Cambridgeshire and Peterborough NHS Foundation Trust

Evidence appendix Elizabeth House, Cambridge Road Date of inspection visit: Fulbourn 20 May 2019 to 13 June 2019 Cambridge Cambridgeshire Date of publication: CB21 5EF 5 September 2019

Tel: 01223726789 www.cpft.nhs.uk

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Facts and data about this trust

The trust had 10 locations registered with the CQC (on 7 May 2019). Registered location Code Local authority Brookfields Hospital RT1W1 Cambridgeshire Cavell Centre RT199 Peterborough City Care Centre RT1DN Peterborough Fulbourn Hospital RT113 Cambridgeshire Ida Darwin Hospital RT115 Cambridgeshire Addenbrookes Hospital RT190 Cambridgeshire North Cambridgeshire Hospital RT182 Cambridgeshire Princess of Wales Hospital RT1FD Cambridgeshire Doddington Hospital RT1GD Cambridgeshire Ida Darwin Learning Disability & Specialist RT1Y1 Cambridgeshire Services

Page 1

The trust had 315 inpatient beds across 24 wards, 36 of which were children’s mental health beds. The trust has not supplied any information regarding the number of outpatient clinics.

Total number of inpatient beds 315 Total number of inpatient wards 24 Total number of day case beds Not Supplied Total number of children's beds (MH setting) 36 Total number of children's beds (CHS setting) Not Supplied Total number of acute outpatient clinics per week Not Supplied Total number of community mental health clinics per week Not Supplied Total number of community physical health clinics per week Not Supplied

The methodology of CQC provider information requests has changed, so some data from different time periods is not always comparable. We only compare data where information has been recorded consistently.

20190830 RT1 Evidence appendix Page 2

Is this organisation well-led?

Leadership The trust board had the appropriate range of skills, knowledge and experience to perform its role. The board was well established. The chief executive had been in post since August 2017 and the chair since July 2014. The board consisted of a chair, the chief executive, director of nursing and quality, director of finance, medical director, director of service transformation, director of people and business development, chief operations officer and director of corporate affairs. There were six non-executive directors and two advisory non-executive directors who had a wide range of skills and suitable experience. This ranged from private business leadership, financial, legal, medical research, HR, technology and third sector organisations. We found that that board was multi-skilled and had a wide range of experience allowing many views and experiences to inform how the trust was led.

We attended a trust board meeting during the inspection and saw that the board was focussed on ensuring the delivery of high quality and compassionate care. The trust leadership team had a comprehensive knowledge of current priorities and challenges across all sectors and acted to address them. The trust board and senior leadership team set the tone for the values of the trust on an ongoing basis. The non-executive directors provided appropriate and effective challenge, holding the executive team to account to improve the performance of the trust and ensure that quality and safety were at the centre of all decision making.

The trust had an experienced senior leadership team with the skills, abilities, and commitment to provide high-quality services. Each of the trust’s three directorates had a head of nursing, clinical director and associate director of operations. Leadership was developing well in older peoples and adult community services and the children’s and young people’s directorate. This was beginning to pay dividends for example the plans for the children’s hospital were very positive. The leadership team had worked hard to model behaviours and practices that underpinned the values of the trust. The trust had a lead for child and adolescent mental health, learning disability and autism within the relevant clinical directorates.

Executive directors and directorate leads were known to staff and visited most services. They provided leadership and the board encouraged feedback from all levels of the organisation. The chief executive also held regular monthly drop-in sessions for staff and had an open direct email system. Front line staff confirmed they found these visits supportive and most knew who the trust’s directors were. Local leadership across the trust was also visible and effective. Staff felt supported by their leaders. Staff confirmed that they found board and senior trust leaders approachable and easy to talk to. Front line staff were particularly positive about the chief executive’s approach.

Succession planning was in place throughout the trust, aligned to the trust strategic objectives and leadership capacity and capability was reviewed on an ongoing basis. The trust supported staff to develop their leadership skills. The trust provided a range of leadership development programmes both internally and externally. Leadership training was available for staff at all levels, irrespective of their job role. The trust provided staff with opportunities for career progression. Talent planning had been encompassed in the appraisal system and an ‘effectively managing our talent action plan’ was in place to develop talent to take up critical and hard to recruit posts.

The trust had undertaken a review of how they developed and supported leaders. The leadership, talent and organisational development strategy had been developed alongside a coaching strategy aimed at building a workforce that was highly skilled, competent and compassionate, but also empowered and enabled. The trust had worked with the National Leadership Academy to develop a national talent management toolkit. The trust had offered the NHS Mary Seacole Programme

20190830 RT1 Evidence appendix Page 3

locally and invested in an accredited internal leadership development programme. On appointment all managers joined the first 100 days new managers induction programme. NHS trusts are required to ensure that all directors are fit and proper persons. The trust had ensured that relevant policies and procedures included the requirement to check all future senior staff had the met this standard. During the inspection the trust provided us with details of all the checks they had undertaken to meet this regulation. We reviewed the personnel files of senior staff and found that checks were carried out, disclosure and barring checks were completed on appointment and within the last three years. There was an annual declaration of interests and records maintained of professional qualifications and registrations with expiry dates present. Appraisals were completed, with actions identified.

The four largest ethnic minorities within the trust’s catchment population are: White (90.8%), Asian/Asian British (4.8%), Black/African/ Caribbean/ Black British (2%) and Mixed/ Multiple Ethnic Groups (1.9%). The trust board did not reflect the ethnic make-up of the local population. The executive board had no (0%) black and minority ethnic (BME) members and six (75%) women. The non-executive board had no (0%) BME members and three (38%) women. We found that there was also underrepresentation at senior manager level for BME groups. We felt that the trust needed to consider further how to address this.

Vision and strategy The board and senior leadership team had set a clear vision and values that were at the heart of all the work within the organisation. The trust’s vision and values were embedded at board level and informed how the senior leadership team operated. The board culture was open and honest. The values were embedded within trust processes and the leaders worked hard to make sure staff at all levels understood them in relation to their daily roles. The trust’s vision and values are: CPFT strives to improve the health and wellbeing of the people we care for, our staff and members, to support and empower them to lead a fulfilling life. PRIDE illustrates the trust’s values as detailed below:

Professionalism - We will maintain the highest standards and develop ourselves and others...by demonstrating compassion and showing care, honesty and flexibility Respect - We will create positive relationships...by being kind, open and collaborative Innovation - We are forward thinking, research focused and effective...by using evidence to shape the way we work Dignity - We will treat you as an individual... by taking the time to hear, listen and understand Empowerment - We will support you...by enabling you to make effective, informed decisions and to build your resilience and independence

Staff had been involved in the development of the trust vision and overall knew of plans to develop their service. Staff were clear about their roles and accountabilities. Managers discussed the values with staff in supervision and appraisals and recruitment processes were based on the values. Staff knew the trust values and demonstrated these in the care that they delivered to patients. Staff spoke with passion and commitment and were able to explain how they worked to deliver high quality care within the budgets and resources available to them.

The trust strategy was directly linked to the vision and values of the trust. The trust involved clinicians, patients and groups from the local community in the development of the strategy and from this had a clear plan to provide high-quality care with financial stability. Patients and frontline

20190830 RT1 Evidence appendix Page 4

staff were encouraged to make suggestions for improvements at service level. The trust had responded to feedback and changed the way that it worked as a result.

The trust strategy for 2018 to 2021 included four key strategic priorities. These were:

• deliver the best care - working together with service users, their families and carers we will provide excellent care, supporting people on their personal journey to wellbeing • a leading innovator in healthcare and research – nationally and internationally • demonstrate best value • improve the experience of working in CPFT

The strategy was underpinned by clinical, quality improvement, workforce and organisational development, patient experience and involvement, leadership, wellbeing, information management, technology and estates strategies, and an operational plan. Together these set out more detailed objectives to meet this plan, as well as arrangements to monitor progress.

Staff, patients, carers and external partners had the opportunity to contribute to discussions about trust strategy, especially where there were plans to change services. The trust board, executive team and governance committees reviewed performance against the strategy via the business performance report, quality reports and the performance dashboard. Performance against annual objectives was also published within the quality account. The board used regular meetings to monitor progress against delivery of the strategy and we saw minutes of board meetings, governance meetings, business performance meetings and others where staff reviewed, challenged and updated the strategy.

The trust had aligned its strategy to the wider health and social care economy and trust executives led on several Cambridgeshire sustainability and transformation partnership (STP) wide workstreams including workforce, estates and digital. The trust ensured that its strategy aligned with the key STP priorities. We were impressed by the extent to which the trust board and other senior staff formed and led positive relationships within the wider local system. This was building a system that would be sustainable in the future delivery of health and social care.

The trust had highlighted the need to move towards transformational change to support future service delivery in line with strategic priorities and to reduce its cost base. Commissioners and other stakeholders confirmed that the trust was responsive to challenge and worked collaboratively with stakeholders, other local NHS trusts and the third sector to deliver services to patients. For example, the trust was working three other mental health foundation trusts in the east of England to develop new care models. The trust was working with Cambridge University Hospitals NHS Trust to develop a proposal for a new children’s hospital for the integration of physical and mental health services from one site. The trust was delivering services jointly with the third sector to deliver the Sanctuary, a safe space available to people in crisis.

The trust had a strategy for meeting the physical healthcare needs of inpatients with mental health needs. This was confirmed by our findings during the inspection of the core services where patients’ physical health care needs were assessed and responded to appropriately. We were particularly impressed with physical healthcare monitoring within the acute services and work undertaken regarding smoking cessation.

The trust had planned services to take into account the needs of the local population. For example, the trust had amalgamated physical health care and older people’s mental health community services within locally based hubs to better meet the needs of the aging population. The trust had placed mental health support in every GP practice to improve the delivery of care at a local level and reduce admissions. The trust’s joint emergency team and dementia intensive support teams had reduced admissions to NHS acute hospital wards.

20190830 RT1 Evidence appendix Page 5

Culture Leaders showed a positive culture with a shared purpose towards the vision, values and strategy. Leaders modelled and encouraged compassionate, inclusive and supportive relationships between all grades of staff. Leaders at every level lived the vision and prioritised high quality sustainable and compassionate care. Staff showed pride and talked passionately about their roles. Individual teams had positive relationships, worked well together and addressed any conflict appropriately.

Frontline staff felt respected and supported by their line manager and considered that morale was generally good across the trust.

The trust had appointed a freedom to speak up guardian in 2017. The guardian who was part time, worked across the trust, attended staff induction, engaged with staff and attended events, raising awareness of the role. Staff we spoke with were aware of the role and how to make contact if needed. The guardian confirmed that they felt well supported by the trust board. There was a robust system to report to the trust board on their work via the performance and risk executive and quality safety and governance committee meetings. There were 69 contacts to the freedom to speak up guardian between April 2018 and March 2019, this was an increase on the previous year. While the freedom to speak up guardian was effective the trust needed to consider increasing this resource.

Staff felt able to raise concerns without fear of retribution and knew the trust had a freedom to speak up policy which they would use if they needed to.

Individual staff and teams received awards for improvements made. The trust’s pride awards were open to any person or team in the trust who had been nominated by a work colleague, service user or member of staff in a partner organisation. The chief executive invited patients and staff to the award ceremony held every four months, which demonstrated shared success. Recent awards were given to the children’s young people and families peer support worker team, diversity network and the flu team.

The trust worked appropriately with trade unions. Staff side representatives reported that the leadership team were approachable and committed to working in partnership with trade unions. Staff side representatives were consulted about proposed changes at the work force transformation board. The trust had a clear policy for the management of situations where an individual's performance consistently fell below the acceptable standard. The policy encouraged managers to assist staff to improve their performance. However, managers addressed the poor performance of staff when needed. The trust applied the Duty of Candour appropriately and we saw good examples of this in practice. The trust contacted families and carers for their views and kept them informed. The trust had recently appointed a family liaison and investigation officer who worked closely with families and carers affected by serious incidents and unexpected deaths. Those serious incident reports reviewed included clear communication with and attempts to communicate with family and carers throughout the investigation process. We found that the way that the trust engaged with families and loved ones in the incident and complaints investigation process was proactive and helpful in difficult circumstances.

Staff could access the trust’s occupational health service for support with both physical and mental health issues.

