local commissioning group and local safeguarding managers were aware of the problems but there was no adults team told us they were also concerned about the effective strategy in place to tackle them. poor performance of services and that patients may be at risk. Systems in place to audit electronic care records had not identified the poor quality of these records. Assessments were not always carried out in a timely way, there were over 500 patients waiting for assessment at We returned to the trust on 17 February 2016 to check the time of our inspection. A small number of these that the actions specified in the section 29a warning patients had been waiting several months. Some patients notice had been completed. We only checked the trust did not have risk assessments or risk assessments were had completed the specific actions required by 1 not linked to patients' care plans. We found that patients' February 2016. care needs were not always met in a timely way, that We found that there was now an effective system in place some patients did not have care plans whilst others had to monitor referrals. The provider had established a plans of poor quality. In some cases care plans were out tracking tool and escalation process to monitor the of date. waiting lists and times for referral to assessment and There were not enough qualified nursing staff to provide referral to treatment. Individual teams now had care for complex patients, the current information about all patients on the waiting list, how model underestimated number of qualified staff needed. long they had been waiting, and reasons for any wait over Qualified staff needed to devote large amounts of time to four weeks. Staff updated the tracking system daily. supporting recovery navigators (support workers not The trust had provided extra staff resources to address qualified in mental health nursing) in addition to carrying the waiting lists and manage the service. The trust had a caseload which was larger than that planned in the new reached agreement with the Clinical Commissioning model. Group (CCG) to undertake a skill mix review to ensure Recovery Navigators were supporting complex people. there were enough qualified staff to assess and care Recovery navigators often had no experience of working manage patients. within the NHS and didn’t understand how to work with The service had revised its governance structure within such complex patients. There was a 30% turnover of Bristol to focus on gaining detailed assurance that all recovery navigators which meant some people had not teams were delivering safe and effective care in a timely had a consistent worker. The majority of recovery manner. The trust had introduced new governance navigators were new in post. groups across Bristol. There were inadequate governance systems in place. Not The service had established a safeguarding tracking all the assessment and recovery teams had a system in system and was in the process of rolling out additional place to ensure all referrals were tracked and there was training to all staff over the next two months. no effective system in place to identify, track and follow up safeguarding concerns. The trust were aware of the

4 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

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

Are services safe? At our inspection on 8 and 9 December 2015 we found that the Bristol community assessment and recovery services were not safe: • There were not enough staff of the right grades and experience to support complex patients • Risk assessments were not always completed or updated • Patients were not always seen within the two week target and there was no system in place to monitor the health of patients on the waiting list • There was no system in place to ensure patients who missed assessment appointments were followed up • The crisis team did not always make timely safeguarding referrals for patients or their children who were at risk. However, patients who were seen regularly by members of staff had a good response if their health deteriorated. Staff were able to arrange an appointment with a psychiatrist for review. The crisis team had a good handover system to discuss and communicate patient risks amongst the team. Agency staff were employed on contract to provide some continuity of care. We returned to the trust on 17 February 2016 to check that the actions specified in the section 29a warning notice had been completed. We only looked at the specific actions required to be completed by 1 February 2016. The trust now had an effective system in place to monitor referrals. The waiting list had been reduced.

Are services effective? We found that the Bristol community and assessment teams were not effective. • Initial assessments were time limited and were not sufficient enough to complete a full assessment of patients needs • Care plans were out of date, incomplete and did not contain patients views. Some patients had no care plans at all. • Recovery navigators did not receive the correct training and or have the right experience to support complex patients. However, we found that the trust had put a good system in place to support recovery navigators. There was evidence of good multi- disciplinary working and liaison with GPs and other services.

5 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

Are services caring? We found that staff within the assessment and recovery teams and crisis teams were caring. • Staff were committed to providing the best care they could. • Families were able to attend assessments. • Patients were involved in reviews of their care but this was not reflected in care plans. However, we found that patients’ views were not always recorded in the majority of care plans we looked at.

Are services responsive to people's needs? Bristol community assessment and recovery teams were not responsive. • In the north and central teams over half of the patients referred waited more than two weeks to be assessed. For over a third of patients it was over four weeks • Patients who cancelled or missed an appointment were not always followed up by community teams. • Premises at Brookland Hall and The Greenway centre were cramped and noisy with limited access to desk space for staff. However, the crisis team responded within four hours for urgent referrals. Only 5% of patients waited over four weeks to be seen by the south team. There was evidence of learning from complaints in the crisis and recovery teams. We returned to the trust on 17 February 2016 to check that the actions specified in the section 29a warning notice had been completed. We only looked at the specific actions required to be completed by 1 February 2016. The trust had provided extra staff to clear the waiting list. The trust now had a system in place to identify how long each patient had been waiting. Staff were able to identify patients needing assessment and allocation and ensure they were followed up as appropriate.

Are services well-led? Bristol community assessment and recovery teams were not well led.

• Senior manager and the trust board were aware of the problems within the assessment and recovery teams but had not put in effective systems to address issues and improve services • There was no effective system in place across all the assessment and recovery teams to manage the waiting list.

6 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

• There was no system to learn from serious events. • Staff morale was poor with high staff turnover. However, senior staff told us that they had been well supported by the managing director of Bristol services. The trust had provided and additional two senior practitioners to work in the central team. We returned to the trust on 17 February 2016 to check that the actions specified in the section 29a warning notice had been completed. We only looked at the specific actions required to be completed by 1 February 2016. We found that there was now an effective system in place to monitor referrals. The trust had revised its governance structure within Bristol to focus on gaining detailed assurance that all teams were delivering safe and effective care in a timely manner. The trust had introduced new governance groups across Bristol.

7 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

Information about the service

Avon and Wiltshire Mental Health Partnership Trust provide crisis, assessment and recovery services as part of the Bristol Mental Health partnership.

