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Title: CQC Report on the AWP Bristol Community-Based Mental Health Services for Adults of Working Age Agenda Item: 16

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Title: CQC Report on the AWP Bristol Community-Based Mental Health Services for Adults of Working Age Agenda Item: 16 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 • Some patients did not have care plans and others were of poor quality and some were out of date.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.
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