20190830 RT1 Evidence appendix Page 6

The trust had introduced a staff health and wellbeing strategy in 2019. This strategy set out the trust’s goal to improve the health of the workforce and build resilience. Key aims were creating flexible working, improving the culture, reducing poor mental health and stress, reducing bullying and harassment and improvements to the working environment.

The Trust had launched a Heart and Soul Strategy that supported staff in their wellbeing and holistic care at work and underpins the PRIDE values. This sets out a framework for staff on training, advice and guidance in spiritual and religious literacy.

The following illustration shows how this provider compares with other similar providers on ten key themes from the 2018 NHS Staff Survey. Possible scores range from zero to ten – a higher score indicates a better result.

The trust had an action plan in place to address the 2018 NHS staff survey results. This covered work force wellbeing, quality of appraisals, improving engagement and resourcing and support. Senior managers told us they were committed to ensuring that this action plan was implemented fully. The trust’s pulse survey in December 2018 showed that staff felt supported in their role (73.52%) and they could contribute views and ideas (80.89%), had effective supervision (78.57%) and received an appraisal (91.41%). Surveys showed that staff were confident in raising issues and aware of how to raise issues. The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April 2015. Trusts must show progress against nine measures of equality in the workforce.

20190830 RT1 Evidence appendix Page 7

1. The percentages of White and BME staff in each of the Agenda for Change (AfC) pay bands 1 to 9, and at Very Senior Manager (VSM) level (including executive board members), compared with the percentage of staff in the overall workforce. This calculation is undertaken separately for clinical and non-clinical staff.

31 March 2018 Clinical Non-clinical

BME Pay Band White BME White % White BME White % BME % % Under Band 1 0 0 0% 0% 0 0 0% 0%

Band 1 3 0 100% 0% 0 0 0% 0%

Band 2 101 8 90.2% 7.1% 196 57 76.0% 22.1%

Band 3 228 20 89.1% 7.8% 268 36 84.0% 11.3%

Band 4 84 7 85.7% 7.1% 231 8 93.9% 3.3%

Band 5 81 5 93.1% 5.7% 400 94 77.8% 18.3%

Band 6 42 7 85.7% 14.3% 772 143 80.3% 14.9%

Band 7 76 9 83.5% 9.9% 421 56 84.5% 11.2%

Band 8A 52 7 85.2% 11.5% 125 13 88.0% 9.2%

Band 8B 16 3 80.00% 15.0% 28 3 80.0% 8.6%

Band 8C 20 1 87.00% 4.3% 18 1 94.7% 5.3%

Band 8D 4 0 100% 0% 11 0 91.7% 0%

Band 9 5 0 100% 0% 2 0 100% 0%

VSM 5 0 100% 0% 0 0 0% 0%

Medical: Consultants 0 0 0% 0% 78 30 64.5% 24.8% Medical: Non- consultant 0 0 0% 0% 11 8 47.8% 34.8%

20190830 RT1 Evidence appendix Page 8

career grades Medical Trainee grades 0 0 0% 0% 26 16 52.0% 32.0%

Comparison to previous year. Descriptor 31st March 2017 31st March 2018 Number of BME staff in bands 8-9 and VSM 72 82 Total number of staff in bands 8-9 and VSM 281 483 Percentage of BME staff in bands 8-9 and VMS 26% 16.9% Number of BME staff in overall workforce 458 533 Total number of staff in overall workforce 3822 3845 (with declared ethnicity) Percentage of BME staff in overall workforce 12% 13.2%

2. In 2018 (April 2017 – March 2018), 19.5% white candidates against 12.7% of BME candidates gained jobs for which they had been shortlisted. The trust performance against this measure has improved from 10.2% for BME staff in 2017 (April 2016 – March 2017). 3. In 2018 (April 2017 – March 2018), BME staff were less likely to be disciplined1 when compared with white staff. These figures have not been supplied for the previous year. 4. In 2018, (April 2017 – March 2018) 31% of White staff were taking part in voluntary training compared to 35% of BME staff. This is a decrease for BME staff from the previous year’s figure of 78%. 5. The trust had no BME staff at board level in 2018 or the previous year. The trust’s workforce race equality scheme report and action plan for 2018/19 was published on their website in August 2018. This identified actions to be taken by the trust to improve race equality: increase BME staff representation in management at band 7 and above; improve transparency and objectivity in recruitment panel decision-making; unconscious bias training and interventions.

An equality diversity and inclusion strategy had been put in place. This set the vision, approach, key activities and monitoring arrangements in relation to tackling inequalities. It outlined how the trust will advance equality of opportunity, tackle discrimination and foster good relations between different communities and groups. It also described what the trust will do to advance equality within their workforce.

A staff diversity network was in place led by an equality and diversity officer. The trust acknowledged there had been some challenges in this area but had relaunched this. The trust had launched the embrace campaign in 2018. 50+ Diversity Champions, many from BAME backgrounds had been recruited, the trust had offered coaching and mentoring for BAME staff, supported BAME staff to undertake national programs such as ‘Stepping Up’, delivered a diversity

20190830 RT1 Evidence appendix Page 9

conference for over 100 staff and undertaken a ‘deep dive’ into posts where BAME candidates have been unsuccessful.

The trust had an Equality Delivery System 2 improvement plan for 2017- 2021. This covered areas such as better health for all which included a focus on ‘hard to reach’ groups. Links had been established with the Peterborough Multi Agency Forum (MAF) and the Health watch Community Forum to facilitate this. Improved patient access and experience was included in the trust’s improvement plan. This included the delivery of face to face training for staff on peer employment, equality, diversity and dignity at work; supporting vulnerable LGBT people and trans-awareness and unconscious bias training.

The trust reported that 92% of staff had completed the mandatory online e-learning equality and diversity training ‘treating people with respect’. The trust had also provided face to face equality impact assessment training for staff Work was developing on the equality and diversity agenda but was in early stages. Board members recognised that they had work to do to improve diversity and equality across the trust and at board level. We were however very impressed by the leadership of the trust’s diversity network. The Patient Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment. The trust scored between 84% and 89% for mental health services lower than the England average for patients recommending it as a place to receive care for five of the six months in the period (January to June 2019). The trust scored between 96% and 98% for community health services which were either equivalent to or higher than the England average for all six months. The trust was higher than the England average in terms of the percentage of patients in mental health services who would not recommend the trust as a place to receive care in three of the six months. The trust was lower than the England average in community health services in four of the six months. Table detailing Mental Health Services responses Trust wide responses England averages

Total Total % that would % that would England England eligible responses recommend not average average not recommend recommend recommend Jun 2018 6700 384 85% 5% 89% 4% May 2018 6692 330 89% 2% 89% 4% Apr 2018 6509 283 85% 5% 89% 4% Mar 2018 6508 343 87% 5% 89% 4% Feb 2018 6525 322 84% 5% 89% 4% Jan 2018 6783 344 86% 2% 88% 4%

Table detailing Community Health Services responses

20190830 RT1 Evidence appendix Page 10

Trust wide responses England averages

Total Total % that would % that would England England eligible responses recommend not average average not recommend recommend recommend Jun 2018 23694 764 97% 1% 96% 1% May 2018 24112 910 98% 0% 96% 1% Apr 2018 22849 914 98% 0% 96% 1% Mar 2018 23308 1106 97% 0% 95% 1% Feb 2018 22088 769 97% 0% 96% 1% Jan 2018 24390 761 96% 1% 96% 1%

The Staff Friends and Family Test asks staff members whether they would recommend the trust as a place to receive care and also as a place to work. The percentage of staff that would recommend this trust as a place to work in Q2 18/19 stayed about the same when compared to the same time last year. The percentage of staff that would recommend this trust as a place to receive care in Q2 18/19 stayed about the same when compared to the same time last year. It should be noted that there is no reliable data to enable comparison with other individual trusts or all trusts in England.

The trust reviewed the findings of the friends and family test as part of the integrated performance report which was escalated to the trust’s performance and risk executive meetings and the quality safety and governance committee meetings. This provider has reported a vacancy rate for all staff of 8% as of 31 December 2018. This was lower than the rate of 20% reported at the last inspection (at September 2017). This provider reported an overall vacancy rate of 13% for registered nurses at 31 December 2018. The vacancy rate for registered nurses was lower than the 22% reported at the last inspection. This provider reported an overall vacancy rate of 13% for healthcare assistants. The vacancy rate for healthcare assistants was lower than the 28% reported at the last inspection.

20190830 RT1 Evidence appendix Page 11

Registered nurses Health care assistants Overall staff figures

Vacancies Vacancies

Core Vacancies

Establishment Establishment Establishment

Vacancy rate (%) rate Vacancy (%) rate Vacancy service (%) rate Vacancy

Other 5.5 37 15% 15.0 19.3 78% 28.5 65.9 43% MH - Wards for people with learning 5.6 16.8 33% 6.3 17.5 36% 11.9 35.3 34% disabilities or autism MH - Wards for older people with mental 5.6 16.8 33% 6.3 17.5 36% 11.9 35.3 34% health problems MH - Eating Disorders 2.1 27.5 8% 9.3 27.3 34% 19.1 85.2 22% MH - Community mental health services for people with 0 0 0 0 0 0 0.3 1.4 21% a learning disability or autism

MH - Forensic 4.1 15.7 26% 5.1 19.9 26% 8.6 42 20% inpatient MH - Mental health crisis services and health- 32.5 93 35% 7.5 20.6 36% 21.7 122.4 18% based places of safety MH - Child and adolescent mental 18.8 45.7 41% -2.5 15.8 -16% 17.7 110.9 16% health wards

20190830 RT1 Evidence appendix Page 12

Registered nurses Health care assistants Overall staff figures

Vacancies Vacancies

Core Vacancies

Establishment Establishment Establishment

Vacancy rate (%) rate Vacancy (%) rate Vacancy service (%) rate Vacancy MH - Specialist community mental health 18.8 45.7 41% -2.5 15.8 -16% 17.7 110.9 16% services for children and young people. MH - Acute wards for adults of working age and 14.5 111.7 13% -5.6 66.3 -8% 35.0 212.5 16% psychiatric intensive care units MH - Community- based mental 34.2 312.7 11% 35.5 173.2 20% 81.5 624.1 13% health services for older people CHS - Adults 10.3 145.5 7% 22.2 138.4 16% 42.4 417.6 10% Community Other - PMS 0.0 12.8 0% 1.0 2 50% 4.4 45.5 10% Service CHS - Community 5.2 76.3 7% 14.4 113.3 13% 17.8 215.6 8% Inpatients MH - Community- based mental 13.5 74.5 18% -2.4 46.3 -5% 12.3 187.6 7% health services for adults of

20190830 RT1 Evidence appendix Page 13

Registered nurses Health care assistants Overall staff figures

Vacancies Vacancies

Core Vacancies

Establishment Establishment Establishment

Vacancy rate (%) rate Vacancy (%) rate Vacancy service (%) rate Vacancy working age. CHS - Children, Young 0.3 78.3 0% 3.0 27.3 11% 1.4 147.8 1% People and Families Provider Wide -6.9 137.3 -5% 6.0 250.3 2% -1.6 1437.7 0% CHS - Urgent Care 2.5 19.5 13% -1.5 4.9 -31% -1.1 30.4 -4% MH - Other Specialist 3.0 20 15% -1.6 3.6 -44% -3.2 32.9 -10% Services

Trust total 164.0 1294 13% 130.6 1031.7 13% 334.2 3984.1 8% NB: All figures displayed are whole-time equivalents

Between 1 January 2018 and 31 December 2018, 114849 hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reasons for bank and agency usage for the core services were vacancies and the acuity of patients. In the same period, agency staff covered 42162 hours for qualified nurses and 31421 hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling.