Our inspection team

The team comprised two CQC inspection managers, four CQC inspectors, a clinical governance specialist, a crisis team specialist nurse, two social workers, a nurse and an assistant inspector.

Why we carried out this inspection

We carried out this inspection in response to a number of concerns from a whistleblower, Bristol Clinical Commissioning Group, Bristol safeguarding adult team and information CQC had received about a number of serious incidents.

How we carried out this inspection

Before the inspection visit of 8 and 9 December 2015, we • interviewed senior members of the organisation reviewed information that we held about these services including the director of nursing and the chief and asked a range of other organisations for information. executive • attended the crisis team handover meeting. During the inspection visit on 8 and 9 December 2015, the inspection team: We also looked at a range of policies, procedures and other documents relating to the running of the service. • visited the crisis team base at Callington road Hospital and spoke with crisis team staff based within the three Before the inspection visit on 17 December 2016 we assessment and recovery teams looked at the report of actions sent to us by the trust. • visited the South, North and Central and East At our inspection of 17 February 2016, the inspection assessment and recovery teams team: • looked at 110 electronic patient records • spoke with 50 staff across the four teams • spoke with nine members of staff • interviewed the managing director, head of profession • looked at the new policies and procedures introduced and practice and the medical director for Bristol to manage referrals services • looked at 35 electronic patient records to check waiting times, this included the records of patients we had identified at the inspection in December 2015.

8 Community-based mental health services for adults of working age Quality Report 25/02/2016 Summary of findings

Areas for improvement

Action the provider MUST take to improve • Staff providing care to patients did not always have the We issued a Section 29A warning notice on 31 December competence or experience to provide care safely 2015 which told the trust they must make significant • Staff did not always take steps to safeguard patients improvements to the following areas: from abuse • The premises and equipment were not suitable at • Care and treatment was not always provided in a Brookland Hall and the Greenway Centre. timely way • There was a lack of safe care and treatment Significant improvements are required to the quality of • There was a lack of governance systems in place to the healthcare provided by the trust by way of having manage the quality and effectiveness of the service effective systems in place that address the points above.

9 Community-based mental health services for adults of working age Quality Report 25/02/2016 Avon and Wiltshire Mental Health Partnership NHS Trust Community-based mental health services for adults of working age Detailed findings

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

10 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm

* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse We spoke with 50 staff across the crisis and assessment Summary of findings and recovery teams. All staff expressed concerns about staffing levels and staff turnover. Staff told us this had impacted negatively on staff stress, caseload size, and consistency of care for patients and service delivery. Our findings Information provided by the trust showed that one impact on care delivery was the large number of patients awaiting Safe staffing assessment. At the time of our inspection figures from the We inspected three Bristol assessment and recovery teams trust showed that 548 patients were awaiting assessment (north, central and south), the Bristol crisis team and the and that 211 of these had been waiting over four weeks. triage team. The triage team was the single point of access There was significant use of agency staff over the last eight for referrals to the crisis and community teams. Referrals months, apart from in the north team. Trust figures showed were initially followed up by the triage team and allocated agency use as: to the appropriate community or crisis team. • in the central team agency use had increased from The triage team had three nursing staff, one of which was 22%in April 2015 to 65% in September 2015, reducing agency who had been in post over a year,and one slightly to 59% in November 2015 administrator. The original plan had been to staff the triage team with existing crisis staff but the crisis team did not • south team had used between 11% and 42% over this have enough staff. Managers could move staff between the period with agency usage in November 2015 at 33%. crisis and triage teams if required. The crisis service The assessment and recovery teams employed regular manager showed us their proposed new staffing model, agency staff to cover staff shortages. Three members of which included additional staff agreed by commissioners agency staff carried out the assessments in the central for the triage team. team. Agency staff told us that they had originally been The trust’s Bristol risk register dated 1 December 2015 employed to complete assessments but now also had stated, ‘The capacity within the recovery teams has led to a caseloads. Some of the people who have been allocated variety of concerns with case planning and case load had been on the team caseload for a year or longer, management’. The risk register further stated, ‘Use of without any intervention. One member of agency staff gave agency staff where available however there is a clear lack of two examples of where they had contacted patients to ask agency available to support need.’ if they needed a service since their assessment over a year ago. One patient said, “I needed help last year. I don’t need Within the assessment and recovery teams registered help now”, which indicated the response time had been too nursing staff were under pressure as they had higher than long. expected caseloads and there was a rapid turnover of recovery navigators. There had been a 30% turnover of Assessing and managing risk to patients and staff recovery navigators and a reduction in the number of We looked at 110 electronic care records across four registered nursing staff to eight per team since the services. implementation of the new model last year. The new model intended that qualified members of staff would have The crisis teams used a red, amber, green (RAG) rating lower caseloads. This had not happened. The trust’s Bristol screen to assess and identify risk. Red for high risk, amber risk register updated 1 December 2015 stated, ‘Risk for moderate and green for low. We saw the crisis team upgraded as significant concerns regarding staffing. caseloads had these risk ratings allocated to each patient Continued challenges with recruitment and not all recovery on the handover caseload sheet. We observed handover navigator posts filled meaning that the necessary shift in meetings for the crisis team, which was led by the shift co- caseloads has not taken place at the pace needed’.