Core service Bank Usage Agency NOT filled by Usage bank or agency Hrs Hrs Hrs CHS - Community Inpatients 15960 5056 2218 CHS - Adults Community 10510 1572 2862 CHS - Urgent Care 182 536 1709 MH - Community-based mental health services for older people 9578 6817 9487

20190830 RT1 Evidence appendix Page 14

Core service Bank Usage Agency NOT filled by Usage bank or agency Hrs Hrs Hrs MH - Acute wards for adults of working age and psychiatric intensive care units 31608 15924 7478

Other 23 0 8 MH - Forensic inpatient 1801 0 119 MH - Mental health crisis services and health- based places of safety 14117 864 1946

MH - Eating Disorders 6785 1602 1348 MH - Other Specialist Services 954 58 221 MH - Community-based mental health services for adults of working age. 2982 1640 154

MH - Other Specialist Services 0 38 0 MH - Child and adolescent mental health wards 3487 2771 978 MH - Specialist community mental health services for children and young people. 357 179 319

CHS - Children, Young People and Families 0 0 0 MH - Wards for people with learning disabilities or autism 6137 1518 835 MH - Wards for older people with mental health problems 10371 3588 1742

Trust Total 114849 42162 31421

Between 1 January 2018 and 31 December 2018, 202495 hours were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reasons for bank and agency usage for the core services were vacancies and the acuity of patients. In the same period, agency staff covered 31831 hours and 25759 hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. Core service Bank Usage Agency NOT filled by Usage bank or agency Hrs Hrs Hrs CHS - Community Inpatients 23724 18346 3206 CHS - Adults Community 9519 0 5211 CHS - Urgent Care 0 0 156

20190830 RT1 Evidence appendix Page 15

Core service Bank Usage Agency NOT filled by Usage bank or agency Hrs Hrs Hrs MH - Community-based mental health services for older people 2767 0 1295 MH - Acute wards for adults of working age and psychiatric intensive care units 68087 5525 4979 Other 0 0 0 MH - Forensic inpatient 10437 0 1162 MH - Mental health crisis services and health- based places of safety 5071 58 403 MH - Eating Disorders 12264 1189 2210 MH - Other Specialist Services 607 0 38 MH - Community-based mental health services for adults of working age. 2007 0 9 MH - Other Specialist Services 0 0 0 MH - Child and adolescent mental health wards 14591 1384 2061 MH - Specialist community mental health services for children and young people. 0 0 0 CHS - Children, Young People and Families 582 0 143 MH - Wards for people with learning disabilities or autism 13849 1023 721 MH - Wards for older people with mental health problems 38991 4307 4167 Trust Total 202495 31831 25759

This provider had 446.3 (13%) staff leavers between January and December 2018. This was lower than the 16% reported at the last inspection (from 1 October 2016 to 30 September 2017). Substantive Substantive staff Average % staff Core service staff (latest Leavers (over the leavers (over the month) past 12 months) past 12 months) MH - Eating Disorders 64.0 13.2 22% MH - Other Specialist Services 31.9 6.0 21% MH - Child and adolescent mental 46.6 10.4 20% health wards CHS - Urgent Care 31.1 5.5 19% Provider Wide 1433.2 204.9 14% MH - Acute wards for adults of working age and psychiatric 171.6 21.8 13% intensive care units MH - Forensic inpatient 31.2 4.8 13%

20190830 RT1 Evidence appendix Page 16

Substantive Substantive staff Average % staff Core service staff (latest Leavers (over the leavers (over the month) past 12 months) past 12 months) MH - Community-based mental 531.8 65.2 12% health services for older people CHS - Adults Community 369.6 42.2 12% MH - Community-based mental health services for adults of working 171.9 18.3 10% age. MH - Specialist community mental health services for children and 93.3 8.7 10% young people. MH - Wards for older people with 77.6 7.3 10% mental health problems CHS - Community Inpatients 182.7 17.1 9% MH - Mental health crisis services 96.2 6.6 7% and health-based places of safety CHS - Children, Young People and 145.9 10.4 7% Families Other 35.5 1.7 5% Other - PMS Service 39.6 2.2 5% MH - Wards for people with learning 20.4 0 0% disabilities or autism MH - Community mental health services for people with a learning 1.1 0 0% disability or autism Grand Total 3575.2 446.3 13%

The sickness rate for this provider was 4.5% between January and December 2018. The most recent month’s data, December 2018, showed a sickness rate of 5.3%. This was higher than the sickness rate of 4% reported at the last inspection (September 2017). At the time of the inspection (May 2019) the sickness rate had improved to 3.73%.

Total % staff sickness Ave % permanent staff Core service sickness (over the past (at latest month) year) MH - Wards for older people with 6.8% 8.5% mental health problems MH - Wards for people with 9.6% 8.2% learning disabilities or autism

20190830 RT1 Evidence appendix Page 17

Total % staff sickness Ave % permanent staff Core service sickness (over the past (at latest month) year) MH - Acute wards for adults of working age and psychiatric 9.7% 7.8% intensive care units

CHS - Urgent Care 9.4% 7.0%

CHS - Community Inpatients 8.5% 6.3%

MH - Specialist community mental health services for 3.2% 5.6% children and young people. MH - Community-based mental 4.8% 5.2% health services for older people

Other - PMS Service 6.1% 5.0%

MH - Child and adolescent 2.3% 4.8% mental health wards MH - Mental health crisis services and health-based places of 8.0% 4.4% safety CHS - Children, Young People 5.9% 3.9% and Families MH - Community-based mental health services for adults of 5.8% 3.9% working age.

CHS - Adults Community 5.4% 4.2%

MH - Eating Disorders 1.3% 3.8%

Provider Wide 4.5% 3.7%

MH - Other Specialist Services 4.8% 3.4%

MH - Forensic inpatient 5.5% 2.4%

Other 2.3% 2.2%

MH - Community mental health services for people with a 0.0% 0.0% learning disability or autism

Grand Total 5.3% 4.5%

20190830 RT1 Evidence appendix Page 18

Mandatory training rates were monitored by the trust through each directorate’s performance dashboard via each directorate’s monthly performance and risk executive meeting. The compliance for mandatory and statutory training courses at 31 December 2018 was 90%. Of the training courses listed 13 failed to achieve the trust target and of those, five failed to score above 75%. The trust set a target of 90% for completion of mandatory and statutory training. The trust’s training completion is compiled at the end of the year. The training compliance reported for this provider during this inspection was lower than the 92% reported in the previous year. Key:

Not met trust Met trust target Higher No change Lower Below CQC 75% target ✓  ➔  

Training Module Number of Number of YTD Trust Compliance eligible staff staff Compliance Target change trained (%) Met when compared to previous year Safeguarding Children (Level 4) 7 7 100% ✓ n/a

Conflict Resolution 3853 3797 99% ✓ ➔

Working Safely 3853 3790 98% ✓ ➔

Safeguarding Adults 3860 3784 98% ✓ ➔

Treating People with Respect 3853 3772 98% ✓ ➔

PREVENT (Level 1) 2856 2780 97% ✓ # n/a!

Good Governance 3853 3696 96% ✓ 

Infection Control (Level 1) 980 927 95% ✓ # n/a

Safeguarding Children (Level 1) 818 777 95% ✓ 

Fire Safety 3853 3612 94% ✓ 

PREVENT (Level 2) 1000 943 94% ✓ n/a

Infection Control (Level 2) 2880 2689 93% ✓ n/a

Safeguarding Children (Level 2) 1873 1750 93% ✓ 

Dementia 2527 2343 93% ✓ 

Mental Capacity Act Level 1 970 882 91% ✓ 

Basic Life Support (BLS) 2236 2023 90% ✓ 

20190830 RT1 Evidence appendix Page 19

Training Module Number of Number of YTD Trust Compliance eligible staff staff Compliance Target change trained (%) Met when compared to previous year Safeguarding Children (Level 3) 1157 1018 88%  

Deprivation of Liberty 1115 951 85%  # n/a Safeguards

Mental Health Act Level 1 336 282 84%  

Physical Interventions 241 203 84%  

Mental Health Act Level 2 568 474 83%  

Mental Capacity Act Level 2 1520 1239 82%  

Manual Handling (Level 2) 1529 1228 80%  n/a

Carer Awareness 3853 3009 78%  n/a

Medical Emergency Response 742 555 75%  n/a Course (MERC) Safeguarding Children Level 3; 1142 808 71%  n/a Mandatory for Role (3hrs)

Manual Handling (Level 1) 755 506 67%  n/a

Smoking Cessation 3853 2581 67%  n/a

Immediate Life Support (ILS) 2880 2689 12%  n/a

Total 56099 50427 90% ✓ 

By the time of the inspection training rates had improved. All courses were above the 75% target.

The trust’s target rate for appraisal compliance is 95%. At the end of last year (April 2017 to March 2018), the overall appraisal rate for non-medical staff was 76%. This year so far, the overall appraisal rate was 80% (as at January 2019). None of the 19 services achieved the trust’s appraisal target. The services with the lowest compliance were ‘MH - Wards for people with learning disabilities or autism’ with 35%, ‘MH - Eating Disorders’ with 43% and ‘MH - Community mental health services for people with a learning disability or autism’ with 50%. The rate of appraisal compliance for non-medical staff reported during this inspection is lower than the 92% reported at the last inspection.

20190830 RT1 Evidence appendix Page 20

Core Service Total Total % % number of number of appraisals appraisals permanent permanent (as at 31 (previous non- non- January year 1 medical medical 2019) April 2017- staff staff who 31 March requiring have had 2018) an an appraisal appraisal

CHS - Adults Community 420 376 92% 74% CHS - Children, Young People and Families 148 137 90% 90% MH - Community-based mental health services for adults of working age. 184 163 89% 80% MH - Community-based mental health services for older people 584 516 88% 81% MH - Specialist community mental health services for children and young people. 90 77 86% 88%

Other 42 36 86% 74% MH - Forensic inpatient 26 22 85% 93% CHS - Community Inpatients 198 168 85% 67% MH - Mental health crisis services and health- based places of safety 100 83 83% 59% MH - Acute wards for adults of working age and psychiatric intensive care units 168 129 77% 64% MH - Wards for older people with mental health problems 79 61 77% 74%

MH - Other Specialist Services 32 24 75% 56% Provider Wide 1228 913 74% 77% Other - PMS Service 39 24 62% 85% MH - Child and adolescent mental health wards 49 27 55% 81%

CHS - Urgent Care 34 17 50% 65% MH - Community mental health services for people with a learning disability or autism 2 1 50% 100%

MH - Eating Disorders 60 26 43% 61% MH - Wards for people with learning disabilities or autism 20 7 35% 28%

Total 3503 2807 80% 76%

The trust’s target rate for appraisal compliance is 95%. At the end of last year (April 2017 to March 2018), the overall appraisal rate for medical staff was 42%. This year so far, the overall appraisal rate was 65% (as at January 2019). Six of the ten teams (60%) achieved the trust’s appraisal

20190830 RT1 Evidence appendix Page 21

target. The services with the lowest compliance were ‘MH - Other Specialist Services’ with 0%, ‘MH - Forensic inpatient’ with 0% and ‘CHS - Children, Young People and Families’ with 57%. The rate of appraisal compliance for medical staff reported during this inspection is not comparable to the rate reported at the last inspection.

By the time of the inspection the trust confirmed that appraisal rate was 77% for all staff.

Core Service Total number Total number % % of permanent of permanent appraisals appraisals medical staff medical staff (as at 31 (previous requiring an who have had January year 1 appraisal an appraisal 2019) April 2017- 31 March 2018) MH - Community mental health services for people with a learning disability or 1 1 100% 0% autism MH - Community-based mental health 1 1 100% 100% services for adults of working age. MH - Specialist community mental health 1 1 100% 0% services for children and young people. CHS - Community Inpatients 2 2 100% 100% MH - Child and adolescent mental health 3 3 100% 0% wards MH - Eating Disorders 5 5 100% 20% Provider Wide 89 56 63% 43% CHS - Children, Young People and 7 4 57% 50% Families MH - Forensic inpatient 2 0 0% 100% MH - Other Specialist Services 1 0 0% 0% Total 112 73 65% 42%

The trust has not set a target for clinical supervision for non-medical staff. Between 1 April and 31 December 2018, the average rate across all 19 core services was 50%. The rate of clinical supervision reported during this inspection was lower than the 67% reported at the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide.