11 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm ordinator, and the caseload document was updated as The manager in the north team told us that 283 patients individuals were discussed. Information was cross had been assessed but not allocated to a member of the referenced with the electronic patient record and planned assessment and recovery team. Some patients were activities were delegated to different members of the team. awaiting allocation and others discharge but there were no clear figures available to identify what proportion of these However, we noted that the central crisis team did not patients were awaiting allocation. clearly discuss individual patient risks and there was a lack of clarity about why care plans were in place. For example, The trust had no system in place to monitor the health of two members of staff needed to visit one patient. Another people who had not been seen or were awaiting allocation. patient needed a male member of staff to visit. Neither Triage staff told us they tried to call patients who were patient’s record contained information about why this was awaiting assessment but did not always have capacity. necessary on either the caseload document or the The time lapse between triage and assessment increased electronic patient record. This meant that staff unfamiliar the risk to staff. Staff visited alone unless specified with these patients would not have all the information otherwise. The time lapse meant the risk could have about the patients’ needs and risks. changed or increased and staff would be unaware of this. Records we looked at across the four teams showed that of Records for one patient in the central team showed their 110 patients 15 had no current risk summary. Staff had not recovery navigator, who left in February 2015, had been the always updated summaries following an incident, or last member of staff to see them. In April 2015, the patient reviewed risk regularly. This meant that due to the high rang the crisis team in distress. They were reviewed and in turnover of recovery navigators and the use of agency staff July 2015, a decision was taken to allocate a new recovery the trust could not ensure patients were always supported worker. The new worker arranged to visit in November by staff with which they had developed a therapeutic 2015. relationship. The lack of risk assessments meant that staff might not recognise that patients were deteriorating and Another patient had waited 148 days for assessment and a that they were potentially a risk to themselves or others. further 79 days before their notes stated, ‘to be allocated a recovery navigator’. At the time of our inspection on 7 and 8 Over the four teams, we visited 2405 patients who were in December 2015, this had not happened. A third patient receipt of a service. Electronic care records we looked at referred on 19 June 2015 missed an assessment showed that patients seen regularly by a member of the appointment in August 2015. The electronic patient record team had a quick response when there was deterioration in showed that the triage team had not reviewed them or their health. Records showed that patients could access a arranged a further appointment during this time. medical review with a psychiatrist if necessary, for example, for a medication review. Staff were able to discuss concerns The central team had not assessed a fourth patient referred about patients with more senior members of the MDT. on 07 May 2015. A fifth patient referred on 27 January 2015 had been unable to attend an assessment appointment Assessment and recovery teams did not always assess due to their child being sick. The service had not offered a patients within the trust’s target of two weeks for non- further appointment. This patient’s GP followed up in urgent referrals. The trust figures for waiting times on the 8 September 2015 but nothing further had happened until 1 December 2015 showed that: December 2015 when the crisis team contacted the triage • There were a total of 548 patients on the waiting list service. The central team offered the patient an appointment for a telephone consultation on 23 December • 325 ( 59%) of patients had been waiting more than two 2015. weeks to be assessed The triage team had not reviewed any of the above patients • 70 patients out of 83 referred to the south team were to monitor their health in order to ensure they did not need seen within two weeks a service urgently or to check that their risks had not • 130 patients referred to the north team, 78 patients increased. The trust could not be sure that patients waiting referred to the central team and three patients referred assessment and allocation were safe and that any risk of to the south team waited over 4 weeks to be seen. harming themselves or others had not increased.

12 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm

The minutes from the trust’s quality and standards meeting We reviewed 12 serious incidents across the crisis team and in November 2015 identified the risk associated with assessment and recovery teams. Of the 12 we found that unallocated cases in Central Recovery. The meeting five identified issues with either care planning and/or risk minutes stated that the electronic care records system assessment. However, we found no evidence that this had could not flag up how long patients had been waiting and led to improvements in care planning and risk assessing who was awaiting allocation to a care coordinator and that across teams. the trust was looking at a system to manage this. We returned to the trust on 17 February 2016 to check that Staff in the crisis team told us about the impact the lack of improvements had been made. The trust now had an staff within the community teams had on their capacity to effective system in place to monitor referrals across all the focus safely on crisis work. Crisis team staff told us that the assessment and recovery teams. Staff were able to identify community teams who did not always have enough time to how long all patients referred had been waiting for work effectively with patients they transferred. This meant assessment. The trust now had a system in place to ensure individuals either stayed on the crisis team caseload longer patients were allocated to a care coordinator. than necessary, or frequently re-presented in crisis. One We looked at the electronic records of all patients we had member of staff told us about a patient this had happened identified at the visit in December 2015 as either waiting to and the crisis team saw the patient. several weeks to be assessed or allocated. Staff had Staff had received training in safeguarding but we ensured all these patients had been followed up and identified a number of cases where the crisis team had not appropriate actions taken. taken appropriate action. The crisis team should have referred six patients, or their children, to local authority safeguarding services but this had been delayed or had not happened. We raised this with the crisis team service manager who reviewed these cases.

13 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services effective? By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

Of the six records reviewed in the Bristol crisis (south spoke) Our findings two patients had no care plan, three patients had no risk assessment and one patient had no care plan nor risk Assessment of needs and planning of care assessment. Over all four teams inspected, we looked at electronic 110 We reviewed 27 care records in Bristol south assessment care records and recovery team. Three patients had no care plan at all. Individual patient records we reviewed contained a basic Nine patients had care plans that related to previous assessment of patients’ needs. This had been carried out in episodes of care but not their current episode with their assessment appointment, which usually took place recovery team. Some patients had care plans that the over an hour. The presenting situation in the core recovery team had not completed; for example, the care assessment was completed but for the majority of records plan was for an in-patient stay, and did not address current we reviewed other sections of the core assessment such as needs and risks. mental health history, social circumstances, substance In Bristol central and east assessment and recovery team, misuse history and other sections of the assessment were we looked at 49 electronic care records and found that not completed. We did not find evidence that any further some patients’ care plans were marked as ‘updated’ when assessment, apart from the medical assessment, took the recent review provided no evidence that all areas of the place following the half hour assessment. Staff told us that care plan had been reviewed. Care plans in central and east half an hour was not sufficient time to complete an initial were of poor quality and generic. Staff responsible for assessment. updating patients’ care plans did not always link risk to 30 of the 110 records we looked at contained no care plan, care plans and did not always update care plans following an out of date care plan or a care plan from a previous significant incidents. We found seven patients who had no episode of treatment. Care plans were brief and did not care plan. Staff told us that some care plans and risk always contain patients’ views or preferences. Care plans assessments were out of date and that this was due to lack did not contain goals that were specific, measurable, of time to update them. attainable, realistic and time limited. Goals were not The lack of comprehensive and up to date care plans specific and care plans did not contain any information meant that there was a risk that patients would not get the about how they would be reviewed and progress assessed. care they needed. Due to high turnover of recovery Some plans were from previous episodes of care or had navigators and use of agency staff, the trust could not been written over three years previously. These plans had ensure patients were always supported by staff with which been marked as ‘updated’ on the electronic system. they had developed a relationship. For example, six However, there was no evidence in reviews that staff different recovery navigators had supported one patient. reviewed all the goals and that the needs were still current. We looked at this patient’s records and saw that staff had Staff consistently told us that some care plans and risk not updated care plans and the risk summary following a assessments would not be up to date due to the current recent episode of self harm. There was no information in work pressures. their care plan about how to identify when their mental In Bristol crisis (north spoke) of five cases reviewed only two health was deteriorating and how to support them with patients had a care plan and a further two patients had no this. risk assessment or care plan. Patients’ preferences were not always recorded in their In Bristol crisis (central spoke) of 14 care records reviewed care plans. This meant that the trust could not be sure that three patients had no risk assessments, three patients had patients were consulted about, or involved in the planning no care plans and a further three patients had neither a of their care. care plan nor a risk assessment. Electronic records we looked at in the assessment and recovery teams showed that, where required, doctors

14 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services effective? By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. carried out a comprehensive medical assessment following Most recovery navigators expressed concerns at having initial assessment. We saw that a letter was sent to the complex service users with high needs on their caseloads. patient’s GP with details of the medical assessment and Caseloads ranged from 15 to 27 and could reach 30. One outcome. navigator told us, “It would not be safe or even possible to manage 30”. We saw records of two incidents where Staff were experienced and qualified. recovery navigator’s care coordinated complex patients. In Qualified nursing staff employed by the trust were one case inadequate medicines management had resulted experienced in working with patients with mental health in harm to the patient. In the second case, the navigator problems. Recovery navigators were employed by three had not discussed risks with a clinician following an voluntary sector partners, one of whom who told us there overdose. was a 30% turnover of recovery navigator staff. The Recovery navigators received monthly management experience of recovery navigators varied, for example, supervision, which included a case review, and monthly some were psychologists or social workers whilst others clinical supervision. They attended weekly meetings and had limited experience of working with patients with once a month a meeting where they could discuss their complex needs. patients. The trust had no input to the recruitment of recovery We looked at nine supervision records for recovery navigator staff and was not responsible for their training. navigators and saw that they all received regular The terms of the Bristol Mental Health partnership specified management and clinical supervision. Where recovery that recovery navigators were employed by voluntary navigators were being directly supervised by any one of the sector agencies who were responsible for recruitment, three managers, records were present and up to date. induction and training. This meant that the trust could not However, those recovery navigators who were being ensure new recovery navigators understood the trust’s risk supervised by a Band 6 member of staff held their own assessment and care planning procedures and understand records. We asked four recovery navigators about their how to deliver safe and effective care. The trust was not supervision records and they were able to produce them. able to assess the competency of recovery navigators before allocating patients to them. Multi-disciplinary and inter-agency teamwork In response to the need for consistency and to support new Regular multi-disciplinary team (MDT) meetings took place. recovery navigators to understand their role, the trust had In addition, there were work stream meetings where staff introduced their own induction. However, due to staffing could discuss patients. In the central team, each work pressures recovery navigator staff did not always complete stream had a weekly assessment meeting to discuss this induction before taking patients onto their caseload. referrals and allocations. Recovery navigators told us that they had not received The crisis team had meeting structures and systems in specific training on care planning, risk assessments and place to provide oversight and safer working. This included medications awareness. These were “learnt on the job”. twice-daily handovers with a handover sheet. There were Recovery navigators told us they were expected to cover clear email updates from the night staff, weekly MDT the duty phone and that this was not in the job description. meetings and monthly whole team meetings. The duty phone was also “learnt on the job”. Covering the We saw records which showed effective working by duty phone involved taking calls from patients and making recovery navigators with other teams external to the decisions regarding advice, support, or transferring the call organisation, for example social care organisations. Letters to a more senior clinician. This meant there was a risk that were sent to GPs informing them of changes to patients’ recovery navigators would not be able to provide the care, for example medication changes. correct advice or support. The trust could not be sure that an untrained navigator would be able to assess risk correctly and escalate concerns.

15 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

patients about their current circumstances but there was Our findings little evidence of planning or discussion of treatment goals and outcomes. We saw that staff carried out reviews with All the staff we spoke with demonstrated a commitment to patients but did not always address care plan goals. delivering the best care they could. Most of the staff we spoke with told us they were frustrated by gaps in the Families and carers were able to attend assessments if the systems and the difficulty of recruiting and retaining staff as patient wished. Electronic records did not always evidence this had a negative impact on the care patients received. that staff had assessed carer’s needs. Staff did not complete this section of the core assessment. Electronic records showed that staff who saw patients regularly developed effective working relationships which The crisis team had a service user reference group which focused on helping patients manage their lives. the service manager attended. This enabled service users to have some input to how the crisis service operated. There was little evidence in care plans of patients’ involvement. Progress notes showed that staff talked to

16 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services responsive to people’s needs? By responsive, we mean that services are organised so that they meet people’s needs.