Core service Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) MH - Community mental health services for people with a learning disability or 13 12 92% autism

20190830 RT1 Evidence appendix Page 22

Core service Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) MH - Specialist community mental health services for children and young people. 874 601 69% CHS - Children, Young People and Families 1389 863 62%

MH - Other Specialist Services 101 62 61% MH - Community-based mental health services for adults of working age. 1965 1131 58%

Other - PMS service 359 205 57%

CHS - Adults Community 3794 2072 55% MH - Acute wards for adults of working age and psychiatric intensive care units 1503 771 51%

Provider wide 11178 5610 50% MH - Child and adolescent mental health wards 503 240 48% MH - Community-based mental health services for older people 5160 2464 48%

MH - Eating Disorders 502 243 48%

MH - Forensic inpatient 292 139 48% MH - Wards for older people with mental health problems 726 326 45%

Other 363 155 43% MH - Mental health crisis services and health-based places of safety 912 376 41% MH - Wards for people with learning disabilities or autism 176 49 28%

CHS - Community Inpatients 1780 474 27%

CHS - Urgent Care 291 42 14%

Total 31881 15835 50%

The trust has not set a target for clinical supervision for medical staff. Between 1 April and 31 December 2018, the average rate across the two services supplied was 0%. The rate of clinical supervision reported during this inspection was not comparable to the rate at the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide.

20190830 RT1 Evidence appendix Page 23

Core service Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) MH - Specialist community mental health services for children and young people 3 0 0%

Provider-wide 23 0 0%

Total 26 0 0%

At core services we found that generally staff had received management and clinical supervision. Managers kept their own records as there could be a delay in data. Staff reported that supervision was of good quality.

Governance The trust had effective structures, systems and processes in place to support the delivery of its strategy including monthly performance and risk executive meetings for each of the three directorates and team meetings at ward level. The trust regularly reviewed these structures. The trust had a board of directors who were accountable for the delivery of services and assurance through its governance structure for the quality and safety of the trust. During the inspection we attended the trust board. There was robust scrutiny at board level and non- executive directors challenged decisions appropriately. Trust board papers also evidenced that the trust board was provided with updates from all board sub-committees at the correct level of information to enable them to make informed decisions.

There were five committees which reported to the trust board that together provided additional assurance:

o Quality, Safety and Governance Committee o Audit and Assurance Committee o Business and Performance Committee o Charitable Funds Committee o Joint Children’s Partnership Board (with Cambridgeshire Community Services NHS Trust)

Reporting to these were a range of sub committees and directorate meetings that together provided scrutiny, challenge, detailed decision making, problem solving and additional assurance across key areas of safety and quality.

Executives, non-executives and senior leaders knew their responsibilities and chaired appropriate governance committees. They took ownership of their areas and knew key areas of risk and good practice.

Team managers attended directorate clinical governance meetings, which fed into the trust wide governance meetings. Team managers confirmed that they able to raise issues through the risk register and operational groups. Local governance meetings discussed team issues, such as incidents, safeguarding, staffing concerns, and identified and shared learning. Managers fed this learning back to front line staff and patients through team meetings, supervision and learning bulletins.

Staff demonstrated they were aware of their responsibilities in relation to governance. Staff told us that they were aware of the governance structure and had access to performance information and meeting minutes. Staff felt able to report issues and successes through local meetings and

20190830 RT1 Evidence appendix Page 24

through local risk registers which fed into the directorate’s monthly performance and risk executive meeting attended by the chief executive. This meant that the board had oversight of local challenges, developments and successes.

We reviewed papers from a variety of meetings during the inspection which demonstrated staff reviewed risk, quality and performance. Local managers knew the reporting structure for sharing information and escalating concerns and could describe the ward to board governance structure.

Our findings from the core services demonstrated that governance processes operated effectively at team level and that performance and risk were managed well. The trust had improved on many levels since our last inspection although there was work left to do. Recruitment and retention had improved significantly, particularly in the CAMHs, eating disorder and First Response services. In addition, staffing metrics such as sickness, stability rate and appraisal had improved. Staff stability was beginning to have an impact on the quality of service delivered. However, it is of concern that the trust had not addressed all safety concerns within the acute wards that had been raised with the trust following the previous inspection.

Arrangements were in place for the governance of the Mental Health Act and Mental Capacity Act. The medical director was the executive lead for mental health law. The MHA legislation group reported to the Quality, Safety and Governance Committee and both were sighted on regular performance information. The board received an annual report on the operation of the legislation.

The trust had a section 75 agreement in place for the delivery of Local Authority functions. There was representation from partner agencies on Mental Health Act working groups and committees. Joint working groups included the Crisis Concordat Mental Health Delivery Board and Mental Health Law Liaison group. The trust had a positive partnership with the police to deliver section 136 responsibilities.

The trust provided psychiatric liaison services at three hospitals across Cambridgeshire. All three services were accredited by the Psychiatric Liaison Accreditation Network as excellent.

In May 2019, the trust was categorised as being ‘offered 'targeted support' by the NHS Improvement Single Oversight Framework. The trust had a process in place for managing complaints and cross checking for any safeguarding and welfare concerns and immediate actions. The trust had a complaints policy in place . Staff who investigated complaints received additional training and had access to trust guidance on complaint investigation. Information on how to make a complaint was available throughout the trust and patients told us that they knew how to make a complaint and staff had supported them to do so. Staff were encouraged where possible to resolve complaints locally. The trust worked with their Patient Advice and Liaison Service to provide patients, their carers and families with help, information and support to resolve any concerns quickly and efficiently. Duty of Candour consideration had been included in the investigation process. Final investigation letters were approved by the Directorate Heads of Nursing and signed off by the Chief Executive. Managers shared learning and action plans from complaints at ward-based team meetings and more widely via the trust’s quarterly ‘lessons in practice’ bulletin. The records seen showed us that the trust had received 202 formal complaints between January and December 2018. Of these 33 were upheld and 73 partially upheld. Twenty-five complaints had been reinvestigated as the complainant was unhappy with the outcome. Fourteenof these complaints were subsequently upheld due to additional information supplied by the complainant.

20190830 RT1 Evidence appendix Page 25

Ahead of the inspection, the trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months. The trust submitted the following data:

Current In Days Performance What is your internal target for responding to* complaints? 3 90% What is your target for completing a complaint? 30 100% If you have a slightly longer target for complex complaints please n/a n/a indicate what that is here

* Responding to defined as initial contact made, not necessarily resolving issue but more than a confirmation of receipt **Completing defined as closing the complaint, having been resolved or decided no further action can be taken

Total Date range

Number of complaints resolved without formal process*** in the 379 last 12 months 1 January to 31 Number of complaints referred to the ombudsmen (PHSO) in the 9 December last 12 months 2018 Number of complaints referred to the ombudsmen (PHSO) in the 0 last 12 months that were upheld **Without formal process defined as a complaint that has been resolved without a formal complaint being made. For example, PALS resolved or via mediation/meetings/other actions However, at the time of the inspection not all complaints had been addressed within the timeline of 30 working days. This had dropped to an average of 44 days in May 2019 to fully respond to complaints. This trust received 6654 compliments during the last 12 months from 1 January to 31 December 2018. This was lower than the 7967 reported at the last inspection. ‘MH - Community-based mental health services for older people’ had the highest number of compliments with 30%, followed by ‘CHS - Adults Community’ with 23% and ‘CHS - Urgent Care’ with 9%.

This trust received 6654 compliments during the last 12 months from 1 January to 31 December 2018. This was lower than the 7967 reported at the last inspection. ‘MH - Community-based mental health services for older people’ had the highest number of compliments with 30%, followed by ‘CHS - Adults Community’ with 23% and ‘CHS - Urgent Care’ with 9%.

Cambridgeshire and Peterborough NHS Foundation Trust submitted details of six external reviews commenced or published in the last 12 months (1 January 2018 – 31 January 2019). The trust provided details of the actions it had taken in response to these external reviews. External Review/Investigation Key Outcomes Three external serious incident One SI report is due to be published by Consequence UK investigations commissioned by (multi agency) Cambridgeshire and Peterborough CCG. Key findings: • MWs death was not preventable These relate to patients under the Eating • There were several aspects of her care and treatment that could and should have been better.

20190830 RT1 Evidence appendix Page 26

Disorder Services involving other • Only 2 recommendations relate directly to the care organisations. provided by CPFT. • Local and national recommendations.

Two investigations currently being undertaken by Niche commissioned by the CCG. One External SI investigation Various conclusions linked to: Diagnosis, Medical commissioned by CPFT Treatment, risk assessment and management. Peer Review Report - Willow ward. Review Willow ward peer review - by College Centre for Quality Improvement Highlights: (CCQI) - Spacious physical environment - Engaged passionate staff - Well-structured and executed ward processes - Good access to staff training Areas for Improvement: - Lack of psychological input for patients - Blind spots on wards requiring mirrors - Regular support and training for staff on psychological skills and therapies In November 2018 there was a Health & HSE inspection Safety Executive (HSE) inspection across • examples of good practice were identified in both the Trust focussing on the management areas • Notification of Contravention received, regarding arrangements for Violence & Aggression issues highlighted with the management of patient lifting and Moving & Handling. This included visits equipment on a particular inpatient unit. This was escalated to a selection of inpatient and community and prompt action was taken. services and interviews with key members of staff. Further advice was also received for the Trust to consider improving practice, although there were no other Notices. Developed comprehensive action plan to address the Notification of Contravention and act on further advice of the inspectors. Ratified by the Board. Inspectors approved the plan and all actions in February 2019, closing down the inspection on their records. and All actions are either already completed or on track and are monitored by the Risk Reduction Group. Two recent audits by Peterborough City Not supplied Council (PCC) Adult Social Care (ASC). UNICEF Baby Friendly Accreditation - Not supplied November 2018

Management of risk, issues and performance The service had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

The trust told us that they had reviewed and refined the risk management and escalation framework to ensure all risks were accurately recorded, appropriately managed, routinely reviewed and escalated where necessary.

In line with the trust risk management framework, the board had reviewed the organisational risk appetite on an annual basis to agree the risk tolerance thresholds for the next financial year. 20190830 RT1 Evidence appendix Page 27

The trust monitored strategic risks via the board assurance framework (BAF) and reviewed this regularly. The trust had an integrated board assurance framework and operational risk register which was reviewed by the board, its sub-committees, and the performance and risk executive on a regular basis. The trust provided its BAF. This detailed any risk scoring 15 or higher or where there were gaps in the risk controls that affect strategic ambitions. At the time of the inspection there were 16 corporate risks recorded on the BAF. Most risks that we observed during this inspection had been included such as staffing levels, financial viability, failure to deliver cost savings and reputational risks in line with planned inquests. We found this document gave assurance to the board. However, we identified some further areas for improvement and some action required to address previous breach of regulation. The board assurance framework has not included this information.

Risk registers were in place at trust, directorate and team level. The board knew their high-level risks and the actions being taken to mitigate these. Senior trust staff reviewed the trust risk register and non-executive directors openly challenged issues through board and governance meetings. Service, directorate and organisational risk registers were monitored at scrutiny groups to ensure recorded risks were being appropriately managed, mitigated and escalated. Local risk registers were in place and fed into the wider trust high level risk register through the performance review executive of each directorate. Staff could escalate concerns and submit items to the trust risk register. Staff’s concerns were generally reflected in local risk registers.

The risk reduction group acted as a single forum to consider the health, safety and well-being of service users, staff and visitors and to promote a safety culture. This group considered health and safety, medical devices, safety alerts, security and environmental factors including ligature reduction.

Managers used a systematic approach to continually improve the quality of its services. Staff were committed to improving services by learning from when things went well and when they went wrong. Wider trust learning was supported by the quarterly ‘lessons in practice’ bulletin which was widely disseminated throughout the trust. This included learning for trust staff from complaints, incidents, safeguarding, stop the line, and patient experience feedback.

The trust had effective structures, systems and processes in place to support the delivery of its strategy including monthly performance and risk executive meetings for each of the three directorates and team meetings at ward level. The trust regularly reviewed these structures. The safety quality and governance committee and the trust board reviewed performance reports and board members encouraged challenge on issues. Leaders regularly reviewed and improved trust processes to manage current and future performance. The trust had a comprehensive programme of clinical audit that was embedded into the governance processes at all levels of the organisation. The trust also has a programme of internal audits which was based on the key risks identified in the BAF. The plan was agreed in advance by the executive team and progress was monitored throughout the year at the audit and assurance committee. There were 98 audits in progress at March 2019. The trust had a major incident and continuity plan in place for emergencies. This covered a range of potential concerns. In line with national requirements, the trust completed a self-assessment in September 2018, against the national emergency preparedness, resilience and response (EPRR) core standards. This had concluded the trust to be non-compliant at that time. Since, the trust has undertaken a comprehensive review of all of it EPRR functions and revised all supporting documentation, policies and procedures. The trust was on track to be compliant by the end of the year. The financial information provided to Board was clear and consistent with the monthly financial returns submitted to NHS Improvement. Despite significant financial challenge in the local system, the trust has demonstrated good financial management over previous years. The trust had a

20190830 RT1 Evidence appendix Page 28

surplus of £4.1 million for the financial year 2018/19. The trust also received an additional £4.5 million in funding from the STP to support mental health and community healthcare initiatives. Where cost improvements were taking place there were arrangements to consider the impact on patient care. The board monitored changes for potential impact on quality and sustainability. Board members challenged business development proposals if the impact on patient care or service delivery was not clearly mitigated. The Trust’s financial recovery plan was discussed with the Director of Finance. They were clear where the risks were and were able to describe the actions being taken to manage and mitigate these.

Historical data Projections Financial Metrics Previous financial Last financial This financial Next financial year (2 years ago) year year year (1 April 2016 – (1 April 2017 – (1 April 2018 – (1 April 2019 – 31 March 2018) 31 March 2019) 31 March 2020) 31 March 2017) Actual income £199,837 £224,997 £218,264 £229,791 Actual surplus £2,263 £14,074 £3,176 (£2,624) (deficit) Actual costs/expenditure - £197,574 £210,923 £215,088 £232,415 full Planned budget or £1,447 £2,249 £3,176 (£2,624) (deficit)

The trust has submitted details of four serious case reviews commenced or published in the last 12 months. Reference Team/Ward/Unit Recommendations Actions Taken Outstanding Actions Number Op Dunholt Peterborough Thematic overview The School All actions completed. SCR school nursing SCR around child Nursing service and all CPFT sexual exploitation should develop a guidance document for school nursing regarding actions to be taken when they when they receive notifications from the WIC and/or A and E and response to causes for concern

20190830 RT1 Evidence appendix Page 29

Reference Team/Ward/Unit Recommendations Actions Taken Outstanding Actions Number 1. Embed a Completed - embedded consistent approach through supervision and and a robust process training - in safeguarding on receiving satchel CSA strategy notifications from the written and supporting WIC and/or A and E training and resources developed. Countywide CSA conference to be held in June 2018 Quality assurance activity undertaken by both the LSCB and single agencies will reflect the changes made by the recommendations

2. All clinical staff are ALL CPFT Completed - embedded equipped and able to clinical staff to through supervision and identify signs of have access to training - CSA strategy grooming and risk training around developed – use of the indicators of sexual recognising, Brook Traffic Light tool abuse and report it responding to included as a tool to help appropriately and recording practitioners identify child sexual concerns regarding CSA. abuse and Quality assurance activity exploitation. undertaken by both the LSCB and single agencies will reflect the changes made by the recommendations 3. staff to recognise completed - embedded sexualised via training advice and behaviours which supervision - guidance in may be a nonverbal satchell and user guide indicator that a child is being sexually abused/exploited.

4. CPFT to engage in CPFT staff to processes which receive advice share community and support in intelligence managing suspected cases of CSE, and access to bespoke tools. Peterborough school nurses and LAC nurses take part in MASE. CPFT contribute to all strategy discussions about CSA and CSE.

20190830 RT1 Evidence appendix Page 30

Reference Team/Ward/Unit Recommendations Actions Taken Outstanding Actions Number CMAR Psychiatric CMAR- was a SCR in progress focus group 1 liaison services relating to a mother February 2019 who experienced mental illness and had learning difficulties whose child was significantly injured- awaiting publication due to police investigations Perinatal The LSCB should 1. CPFT to Task & Finish group took services review and reissue redraft the place on 1-2-19 - Staff the guidance guidance around who attended are feeding ‘Safeguarding ‘Safeguarding back contributions. Children who have a Children who Ongoing Parent or Carer with have a Parent or Mental Health Carer with Problems. Guidance Mental Health for Effective Joint Problems. Working’ ensuring Guidance for that perinatal needs Effective Joint are appropriately Working’ addressed ensuring that a wide spread of adult mental health services contribute to this guidance in partnership with CSC and other agencies Trustwide "How practitioners CPFT action: Complete respond to situations establish a where they believe Complex case that the escalation recommended process course of action is insufficiently rapid to deal with presenting risk" The trust had a robust system in place for the recording, monitoring and evaluation of serious incidents and complaints. Trust wide learning from these was evident and demonstrated a real attempt to improve practice. The trust had a policy for reporting incidents which set out how staff should manage and report incidents. This was supported with effective staff guidance. Root cause analysis training had been undertaken by over 150 staff members. The trust had more than 100 investigators who had received advanced training. The trust had systems in place to identify learning from incidents, complaints and safeguarding alerts. Safety and governance teams regularly reviewed these systems. The serious incidents group (SIG) led on this work and provided an open forum to understand why things went wrong and to support any learning. In addition, the mortality review group (MRG) was responsible for implementing any national requirements in relation to learning from deaths.

20190830 RT1 Evidence appendix Page 31

We reviewed six investigations and found that they were detailed, established the facts of what had happened and analysed the root cause of the incident. Where actions were put in place, these were monitored by the directorate heads of nursing and the patient safety team for assurance that actions were completed. There was a centralised process in place to record action plans and these were only deescalated once the action plan was completed. There was a clear structure on how learning was shared following incidents. This included a lessons’ in practice bulletin and discussions at team-based meetings. Patients safety roadshows were scheduled and a patient safety improvement day had also occurred. Staff described the investigation process as reflecting a no blame culture in the trust. Commissioners had reported that the trust performance in timeliness and quality of investigations was good. We analysed data about safety incidents from three sources: incidents reported by the trust to the National Reporting and Learning System (NRLS) and to the Strategic Executive Information System (STEIS) and serious incidents reported by staff to the trust’s own incident reporting system. These three sources are not directly comparable because they use different definitions of severity and type and not all incidents are reported to all sources. For example, the NRLS does not collect information about staff incidents, health and safety incidents or security incidents. Between 1 January and 31 December 2018, the trust reported 94 serious incidents. The most common type of incident was ‘apparent/actual/suspected self-inflicted harm’ with 63, of these incidents, 24 occurred in MH - Community-based mental health services for adults of working age.

We reviewed the serious incidents reported by the trust to the Strategic Information Executive System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with 95 reported. Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systematic protective barriers, are available at a national level, and should have been implemented by all healthcare providers. The trust reported no never events during this reporting period.

The number of serious incidents reported during this inspection was comparable to the 92 reported at the last inspection.

20190830 RT1 Evidence appendix Page 32

and and

crisis services and health and services crisis

based mental health services services health mental based services health mental based

- -

Adults Community Adults Inpatients Community

Acute wards for adults of working age age working of adults for wards Acute wards health mental adolescent and Child Community Community Disorders Eating health mental community Specialist health mental with people older for Wards

Mental health health Mental Services Specialist Other

- -

Type of incident

------

reported

psychiatric intensive care units care intensive psychiatric age. working of for adults people for older safety of places based people. young and children for services problems

CHS CHS CHS MH MH MH MH MH MH MH MH MH Other Provider Total Apparent/actual/susp ected self-inflicted 2 0 4 0 24 8 0 15 8 1 0 1 0 63 harm

Pressure ulcer 6 0 0 0 0 0 0 0 0 0 0 0 0 6 Slips/trips/falls 0 0 0 0 0 0 0 1 0 0 5 0 0 6 Confidential information leak/information 0 0 0 0 0 0 1 0 0 0 0 0 3 4 governance breach

Medication incident 2 1 1 0 0 0 0 0 0 0 0 0 0 4 Disruptive/ aggressive/ violent 0 0 0 0 1 0 0 0 1 0 0 0 0 2 behaviour Abuse/alleged abuse of adult patient by 0 0 0 0 0 0 0 0 0 0 1 0 0 1 third party Abuse/alleged abuse of child patient by 1 0 0 0 0 0 0 0 0 0 0 0 0 1 staff Abuse/alleged abuse of child patient by 0 0 0 1 0 0 0 0 0 0 0 0 0 1 third party Accident e.g. collision/scald (not 1 0 0 0 0 0 0 0 0 0 0 0 0 1 slip/trip/fall) Adverse media coverage or public concern about the 0 0 0 0 0 1 0 0 0 0 0 0 0 1 organisation or the wider NHS Major incident/ emergency 0 0 1 0 0 0 0 0 0 0 0 0 0 1 preparedness. resilience and

20190830 RT1 Evidence appendix Page 33

and and

crisis services and health and services crisis

based mental health services services health mental based services health mental based

- -

Adults Community Adults Inpatients Community

Mental health health Mental Services Specialist Other

- -

Type of incident

------

reported

psychiatric intensive care units care intensive psychiatric age. working of for adults people for older safety of places based people. young and children for services problems

CHS CHS CHS MH MH MH MH MH MH MH MH MH Other Provider Total response/ suspension of services Operation/treatment given without valid 0 0 0 0 0 0 0 0 0 0 1 0 0 1 consent Sub-optimal care of the deteriorating 0 0 0 1 0 0 0 0 0 0 0 0 0 1 patient Surgical/invasive procedure 1 0 0 0 0 0 0 0 0 0 0 0 0 1

Total 13 1 6 2 25 9 1 16 9 1 7 1 3 94

Providers are encouraged to report patient safety incidents to the National Reporting and Learning System (NRLS) at least once a month. The highest reporting categories of incidents reported to the NRLS for this trust for the period 1 January to 31 December 2018 were ‘self-harming behaviour’, ‘patient accident’ and ‘implementation of care and ongoing monitoring / review’. These three categories accounted for 4413 (58%) of the 7582 incidents reported. Self-harming behaviour accounted for six of the eight deaths reported. 94% percent of the total incidents reported were classed as no harm (49%) or low harm (44%). Incident type No harm Low Moderate Severe Death Total harm Self-harming behaviour 153 1971 90 6 6 2226 Patient accident 723 364 35 1 0 1123 Implementation of care and ongoing monitoring / 173 610 272 9 0 1064 review

Treatment, procedure 505 119 7 0 0 631 Medication 504 41 2 0 0 547

20190830 RT1 Evidence appendix Page 34

Incident type No harm Low Moderate Severe Death Total harm Access, admission, transfer, discharge 392 66 22 1 0 481 (including missing patient) Disruptive, aggressive behaviour (includes 283 129 8 0 0 420 patient-to-patient) Infrastructure (including staffing, facilities, 293 1 6 0 0 300 environment) Documentation (including electronic & paper records, identification and 284 4 0 0 0 288 drug charts) Consent, communication, confidentiality 250 8 4 0 0 262 Clinical assessment (including diagnosis, scans, tests, 102 19 11 2 0 134 assessments) Medical device / equipment 37 3 1 0 0 41

Infection Control Incident 23 1 1 0 0 25 Other 11 5 4 0 2 22 Patient abuse (by staff / third party) 9 8 1 0 0 18

Total 3742 3349 464 19 8 7582

Organisations that report more incidents usually have a better and more effective safety culture than trusts that report fewer incidents. A trust performing well would report a greater number of incidents over time but fewer of them would be higher severity incidents (those involving moderate or severe harm or death). Cambridgeshire and Peterborough NHS Foundation Trust reported more incidents from 1 January to 31 December 2018 compared with the previous 12 months. Level of harm 1 January 2017 – 31 1 January 2018 – 31 December 2017 December 2018 No harm 3650 3742 Low 2404 3349 Moderate 431 464 Severe 28 19 Death 1 8 Total incidents 6514 7582

20190830 RT1 Evidence appendix Page 35

Information Management The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

The trust collected and used information and data to consider its performance on service quality and sustainability. Trust wide information was in an accessible format, timely, accurate and identified areas for improvement.

The trust used key performance indicators to monitor performance. The data warehouse had been developed to provide a single version of the data held within the trust, with reporting of the same information aggregated or disaggregated to the required reporting level.

Leaders used meeting agendas and performance data to address quality and sustainability sufficiently at all levels across the trust. Executives had access to a performance dashboard that included a range of measures encompassing clinical, workforce, patient experience and financial data. The performance dashboard fed into a board assurance framework and was considered at the board and all relevant governance committees.