urgent at the point of referral may deteriorate due to lack of Our findings timely assessment and treatment. They would try to call individuals to keep them up to date and check on any Access and discharge changes in presentation. All new referrals to Bristol mental health came through a Patient waiting times from referral to assessment differed single access point via the triage team. The triage service according to which team they were allocated. The triage screened all referrals and organised these into the same team allocated patients to teams on a geographical basis. three geographical sectors as the crisis team spokes and The trust figures for waiting times at 8 December 2015 assessment and recovery teams. The triage team clinicians were: contacted the person who made the referral, the patient referred and any other relevant involved parties. The team • In the south team 70 patients had been waiting less then agreed the most appropriate service and the than two weeks with three patients waiting over four timescale within which the patient needed assessment. weeks The triage team booked in assessment slots via an • In the central team 76 patients had been waiting less electronic diary, with the relevant community mental than two weeks and 78 patients waiting over four weeks health team. If the referral was urgent, they referred the • In the north team 77 patients had been waiting less than patient for urgent assessment to one of the crisis team two weeks and 130 patients waiting over four weeks. spokes. Each community mental health team provided a number of assessment slots each week. The timescale for The community services public risk log, dated 28 October referral to assessment was: 2015 stated there was a,’ Risk of not achieving waiting times standard, 14 day referral to treatment’. The service manager • within four hours for an emergency referral for the crisis team had added increased waiting time for • within 72 hours for an urgent referral patients in crisis to their concerns log on 4 December 2015. • one to two weeks for a routine referral. The crisis team saw urgent referrals; however, as shown in the above figures, recovery teams did not always see non- The triage service received a high volume of referrals, for urgent referrals within the target time of two weeks. example, the week commencing 3 December 2015, 154 referrals had been triaged and allocated. However, triage When we returned on 17 February 2016 we found that the staff were not always able to allocate assessment slots to waiting list had been reduced. Staff were now able to community teams due to lack of capacity. For example, on identify which patients had been waiting more than four the day of our inspection, triage staff told us that there weeks for assessment and had a spread sheet which were no assessment slots available with the central tracked these patients. Staff had an electronic system community mental health team, there was one assessment which identified how many patients were waiting to be slot available within the north community mental health allocated a care coordinator. We saw that only 21 patients team and there were 22 assessment slots within the south across all three assessment and recovery teams had waited community mental health team. All of the community over four weeks. We looked at records for a sample of these teams except south team already had waiting lists for patients and saw that staff had maintained contact and assessments allocated in previous weeks. taken any action needed. This meant that any individuals requiring allocation to the Meeting the needs of all people who use the service north or central teams were unlikely to be assessed. The Records we looked at showed that patients who needed triage team reported they `held` a number of individuals additional arrangements to access the service did not that were awaiting allocation for assessment in addition to always have suitable arrangements put in place. For continuing to triage incoming referrals. Staff raised example, we looked at records for one person who was concerns that the mental health of patients who were not homeless and referred in July 2015. After the patient had missed their first appointment, the service did not arrange another appointment until the end of September. Staff

17 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services responsive to people’s needs? By responsive, we mean that services are organised so that they meet people’s needs. booked the appointment to take place at the night shelter. colleagues to vacate chairs, desks and computers. Staff told However, the night shelter was closed at the time the us that due to competition for computers, on occasion they appointment was booked. Records showed that a further had left the office briefly and been logged off by another appointment ‘didn’t happen’ and there was no record of member of staff. This had resulted in their losing work. any further appointments offered. Staff at The Greenway Centre, the north team base, told us One patient requested home visits due to panic attacks in that the office space available was cramped and noisy and June 2015. Their notes stated, ‘due to be assessed on 08 our observations during the visit confirmed this. The June but does not seem to have happened’. A final note Greenway was a community centre where a range of recorded an assessment appointment for 01 September activities took place, the north team had an office and 2015 but there were no further notes. The patient had still interview rooms on the first floor. Staff told us that on the not been seen at the time of our inspection on 7 December days when a Zumba class (an exercise class to music) took 2015. Another patient requested an evening appointment place downstairs it was difficult to work due to the noise but notes stated there was none available. Secretarial staff levels. There was no separate waiting area at the Greenway sent a letter nine days after the proposed appointment Centre for patients, which potentially compromised date to offer a morning appointment. There were no further confidentiality, as they had to share the space with people notes made regarding this patient. using the centre for a range of activities. Patients had complained about this and it was on the local risk register. We noted that patients who got lost in the system were Patients had also complained that it was cold and noisy. often patients who missed initial appointments or did not respond to telephone calls. There was no system in place Listening to and learning from concerns and to ensure that staff followed up hard to engage patients. complaints Qualified nursing staff expressed concerns about not being We saw the complaints log for the service and the crisis able to provide an effective assertive outreach service. One service manager kept a log of informal complaints or registered nurse said there was no assertive outreach team concerns raised. We saw the crisis service manager worked in the area and staff in the assessment and recovery teams hard to identify the issues and work with individuals and did not have the dedicated time that an assertive outreach staff for resolution. team would have. We saw that there was a log available of issues across the When we returned on 17 February 2016 we checked the Bristol community services. This log included complaints, electronic records of the above two patients and found that action taken to address them and an update on progress. staff had taken action in respect of the two patients mentioned above. We saw examples of implementing learning from complaints. For example, following a number of complaints Records we looked at showed that when patients needed in relation to the crisis line about poor experience due to an interpreter this was available. response and attitude from staff, the service manager had All staff at Brookland Hall expressed concerns at the lack of put in place the crisis line protocol. This included good an appropriate work environment. This affected their practice guidelines for telephone skills, how to operate the ability to complete work and make phone calls. It also telephones and a flow chart for call handling, for example, added to stress and pressure. Staff gave examples such as signposting to other services or recognising when to pass not being able to access a desk or computer. Connection the call to a registered practitioner in the triage team. was often poor on the laptops and at the community The crisis team service manager had been attending the centre. The community centre was cold and had limited service user reference group for crisis services. We saw space. Phone calls made in the main office were difficult sample minutes from the meeting. There was a patient due to noise. The duty phone was located in the main safety development plan monthly report, compiled by the office and was often manned by the recovery navigators. patient safety team, of root cause analysis and complaints We observed that by mid-afternoon, there was no space left recommendations. These were discussed in the monthly for staff to sit, no access to computers and the office was community services quality meeting. very noisy. We observed staff standing waiting for