At directorate level, service line reporting meetings considered benchmarked service performance data. Directorate performance was then subject to scrutiny by the executive team at the monthly performance and risk executive (PRE) meetings, using an integrated performance report (IPR) and supporting contextual analysis and insight.

Local managers had access to a variety of performance information via a dashboard that supported their management roles. Information included fill rates, incidents and supervision and appraisal compliance. Local managers provided staff with performance information which highlighted the key items and areas to address. Staff said they had access to all necessary information and were encouraged to challenge its reliability.

The board and senior staff expressed confidence in the quality of the data and welcomed challenge. Data validity was audited on an ongoing basis to ensure compliance, accuracy and relevance of information. Prior to submission to the PRE and governance groups the data is taken through clinical team meetings and directorate operational meetings to ensure accuracy. The trust told us that they had further developed their performance dashboard over the last year and had added new metrics across a range of clinical and operational performance indicators.

Final versions of the data, and associated analysis and insight, are then presented to subcommittees of the Trust Board, prior to publication to the Board itself. Through robust and transparent extraction, to effective challenge and discussion, the trust has a strong assurance process to monitor and manage data quality and validity.

The trust was continuously identifying efficiency opportunities highlighted by benchmarking against similar organisations. The trust used the model hospital database to compare performance and identify opportunities for development.

The trust provided financial information to NHS Improvement regularly. Information presented to board was consistent with the information submitted in their monthly finance returns. The Trust

20190830 RT1 Evidence appendix Page 36

was able to provide a clear explanation of their financial performance. Cost improvement plans (CIPs) were driven by the analysis of model hospital data to deliver financial efficiency savings.

Staff had access to a range of policies and procedures via their intranet. Policies gave clear direction to staff, were accessible, reflected best practice and had been reviewed in accordance with approved timescales.

Staff had access to the equipment and information technology they needed to do their work. The information technology infrastructure, including the telephone system, worked well and helped to improve the quality of care. Where necessary staff had laptops, Wi-Fi access and mobile phones. The trust invested in electronic tablets for surveys and to access the clinical note system. Community teams had security systems to maintain staff safety when lone working. Staff reported that that the IT system worked well, and access speeds were generally good.

The trust had robust information governance systems in place including the confidentiality of patient records in line with best practice.

The trust had a senior information risk owner and a Caldicott guardian. The senior information risk owner was accountable for how the trust managed information risks and incidents. An information governance and records management steering group was in place to oversee an annual information management work programme and to ensure appropriate records management processes to assess risks to the security, confidentially, integrity and availability of patient, staff and business information.

The General Data Protection Regulation (GDPR) has been rolled out successfully. The trust had since audited compliance with the GDPR and substantial assurance was awarded for both the design and operational effectiveness of the controls in place.

The trust had declared a satisfactory level of compliance at 85% for the information governance toolkit in June 2018.

There had been two information governance breaches reported by the trust within the previous 12 months. These had been investigated with action plans put in place to address findings. Incidents that did not reach the threshold for external reporting were also investigated. Lessons learnt from these incidents was shared across teams via staff and business meetings and lessons learnt bulletins.

The Trust had a suite of information governance policies and guidance available to staff which set out arrangements for the effective management of information. Staff knew the importance of managing patient confidential personal information securely. Access to electronic patient care and treatment records was password protected and via smart cards. Information was stored securely, both in paper and electronic format.

The trust notified and shared information with external organisations when necessary, seeking patient consent when required to do so.

Engagement The trust told us that they were committed to engaging with people who use services, their carers and their representatives. The trust’s approach to engaging with patients, carers and stakeholders was set out in several strategies including a partnership strategy and the trust’s priorities statement. Underpinning this, was a detailed user and carer engagement programme. This work was overseen by a trust wide patient participation forum supported by a dedicated patient experience team and service-based engagement co-ordinators. Work undertaken had included promotion of advocacy and local forums, increased partnerships with voluntary and community

20190830 RT1 Evidence appendix Page 37

groups and service user involvement in training, recruitment, research and audit. The trust was also developing QI plans at directorate level to increase engagement. An event, learning together to improve care, had been held in April 2019 to begin this process. The board received a patient or carer story at each of its formal meetings which gave them chance to hear directly the impact of patient experience.

The trust told us that they were committed to ensuring service users were at the heart of service delivery. The trust formally employed over 70 peer support workers within the recovery college and across the trust. The trust had promoted the Wearing2Hats campaign which is a group of staff who share their own experiences of mental and physical ill-health and who want to help the organisation to become a more mindful employer. The trust had also worked with a third sector organisation, Help-force, to increase volunteer engagement: as a result, the trust had recruited over 160 volunteers, many had lived experience of services.

The participation and partnership forum aimed to ensure that the voices of people who used the services were heard and embedded in the organisation. In addition, inpatient services had community meetings to engage patients in the planning of the service and to capture feedback. In most services this meeting was chaired by patients and was attended by relevant staff. Some meetings were supported by local advocacy services. Minutes were usually taken, and we saw evidence of actions that were raised being completed. Patients told us they felt able to raise concerns in the community meetings and that they usually felt listened to. Across services we found good patient involvement of patients in their care. Almost all care plans and records reviewed demonstrated the person’s involvement. In all services we found that there was an opportunity for patients to attend care planning meetings. We found a number of examples of relatives being involved in care planning where this was appropriate. The trust aimed to ensure that carers were getting the right support, so they could provide the best possible care to their loved. A carer programme board had been set up to increase carer awareness and engagement across the trust. Chaired by the lead governor the programme board reported directly to the council of governors and linked into the trust’s operational and governance structures. Other initiatives developed included partnerships with the third sector carers organisations, carers’ leads within services, regular carer events and use of the ‘triangle of care’ toolkit which provides an accredited framework to develop carer involvement within local services. The trust told us that they were pro-active about engaging with underrepresented groups. Access to information for all patients had been a key piece of work undertaken. The trust had a policy regarding accessible information and had developed a range of leaflets, letters and tools in easy read formats. We saw that there was information available throughout the trust and via its website about how to provide feedback on the specific services received by people. Patients and their families or carers were also engaged by staff in community services using a variety of methods. The trust had used the friends and families test (FFT). The Patient Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment. Between January and June 2019, the trust scored between 84% and 89%, worse that the England average for patients recommending it as a place to receive care for five of the six months in the period. However, during the inspection we spoke with a number of user groups, community support organisations patients and carers. Generally, we heard of positive relationships with the trust and of opportunities to be involved in providing feedback on how services were run or planned. Many patients told us that they felt listened to and their requests were usually acted upon.

During this inspection we met with the council of governors. The trust had elected members and appointed individuals who were patients, service users, staff or other stakeholders who represent members and other stakeholder organisations. Work was underway to provide development opportunities to governors. Governors told us that they felt that they could hold the trust to account via the non–executive directors on key issues and were confident that the response they received

20190830 RT1 Evidence appendix Page 38

was timely, open and transparent. They reported they could call individual directors to the meetings should this be required.

The trust strategy and supporting plans were challenging and innovative, while remaining achievable. The trust aligned its strategy to local plans in the wider health and social care economy and had developed it with external stakeholders. The trust was working with other local health economy stakeholders with an intention to improve the sustainability of the care the system delivered to the population of Peterborough and Cambridgeshire. Partnership working was in place with third sector organisations, social enterprises, the independent service user network and Healthwatch. Reports from external sources, including NHS improvement, commissioners and other stakeholders confirmed the trust was responsive to challenge and worked collaboratively with stakeholders, other local NHS trusts and the third sector to deliver services to patients. Key personnel were actively involved in the sustainability and transformation partnership (STP).

There were a number of multi-agency policies and protocols in place, developed in partnership with other organisations to ensure collaborative working. For example, multi-agency policies relating to Section 117 after-care provision of the Mental Health Act. The trust had a section 75 agreement in place for the delivery of Local Authority functions. There was representation from partners on Mental Health Act working groups and committees, including approved mental health practitioners, police, ambulance services and children young people and family services. The trust had service level agreements with Peterborough City Hospital and Cambridge University Hospitals NHS Trust to provide out of hours support from approved clinicians, Mental Health Act administrators and hospital manager panels. Learning, continuous improvement and innovation The trust used research and innovation to improve patient care. The trust participated in a wide range of audits and accreditation schemes and shared learning. There were organisational systems to support improvement and innovation work. The trust had developed a learning framework, to strengthen and provide a consistent framework on the way to identify and embed learning across services. The trust had also strengthened their processes around NICE implementation and learning from incidents, complaints, and other forms of feedback such as patient and staff surveys. The trust had also set up a transformation development forum, which provided a space for sharing ideas, innovations and information across services and for improving performance against best practice and national benchmarks. There were effective systems in place to identify and learn from unanticipated deaths. The serious incidents group (SIG) led on this work and provided an open forum to understand why things went wrong and to support any learning. In addition, the mortality review group (MRG) was responsible for implementing any national requirements in relation to learning from deaths. Learning was shared via ‘learning lessons’ bulletins, monthly quality & safety reports and regular learning events. NHS trusts can take part in accreditation schemes that recognise services’ compliance with standards of best practice. Accreditation usually lasts for a fixed time, after which the service must be reviewed. There were no specific trust wide services awarded an accreditation however, several core services had accreditation: four acute wards had Accreditation for Inpatient Mental Health Services (AIMS); In CAMHS Darwin is accredited for Quality Network for Inpatient CAMHS (QNIC), Croft is participating in the accreditation process but not yet accredited while accreditation for Phoenix was paused due to the temporary closure of the ward; In crisis services two of the

20190830 RT1 Evidence appendix Page 39

liaison services operating from Acute hospitals in Cambridge and Peterborough had Psychiatric Liaison Accreditation Network (PLAN) accreditation. The service at Huntingdon commenced accreditation in January 2019 The trust had established a clinical effectiveness and improvement team to support the clinical audit and service development programme. The trust undertook a wide range of clinical effectiveness and quality audits. These included safeguarding practice, medicines management, prescribing, compliance with NICE guidance, suicide prevention, clinical outcomes, physical healthcare, care planning, record keeping, pressure ulcer management, consent and capacity, Mental Health Act administration and patient satisfaction. We also found many localised audits looking at practice within services. The trust worked with national and local partners to conduct a wide range of research into mental and physical health. The trust led the Collaborations for Leadership in Applied Health Research and Care East of England (CLAHRC) and was actively involved in over 150 clinical research studies. Studies had contributed to the knowledge base behind the revised National Institute for Health and Care Excellence (NICE) guidelines for dementia. The trust had secured a £1.5M grant from the Medical Research Council for mental health clinical informatics. The trust was developing their quality improvement (QI) capacity and capability. The quality strategy had been updated and the first cohort of QSIR (quality, service improvement and redesign) practitioners had been trained. The trust had a three-year plan to cascade training to all front-line staff. The board had undertaken QSIR training and a QI college was in development. However, QI was embryonic and needed significant profile to encourage and enthuse staff to improve. We heard about and saw many examples of innovative practice throughout the trust. Staff were enabled to take actions to improve services and to make a difference. Examples included: • The First Response service had developed well and along with the sanctuary was providing a positive response to people in crisis. The service had led to a reduction in waiting times and presentation at local accident and emergency departments. The team was recognised in several national awards including first place in the Mental Health Initiative Award in November 2018. • Physical health monitoring had improved greatly since our last inspection, particularly in acute mental health services. A visual sensor had been developed to remotely monitor respiratory rate, pulse and movement. It had reduced falls on dementia wards by 30% and provided a means to monitor vital signs without waking patients. Community adult services had set up COPD clinics at homeless shelters. The project started in 2018 to address the high incidence of COPD prevalence amongst this group. • Innovative practice initiatives included the roll out of health coaching and patient centred care planning as an innovative and empowering approach to supporting people with long term conditions to manage their own lives. • The smoking cessation team were very impressive and had encouraged both patients and staff to quit smoking. CPFT also took part in a national study (SCIMITAR+) to help people using mental health services stop smoking. • A pilot project was undertaken by the tissue viability specialist nursing team in the management of chronic leg oedema was proving positive.