18 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

We looked at reviews of 12 serious incidents which had Our findings identified issues with care planning and/or risk assessment. There was no system in place to ensure that There was no operational policy for the Bristol assessment an action plan was developed and implemented to ensure and recovery services. This meant that there was no clear future improvements in planning and risk assessing were framework for the delivery of services. There were no made. clearly defined working practices, lines of responsibility and a lack of clarity about roles and responsibilities. There was We were shown the trust assurance system where 10 a lack of measureable outcomes and no clear strategy to electronic care records, for 10 patients chosen at random, inform the running, development and review of the service. were audited at random each month as part of the quality assurance monitoring. One of the senior practitioners There was an operational policy in place for the crisis carried this out. Audits of these records were used to teams. The crisis teams were not able to achieve all off the determine the quality of the teams’ care records and fed operational standards due to resource constraints and into the trust’s assurance system. We saw that on their service wide pressures. For example, the crisis team did not dashboard the central and east team was scoring as ‘green’ have sufficient staffing to make contact within two hours with records audited being judged to be of an appropriate for people in crisis. standard. We found that the care records we viewed across The trust risk report to the board for November 2015 all teams did not correlate to these results and that the identified a risk of ‘Serious quality failure event if the Trust's audit system was ineffective in identifying this. quality system fails to proactively identify areas of poor There was no effective system in place to track practice.’ safeguarding referrals. Staff had not completed the north In a letter to Bristol medical colleagues dated 4 December Bristol team safeguarding tracking spread sheet. This 2015 the clinical director of Bristol community services meant the trust was not always able to identify if or what acknowledged, ‘the quality of care for our patients is safeguarding referrals had been made and outcomes. This inconsistent, processes and systems do not always make it meant there was no assurance that procedures had been easy to deliver the care we would want, and our key followed. performance indicators are not what stakeholders had Leadership, morale and staff engagement hoped for at this stage.’ The team manager for the central team had recently left Minutes from the quality and standards meeting in and the trust had not yet recruited to the post. In response November 2015 noted issues with responsiveness and to the difficulties in managing caseloads and allocations, timeliness to patient referrals, predominantly found in two additional senior practitioners had been seconded to Bristol. Minutes from the meeting stated these issues were the central team. The team had been divided into three being addressed in the Bristol Service Improvement Plan. work streams, each with a senior practitioner and We looked at two action plans for improvement developed consultant psychiatrist. by the trust; one which was part of the quality performance The post of service manager for the three assessment and agenda which was presented to the board and one which recovery teams was vacant and being covered by the was agreed with Bristol clinical commissioning group. Both overall community services manager. This meant there was were lacking in details such as outcomes required, no current manager who could oversee the measureable progress and timescales. The member of staff implementation of consistent working practices across the responsible for the actions was not always identified. It was three assessment and recovery teams. not clear how the trust would monitor or evaluate actions. This meant the trust could not be sure that the Senior staff told us that they found the managing director improvement plan was effectively addressing the concerns, of the triumvirate very helpful, supportive and willing to or that there was effective senior oversight or management listen. of risks. We did not find any plans that addressed all the Staff engagement in Bristol was one of the two highest issues in a strategic, coordinated, planned and organised scoring risks on the operations executive risk register. The way.

19 Community-based mental health services for adults of working age Quality Report 25/02/2016 Are services well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. risk had been identified on 1 July 2014, 18 months Recovery navigators at the central team said the job was previously. There were broad actions in place to address not what they expected it was going to be, based on the engagement but did not identify how staff engagement advertised job. One recovery navigator said, “The job would be measured or what it would look like. It was not description does not bare any resemblance to the actual clear when this would be downgraded or the risk mitigated role”. Other navigators said the job was “miss sold” and that to acceptable levels. they were “sold a lie” by their voluntary sector employer. Staff told us that an example of poor engagement with staff Many of the staff we spoke with told us that the new model was the way the trust implemented weekend working. The was potentially good for patients. Staff said it was positive community services manager told us that whilst meetings that they were moving towards a more inclusive social and consultations with staff were being undertaken about model; however, the new model was under-resourced with a possible start date of October 2015 the trust had already qualified nursing staff and had been implemented too agreed an implementation date of September 2015 with quickly. commissioners. This meant that there was not a genuine We returned to the trust on 17 February 2016 to check that attempt to engage and negotiate with staff about a the actions specified in the section 29a warning notice had significant change to their working hours. been completed. We only looked at the specific actions The board assurance framework identified bullying as one required to be completed by 1 February 2016. of the three most concerning areas following the latest staff We found that there was now an effective system in place survey. The trust had commissioned a survey by an to monitor referrals. The provider had established a external agency and 49 staff across the trust chose to tracking tool and escalation process to monitor the waiting participate. Bristol was one of the three hot spot areas for lists and times for referral to assessment and referral to bullying identified by the external agency. The analysis of treatment. Individual teams now had information about all responses identified staff on staff bullying as the major patients on the waiting list, how long they had been problem with 88% of this being manager on staff. The plan waiting, and reasons for any wait over four weeks. Staff to address this included teams to receive team monitored the tracking system daily. development. Bristol had the second lowest delivery of this with only 20% of teams having received it. The trust had provided extra staff resources to address the waiting lists and manage the service. The trust had reached Staff told us that there was a “closed culture” in the trust. agreement with the Clinical Commissioning Group (CCG) to Some staff had raised concerns directly with the trust and undertake a skill mix review to ensure there are adequate offered advice on how to make positive changes. Staff told qualified staff to assess and care manage patients. us that these concerns were not ‘positively received’ and the trust took no apparent action in relation to them. The service had revised its governance structure within Bristol to focus on gaining detailed assurance that all Staff across all four teams expressed concerns with the teams were delivering safe and effective care in a timely triage system, staffing, adequate training for recovery manner. The trust had introduced new governance groups navigators, workload, work environment and lack of across Bristol. stability. All staff at the central team told us that we would find some care plans and risk assessments incomplete or The service had established a safeguarding tracking system out of date due to not having enough time and was in the process of rolling out additional training to all staff over the next two months.

20 Community-based mental health services for adults of working age Quality Report 25/02/2016 This section is primarily information for the provider Requirement notices

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

21 Community-based mental health services for adults of working age Quality Report 25/02/2016 This section is primarily information for the provider Enforcement actions

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

Regulated activity Regulation

Treatment of disease, disorder or injury Section 29A HSCA Warning notice: quality of health care • Care and treatment was not always provided in a timely way • There was a lack of safe care and treatment • There was a lack of governance systems in place to manage the quality and effectiveness of the service • Staff providing care to patients did not always have the competence or experience to provide care safely • Staff did not always take steps to safeguard patients from abuse • The premises and equipment were not suitable at Brookland Hall and the Greenway Centre. Significant improvements are required to the quality of the healthcare provided by the trust by way of having effective systems in place that address the points above. You are required to make the significant improvements to the quality of care identified above. CQC require you to undertake an immediate review of the services’ waiting lists and case load ensuring all patients are allocated to a care coordinator. We require you to develop a system to ensure all referrals are tracked and followed up to ensure patients are not forgotten. This should be completed by 1 February 2016. You are required to provide us with information on your plans to undertake this. This should be the start of a comprehensive review of the governance, assessment and care planning in the service which should be completed by 16 May 2016.

22 Community-based mental health services for adults of working age Quality Report 25/02/2016

Bristol Community Services Warning Notice Action Plan – Phase 2 This plan has been developed following the receipt of a s29A Warning Notice from the Care Quality Commission in response to an unannounced inspection undertaken on 7 and 8 December 2015. Initial action planning was recorded and monitored on Gemini software. This action plan addresses the Medium and Long Term Actions.

Area of Concern Action Lead Date Due Outcome / Progress RAGB 1 Care and treatment was KG 30.04.16 Treatment will be provided not always provided in a AM in line with required timely way timescales, or where not, there is a clear rationale to track this and the safety of the individual. 1.1 Patient Status and Current manual process for KG 30.04.16 New caseload for triage Capacity is currently monitoring patient status will be team set up on RiO to monitored through a automated enable tracking of all those resource intensive manual referred. process Manually populated dashboard for RTA, RTT and care coordination in use Reportzone – new report (R345) in testing 1.2 No clear actions identified Escalation procedure across BMH KG 30.04.16 Pilot procedure for Triage when capacity exceeds services will be tested and finalised AM and A&R in use. demands BMH System wide procedure drafted and will

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall

be completed once the criteria has been tested in the pilot 1.3 Revised Trust Access Amended policy to be added to new AM 30.04.16 Initial review completed Policy to be approved template and submitted for ratification TR being formatted into current through Governance process template 1.4 Audit and evaluation of CE drafting report on rollout of the CE 31.03.16 Draft report received Triage including use of Trigger Tool across whole of AWP AM 21.03.16 Trigger Tool 1.5 There is no transparent Review and agree criteria for KG 30.04.16 Triumvirate and support system to identify routine requesting a medical assessment. HR team meeting 21.03.16 medical availability and Review workplans of consultants and JE 30.04.16 Medical leads to complete capacity to undertake ensure all are undertaking review of workplans to assessments leading to assessments ensure sufficient insufficient slots assessment slot capacity 1.6 CPI – Referral process and Review referral pathways, KG 30.04.16 Review on 21.03.16 tx pathways not clear interventions, record keeping within SB identified need to extend to RiO and Care Coordination roles for AM other pathway issues service users only open to CPI outside of CPI KG SB setting up review meeting w/c 11.04.16 2 There was a lack of safe DB 30.05.16 Care and treatment will be care and treatment AM provided to revised, agreed standards and adherence to these will be effectively monitored. 2.1 Assessments not Review and approve standards for DB 31.03.16 Trigger Tool implemented in completed to a satisfactory assessment for Triage and Initial

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall

standard Assessment. AM initial actions. Workshop has drafted proposed standards. DB organising finish group to review draft 30.05.16 Trigger Tool being developed into RiO to roll- out across AWP 2.2 Recovery Navigators are Review and Agree criteria for Step Up DB 31.03.16 Workshop undertaken on coordinating care for and Step Down AM 16.03.16 and criteria agreed service users at risk, internally. vulnerable and complex Sign off with Partners TBC 2.3 Assessments not being Standards for Assessment and Triage DB 31.03.16 Workshop undertaken on undertaken to a consistent to be reviewed and agreed (to AM 16.03.16 and criteria agreed standard support effective signposting and internally. ensure consistency) Sign off with Partners TBC 2.4 Care plans not linked to Care Planning Training including DB 15.05.16 DB identifying senior assessment of needs and linking identified risks to care plans AM practitioners to develop risk training programme and materials ensuring RiO Guidance is consistent 2.5 Assessment of Registered Develop assessment tool and AM 30.05.16 Framework for assessment Practitioners competency programme of assessment DB of competency drafted. to asses SJo Capacity to take forward not yet identified 2.6 Check compliance through Undertake records audit SJ 30.04.16 Review audit results and bespoke audit agree any further actions

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall

3 There was a lack of MB 30.04.16 Governance systems will governance systems in be reviewed and approved place to manage the to effectively monitor the quality and effectiveness service, and escalate of the service concerns as required. 3.1 No operational policy for Standard Operating Procedures to be MB 08.04.16 SOPs have been revised Bristol services or clarity reviewed, and revise meeting and consulted on for about roles and structure and clinical governance Assessment and Recovery, responsibilities processes. Crisis, and Triage.