20190830 RT1 Evidence appendix Page 40

• The trust’s recovery college was a successful innovation and was expanding to provide more courses and more involvement with the local communities. Both patients and staff could access the college to gain a range of learning and coaching around mental health issues. We were impressed by the range of developments being planned to enhance the trusts IT capability. A digital strategy had been developed to encourage a digitally confident workforce and improve the digital experience for staff and patients by 2024. Initiatives include a new records system that could be shared across partners, NHS Apps, self-care Apps, wearables and patient held integrated records. The trust was developing collaborations with academic and industry partners to look at the use of technologies such as artificial Intelligence (AI). IAPT services had formed a partnership with a digital company to offer patients the choice of on-line therapy.

20190830 RT1 Evidence appendix Page 41

Community health services

Community health services for adults

Facts and data about this service

Information about the sites and teams, which offer community services for adults at this trust, is shown below: Cambridgeshire and Peterborough NHS Foundation Trust provides community health services for adults at a variety of locations in Cambridgeshire and Peterborough. This was the first inspection of community services for adults since the trust started providing these services in 2015. The primary construct within CPFT for provision of community adult services is the Neighbourhood Teams (NTs). These teams are responsible for the promotion of health and independence in the community working with colleagues across multiple health, social and voluntary sector organisations. NTs offer multi-disciplinary, seamless care closer to a patient’s home. Team composition includes district nurses, staff nurses, health care assistants, , occupational therapists, physiotherapist and mental health practitioners. There are 14 NTs: • Peterborough City 1 • Peterborough City 2 • Borderline • Borderline Central • Isle of Ely • Fenland • Wisbech • Huntingdon Central • St Neots • St Ives • Cambridge East • Cambridge North Villages • Cambridge City North • Cambridge City South The main functions of the NT are: • Care co-ordination; • Integrating physical health, mental health care and social care, including Section 75 funded services • Older People Mental health assessment and treatment

20190830 RT1 Evidence appendix Page 42

• Admission avoidance • Palliative care; • Rehabilitation and recommendations for provision of equipment and adaptations • Building community resilience – i.e. working with local organisations e.g. 3rd sector to develop services that patient can access to support recovery and prevention CPFT provide a range of specialist services alongside the NTs including Dietetics, Podiatry, Respiratory, Continence, Tissue viability, Speech and Language Therapy, Cardiac Service, Diabetes, Neuro conditions and Neuro rehab. These specialist services have a range of referral criteria. Location / site Team/ward/satellite Services provided Address (if name name applicable) Brookfields 05 NT - Cambridge Community, physical and mental Management Hospital City South - District health multi-disciplinary team. Block, Brookfields Nursing (Daytime) Caseload management for a Hospital, 351 Mill defined group of GP practices. Road, Cambridge Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Brookfields 05 NT - Cambridge Community, physical and mental Management Hospital City South - health multi-disciplinary team. Block, Brookfields Community Caseload management for a Hospital, 351 Mill Rehabilitation defined group of GP practices. Road, Cambridge Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Brookfields Neuro Rehabilitation Community Neuro rehab service Davison House, Hospital - Cambridge for people following stroke or Brookfields long-term Neurological Hospital, 351 Mill condition. Service is provided by Road, Cambridge an MDT including OT, PT, Psychology, SALT and rehab assistants Brookfields Neuro Rehabilitation Nature of service: inter agency Brookfields Hospital - Falls Service falls prevention training and Hospital, 351 Mill monitoring, (including strength Road, Cambridge and balance exercise programmes), referral guidance, general help and advice re falls prevention Brookfields Specialist Nursing - This service provides nurse led Nye Bevan Hospital Diabetes - City & care for people over the age of House, South Cambs 18 with Diabetes. The nurse-led Brookfields team supports both patients and Hospital, 351 Mill primary care clinicians such as

20190830 RT1 Evidence appendix Page 43

GPs, Practice Nurses and Road, Cambridge, District Nurses in the recognition CB1 3DF and management of Diabetes Brookfields Specialist Nursing - The Parkinson’s disease service Nye Bevan Hospital Parkinson’s - South provides care for adults over the House, age of 18 with suspected or Brookfields diagnosed Parkinson’s disease Hospital, 351 Mill from Cambridge City and South Road, Cambridge, Cambridgeshire, East CB1 3DF Cambridgeshire and Huntingdon and Peterborough. Brookfields Specialist Nursing - This service is provided by Brookfields Health Hospital Respiratory - City & respiratory specialist nurses and Centre, Seymour South Cambs physiotherapists offering support Street, for adult patients and their Cambridge, CB1 carers who live with long-term 3DQ respiratory conditions. The teams provide community-based element of a service that links with hospital. Brookfields Speech & Language To assess, diagnose and treat Davison House, Hospital Therapy - Adults - adults referred with speech, Brookfields City & South Cambs language or swallowing Hospital, 351 Mill disorders on an in-patient, out- Road, Cambridge, patient and domiciliary basis CB1 3DF (including telephone advice) and to support their families and carers. City Care 13 NT - Community, physical and mental City Care Centre, Centre Peterborough City 1 health multi-disciplinary team. Thorpe Road, - Community Matron Caseload management for a Peterborough defined group of GP practices. Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. City Care 13 NT - Community, physical and mental City Care Centre, Centre Peterborough City 1 health multi-disciplinary team. Thorpe Road, - District Nursing Caseload management for a Peterborough (Daytime) defined group of GP practices. Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. City Care 14 NT - Community, physical and mental City Care Centre, Centre Peterborough City 2 health multi-disciplinary team. Thorpe Road, Caseload management for a Peterborough

20190830 RT1 Evidence appendix Page 44

- Community defined group of GP practices. Rehabilitation Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. City Care 14 NT - Community, physical and mental City Care Centre, Centre Peterborough City 2 health multi-disciplinary team. Thorpe Road, - District Nursing Caseload management for a Peterborough (Daytime) defined group of GP practices. Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. City Care District Nursing (Out Community, physical and mental City Care Centre, Centre of Hours) - health multi-disciplinary team. Thorpe Road, Peterborough Caseload management for a Peterborough, defined group of GP practices. PE3 6DB Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. City Care Neuro Rehabilitation Community Neuro rehab service City Care Centre, Centre - Peterborough for people following stroke or Thorpe Road, long-term Neurological Peterborough condition. Service is provided by an MDT including OT, PT, Psychology, SALT and rehab assistants City Care Specialist Nursing - The Parkinson’s disease service City Care Centre, Centre Parkinson’s - North provides care for adults over the Thorpe Road, age of 18 with suspected or Peterborough, diagnosed Parkinson’s disease PE3 6DB from Cambridge City and South Cambridgeshire, East Cambridgeshire and Huntingdon and Peterborough. City Care Speech & Language To assess, diagnose and treat City Care Centre, Centre Therapy - Adults - adults referred with speech, Thorpe Road, Peterborough language or swallowing Peterborough, disorders on an in-patient, out- PE3 6DB patient and domiciliary basis (including telephone advice) and to support their families and carers. City Care JET - Peterborough Admission avoidance, older City Care Centre, Centre persons in the community Thorpe Road, Peterborough

20190830 RT1 Evidence appendix Page 45

Fulbourn 01 NT - Cambridge Community, physical and mental Granta Medical Hospital East - Community health multi-disciplinary team. Practice, London Rehabilitation Caseload management for a Road, Sawston, defined group of GP practices. Cambridge Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Fulbourn 01 NT - Cambridge Community, physical and mental Granta Medical Hospital East - District health multi-disciplinary team. Practice, London Nursing (Daytime) Caseload management for a Road, Sawston, defined group of GP practices. Cambridge Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Fulbourn 02 NT - Cambridge Community, physical and mental 18-20 Signet Hospital City North - District health multi-disciplinary team. Court, Cambridge, Nursing (Daytime) Caseload management for a CB5 8LA defined group of GP practices. Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Fulbourn 02 NT - Cambridge Community, physical and mental 18-20 Signet Hospital City North - health multi-disciplinary team. Court, Cambridge, Community Caseload management for a CB5 8LA Rehabilitation defined group of GP practices. Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Fulbourn 04 NT - Cambridge Community, physical and mental Histon Police Hospital North Villages - health multi-disciplinary team. Station, 15 District Nursing Caseload management for a Mowlam Close, (Daytime) defined group of GP practices. Impington, Over 18 yrs. for community Cambridge physical health. Over 65 yrs. for community mental health. Fulbourn 04 NT - Cambridge Community, physical and mental Histon Police Hospital North Villages - health multi-disciplinary team. Station, 15 Community Caseload management for a Mowlam Close, Rehabilitation defined group of GP practices. Impington, Over 18 yrs. for community Cambridge physical health. Over 65 yrs. for community mental health. Fulbourn 07 NT - Huntingdon Community, physical and mental Redshank House, Hospital Central - Community health multi-disciplinary team. Kingfisher Way, Rehabilitation Caseload management for a Hinchingbrooke

20190830 RT1 Evidence appendix Page 46

defined group of GP practices. Business Park, Over 18 yrs. for community Huntingdon, PE29 physical health. Over 65 yrs. for 6FN community mental health. Fulbourn 07 NT - Huntingdon Community, physical and mental Redshank House, Hospital Central - District health multi-disciplinary team. Kingfisher Way, Nursing (Daytime) Caseload management for a Hinchingbrooke defined group of GP practices. Business Park, Over 18 yrs. for community Huntingdon, PE29 physical health. Over 65 yrs. for 6FN community mental health. Fulbourn 08 NT - St Ives - Community, physical and mental Kings Hall, 3A Hospital District Nursing health multi-disciplinary team. Parsons Green, St (Daytime) Caseload management for a Ives, defined group of GP practices. Cambridgeshire, Over 18 yrs. for community PE27 4WY physical health. Over 65 yrs. for community mental health. Fulbourn 08 NT - St Ives - Community, physical and mental Kings Hall, 3A Hospital Community health multi-disciplinary team. Parsons Green, St Rehabilitation Caseload management for a Ives, defined group of GP practices. Cambridgeshire, Over 18 yrs. for community PE27 4WY physical health. Over 65 yrs. for community mental health. Fulbourn 09 NT - St Neots - Community, physical and mental Knowledge Hospital Community health multi-disciplinary team. Centre, Wyboston Rehabilitation Caseload management for a Lakes, Great defined group of GP practices. North Road, Over 18 yrs. for community Wyboston physical health. Over 65 yrs. for community mental health. Fulbourn 09 NT - St Neots - Community, physical and mental Knowledge Hospital District Nursing health multi-disciplinary team. Centre, Wyboston (Daytime) Caseload management for a Lakes, Great defined group of GP practices. North Road, Over 18 yrs. for community Wyboston physical health. Over 65 yrs. for community mental health. Fulbourn 11 NT - Fenland - Community, physical and mental Doddington Hospital District Nursing health multi-disciplinary team. Hospital, Benwick (Daytime) Caseload management for a Road, defined group of GP practices. Doddington, Over 18 yrs. for community March

20190830 RT1 Evidence appendix Page 47

physical health. Over 65 yrs. for community mental health. Fulbourn 11 NT - Fenland - Community, physical and mental Doddington Hospital Community health multi-disciplinary team. Hospital, Benwick Rehabilitation Caseload management for a Road, defined group of GP practices. Doddington, Over 18 yrs. for community March physical health. Over 65 yrs. for community mental health. Fulbourn 15 NT - Borderline - Community, physical and mental Botolph Bridge Hospital Community health multi-disciplinary team. Community Health Rehabilitation Caseload management for a Centre, Valley defined group of GP practices. Park Centre, Over 18 yrs. for community Peterborough physical health. Over 65 yrs. for community mental health. Fulbourn 15 NT - Borderline - Community, physical and mental Botolph Bridge Hospital District Nursing health multi-disciplinary team. Community Health (Daytime) Caseload management for a Centre, Valley defined group of GP practices. Park Centre, Over 18 yrs. for community Peterborough physical health. Over 65 yrs. for community mental health. Fulbourn 16 NT - Borderline Community, physical and mental Botolph Bridge Hospital Central - Community health multi-disciplinary team. Community Health Rehabilitation Caseload management for a Centre, Valley defined group of GP practices. Park Centre, Over 18 yrs. for community Peterborough physical health. Over 65 yrs. for community mental health. Fulbourn 16 NT - Borderline Community, physical and mental Botolph Bridge Hospital Central - District health multi-disciplinary team. Community Health Nursing (Daytime) Caseload management for a Centre, Valley defined group of GP practices. Park Centre, Over 18 yrs. for community Peterborough physical health. Over 65 yrs. for community mental health. Fulbourn District Nursing (Out Community, physical and mental Doddington Hospital of Hours) - Fenland health multi-disciplinary team. Hospital, Benwick Caseload management for a Road, defined group of GP practices. Doddington. PE15 Over 18 yrs. for community 0UG physical health. Over 65 yrs. for community mental health.