3.2 No mechanism for Terms of Reference and methods of MB 29.02.16 ToR and meeting structure measuring outcomes escalation and cascade to be re-written and approved for reviewed clinical governance. 3.3 The Trust Records New Records Management audit, RE 30.04.16 New RM audit, based on management audit was based on more qualitative NPSA suicide prevention insufficient assessment to be implemented toolkit agree, to be implemented April 4 Staff providing care to SB 30.04.16 A full service review will patients did not always be completed to identify have the competence or the skill-mix and training experience to provide skills required. care safely A transition plan will be agreed for implementation of this. 4.0 Poor understanding of A&R teams to complete a caseload JD 1.4.16 60% Caseload review caseload complexities and review for analysis submitted by 29.2.16 with staffing requirement further 40% expected by 1.4.16

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall

4.1 To analysis caseload Compare and contrast caseload SB 11.4.16 Comparison completed with review findings review to Otsuka analytics 60% caseload review. Further analytics finalised by 5.4.16 in preparation for staffing establishment review meetings 4.2 Organise and complete Arrange task and finish group to SB 1.4.16 Meetings set up: staffing establishment review analytics and make clear 4.3.16, 22.3.16, 30.3.16, review meetings recommendations to triumvirate for 13.4.16 future staffing 4.3 Agree a communication Communicate caseload review, SB 30.4.16 Staff information meetings plan with staff review meetings and outcomes to set up w/c 09.05.16 staff (weekly comms) 4.4 Review of Crisis Skills Review knowledge, skills and SB 30.4.16 1st meeting set up for experience required of staff recruited 14.3.16 and meetings with to crisis team and feed into workforce CCG established group commencing 29.03.16 4.5 Review of Crisis Model Liaise with CCG re reviewing the SB 23.2.16 1st meeting set up for crisis model, including crisis line. 29.03.16 This action to move into own workstream once set up 4.6 Organise a workforce Set up strategic workforce group to SB 30.05.16 Staff engagement and review group include VCS, L&R, HR to review comms joint strategy recruitment, retention, CPD, L&D staff meeting set up 15.03.16. engagement etc Intention is to move this into a joint strategic workforce group following outcome of skill mix

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall

5 Staff did not always take MB 30.04.16 Staff training will be steps to safeguard AM reviewed and delivered so patients from abuse that all staff know how to safeguard individuals. A tracking process will be implemented to monitor referrals. 5.1 Staff need additional 95% of all BMH Staff will attend MD 31.03.16 Despite additional sessions, training on CQC findings Safeguarding training (not achieved it is unlikely all staff will be and actions required, and in phase 1). trained. in the new tracking 27 staff members still to be process trained to meet 18.03.16 target x2 additional sessions to be provided by 8 April 5.2 All AWP safeguarding In absence of data from LAs, develop MD 31.03.16 System implemented and is referrals to BCC need to tracking system for alerts raised by AM being monitored. have a tracking system AWP to BCC Review effectiveness of new tracking procedure with view to Trust wide rollout. 5.3 Provide assurance on Audit of safeguarding Children / Adult MD 30.04.16 Audit of Safeguarding compliance with procedure across BMH teams standards to be added to safeguarding standards LDU audit plan (L Ralph) 5.4 Insufficient safeguarding Implement revised NQ safeguarding AD Feb 2016 Awaiting NQ Consultation team capacity (NQ) team structure to support delivery Outcome paper units 6 The premises and SB 30.04.16 A review of all premises equipment were not will be completed with

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall

suitable at Brookland agreed actions so that Hall and the Greenway these are suitable for Centre service users and staff 6.1 Identify short term premise SB 29.2.16 Stokes Croft identified options for Central 6.2 Complete move to Stokes Stokes Croft available in part from JD 8.4.16 Croft 29.2.16 and in full from 1.4.16. Communications to team and devise CW 31.03.16 operational procedures to plan move 6.3 Gather feedback from Complete survey of service user BW 29.2.16 Completed and report service users on views on Greenway (Bev Woolmer) circulated with minutes of 1st experience of Greenway Greenway meeting 6.4 Set up Greenway Set up Greenway workstream to SB 30.4.16 Meetings set up: Workstream to review review North Estates, engage staff 1.3.16, 23.3.16, 31.3.16 estate requirements and service users and make recommendations to triumvirate 6.5 Complete PIE audit of Complete and circulate PIE audit on SB 4.3.16 Chris Hannay completed Greenway Greenway and analysed results specifically relating to the Greenway. Circulated with minutes of 1st Greenway mtg

Initial Name Initial Name AM Alan Metherall DB Daniel Badman

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall

JE James Eldred KG Kerry Geoghegan MB Mark Bunker RE Rebecca Eastley SB Sarah Branton SJ Simon Joseph MD Mark Dean SJo Sarah Jones JD Joi Demery CW Carey Wright BW Bev Woolmer AD Andrew Dean HR Harvey Rees

R Significant risk A Some risk to completion G On Target B Completed

Updated: 22.03.2016

Senior Nurses / Nursing / Bristol warning Notice v0 Alan Metherall