20190830 RT1 Evidence appendix Page 48

Fulbourn District Nursing (Out Community, physical and mental Redshank House, Hospital of Hours) - health multi-disciplinary team. Kingfisher Way, Huntingdonshire Caseload management for a Hinchingbrooke defined group of GP practices. Business Park, Over 18 yrs. for community Huntingdon, PE29 physical health. Over 65 yrs. for 6FN community mental health. Fulbourn Intermediate Care This service provides a Fulbourn Hospital, Hospital Service / Hospital at programme of short-term Cambridge Road, Home Service support, tailored to meet Fulbourn, individual needs, where the Cambridge potential exists to learn or re- learn daily living skills following a decline in physical or cognitive ability, optimise independence and reduce dependency. Fulbourn Neuro Rehabilitation Community Neuro rehab service Wendreda Unit, Hospital - East Cambs, Ely for people following stroke or Doddington and Fenland long-term Neurological Hospital, Benwick condition. Service is provided by Road, an MDT including OT, PT, Doddington, Psychology, SALT and rehab March assistants Fulbourn Neuro Rehabilitation Community Neuro rehab service Neuro- Hospital - Huntingdon for people following stroke or Rehabilitation long-term Neurological Unit, condition. Service is provided by Hinchingbrooke an MDT including OT, PT, Hospital, Psychology, SALT and rehab Huntingdon assistants Fulbourn Nutrition & Dietetics The team provides tailored Sackville House, Hospital - City & South nutrition and dietetic advice for Sackville Way, Cambs the adult population of Cambourne, Cambridgeshire and aim to help Cambridge, CB23 them achieve better health and 6HL make appropriate lifestyle and food choices. Fulbourn Nutrition & Dietetics The team provides tailored Doddington Hospital - Ely & The Fens nutrition and dietetic advice for Hospital, Benwick the adult population of Road, Cambridgeshire and aim to help Doddington. PE15 them achieve better health and 0UG make appropriate lifestyle and food choices.

20190830 RT1 Evidence appendix Page 49

Fulbourn Nutrition & Dietetics The team provides tailored Redshank House, Hospital - Huntingdonshire nutrition and dietetic advice for Kingfisher Way, the adult population of Hinchingbrooke Cambridgeshire and aim to help Business Park, them achieve better health and Huntingdon, PE29 make appropriate lifestyle and 6FN food choices. Fulbourn Nutrition & Dietetics The team provides tailored City Health Clinic, Hospital - Peterborough nutrition and dietetic advice for Wellington Street, the adult population of Peterborough, Cambridgeshire and aim to help PE1 5DU them achieve better health and make appropriate lifestyle and food choices. Fulbourn Podiatry - City & Podiatry is a branch of medicine Chesterton Hospital South Cambs devoted to the study, diagnosis Medical Centre, and treatment of disorders of the 35 Union Lane, foot, ankle and lower leg. Cambridge, CB4 Cambridgeshire and 1PX Peterborough NHS Foundation Trust podiatry services provide care to patients defined as high and medium risk Fulbourn Podiatry - Podiatry is a branch of medicine Doddington Hospital Doddington devoted to the study, diagnosis Hospital, Benwick and treatment of disorders of the Road, foot, ankle and lower leg. Doddington. PE15 Cambridgeshire and 0UG Peterborough NHS Foundation Trust podiatry services provide care to patients defined as high and medium risk Fulbourn Podiatry - Podiatry is a branch of medicine Oaktree Centre, 1 Hospital Huntingdonshire devoted to the study, diagnosis Oak Drive, and treatment of disorders of the Huntingdon, PE29 foot, ankle and lower leg. 7HN Cambridgeshire and Peterborough NHS Foundation Trust podiatry services provide care to patients defined as high and medium risk Fulbourn Podiatry - Podiatry is a branch of medicine Healthy Living Hospital Peterborough devoted to the study, diagnosis Centre, Princes and treatment of disorders of the Street, foot, ankle and lower leg. Cambridgeshire and

20190830 RT1 Evidence appendix Page 50

Peterborough NHS Foundation Peterborough, Trust podiatry services provide PE1 2QP care to patients defined as high and medium risk Fulbourn Specialist Nursing - Chronic Fatigue Syndrome Botolph Bridge Hospital CFS-ME (CFS) is a general term for a Community Health wide range of conditions Centre, Valley including Myalgic Park Centre, Encephalomyelitis (ME). Myalgia Peterborough is muscle pain and encephalomyelitis refers to inflammation and dysfunction of the brain and spinal cord. Fulbourn Specialist Nursing - The service is provided by Histon Police Hospital Continence - City & continence specialist nurses and Station, 15 South Cambs specialist physiotherapists in Mowlam Close, women’s health. We offer a Impington, comprehensive service of Cambridge, CB24 continence assessment, 9NA treatment and advice for men and women over the age of 18 with bowel and bladder dysfunction Fulbourn Specialist Nursing - The service is provided by North Cambs Hospital Continence - Ely & continence specialist nurses and Hospital, The The Fens specialist physiotherapists in Park, Wisbech, women’s health. We offer a PE13 3AB comprehensive service of continence assessment, treatment and advice for men and women over the age of 18 with bowel and bladder dysfunction Fulbourn Specialist Nursing - The service is provided by 1 Commerce Hospital Continence - continence specialist nurses and Road, Lynch Huntingdon specialist physiotherapists in Wood, women’s health. We offer a Peterborough, comprehensive service of PE2 6LR continence assessment, treatment and advice for men and women over the age of 18 with bowel and bladder dysfunction

20190830 RT1 Evidence appendix Page 51

Fulbourn Specialist Nursing - The service is provided by 1 Commerce Hospital Continence - continence specialist nurses and Road, Lynch Peterborough specialist physiotherapists in Wood, women’s health. We offer a Peterborough, comprehensive service of PE2 6LR continence assessment, treatment and advice for men and women over the age of 18 with bowel and bladder dysfunction Fulbourn Specialist Nursing - This service provides nurse led Doddington Hospital Diabetes - Ely & The care for people over the age of Hospital, Benwick Fens 18 with Diabetes. The nurse-led Road, team supports both patients and Doddington. PE15 primary care clinicians such as 0UG GPs, Practice Nurses and District Nurses in the recognition and management of Diabetes Fulbourn Specialist Nursing - This service provides nurse led Oaktree Centre, 1 Hospital Diabetes - care for people over the age of Oak Drive, Huntingdonshire 18 with Diabetes. The nurse-led Huntingdon, PE29 team supports both patients and 7HN primary care clinicians such as GPs, Practice Nurses and District Nurses in the recognition and management of Diabetes Fulbourn Specialist Nursing - This service provides nurse led Healthy Living Hospital Diabetes - care for people over the age of Centre, Princes Peterborough 18 with Diabetes. The nurse-led Street, team supports both patients and Peterborough, primary care clinicians such as PE1 2QP GPs, Practice Nurses and District Nurses in the recognition and management of Diabetes Fulbourn Specialist Nursing - The Epilepsy service provides a City Care Centre, Hospital Epilepsy specialist service for people over Thorpe Road, the age of 16 with a confirmed Peterborough, diagnosis of Epilepsy. Referrals PE3 6DB accepted via neurologist or Ambulatory Care Pathway where patients are seen within 1-2 working days from attendance at ED

20190830 RT1 Evidence appendix Page 52

Fulbourn Specialist Nursing - The Heart Failure Nurse Service Oaktree Centre, 1 Hospital Heart Failure - aims to improve the Oak Drive, Huntingdonshire management of patients with Huntingdon, PE29 chronic heart failure, to reduce 7HN hospital admissions and readmissions and provide a link between primary and secondary care. The countywide service provides intensive case man Fulbourn Specialist Nursing - The Heart Failure Nurse Service Doddington Hospital Heart Failure - Ely & aims to improve the Hospital, Benwick The Fens management of patients with Road, chronic heart failure, to reduce Doddington. PE15 hospital admissions and 0UG readmissions and provide a link between primary and secondary care. The countywide service provides intensive case man Fulbourn Specialist Nursing - The Heart Failure Nurse Service 1 Commerce Hospital Heart Failure - aims to improve the Road, Lynch Peterborough management of patients with Wood, chronic heart failure, to reduce Peterborough, hospital admissions and PE2 6LR readmissions and provide a link between primary and secondary care. The countywide service provides intensive case man Fulbourn Specialist Nursing - We offer an open referral system Rehabilitation Hospital Multiple Sclerosis providing there is a definite Unit, diagnosis of MS and consent Hinchingbrooke has been obtained from the Hospital, person with MS. We provide Huntingdon counselling, support and symptom management for all people with MS and those affected by their diagnosis. Fulbourn Specialist Nursing - This service is provided by Doddington Hospital Respiratory - Ely & respiratory specialist nurses and Hospital, Benwick The Fens physiotherapists offering support Road, for adult patients and their Doddington. PE15 carers who live with long-term 0UG respiratory conditions. The teams provide community-based element of a service that links with hospital.

20190830 RT1 Evidence appendix Page 53

Fulbourn Specialist Nursing - This service is provided by Clinic 7, Hospital Respiratory - respiratory specialist nurses and Hinchingbrooke Huntingdonshire physiotherapists offering support Hospital, for adult patients and their Huntingdon, PE29 carers who live with long-term 6NT respiratory conditions. The teams provide community-based element of a service that links with hospital. Fulbourn Specialist Nursing - This service is provided by Healthy Living Hospital Respiratory - respiratory specialist nurses and Centre, Princes Peterborough physiotherapists offering support Street, for adult patients and their Peterborough, carers who live with long-term PE1 2QP respiratory conditions. The teams provide community-based element of a service that links with hospital. Fulbourn Specialist Nursing - The Tissue Viability Service Histon Police Hospital Tissue Viability - operates throughout Station, 15 City & South Cambs Cambridgeshire and Mowlam Close, Peterborough and aims to Impington, support patients, GPs, Practice Cambridge, CB24 Nurses, District Nurses and 9NA other healthcare professionals in the management of complex wounds, particularly the prevention and treatment of pressure ulcers Fulbourn Specialist Nursing - The Tissue Viability Service Doddington Hospital Tissue Viability - Ely operates throughout Hospital, Benwick & The Fens Cambridgeshire and Road, Peterborough and aims to Doddington. PE15 support patients, GPs, Practice 0UG Nurses, District Nurses and other healthcare professionals in the management of complex wounds, particularly the prevention and treatment of pressure ulcers Fulbourn Specialist Nursing - The Tissue Viability Service Oaktree Centre, 1 Hospital Tissue Viability - operates throughout Oak Drive, Huntingdonshire Cambridgeshire and Huntingdon, PE29 Peterborough and aims to 7HN support patients, GPs, Practice Nurses, District Nurses and

20190830 RT1 Evidence appendix Page 54

other healthcare professionals in the management of complex wounds, particularly the prevention and treatment of pressure ulcers Fulbourn Specialist Nursing - The Tissue Viability Service Healthy Living Hospital Tissue Viability - operates throughout Centre, Princes Peterborough Cambridgeshire and Street, Peterborough and aims to Peterborough, support patients, GPs, Practice PE1 2QP Nurses, District Nurses and other healthcare professionals in the management of complex wounds, particularly the prevention and treatment of pressure ulcers Fulbourn Speech & Language To assess, diagnose and treat Doddington Hospital Therapy - Adults - adults referred with speech, Hospital, Benwick Ely & The Fens language or swallowing Road, disorders on an in-patient, out- Doddington. PE15 patient and domiciliary basis 0UG (including telephone advice) and to support their families and carers. Fulbourn Speech & Language To assess, diagnose and treat Hinchingbrooke Hospital Therapy - Adults - adults referred with speech, Hospital, Huntingdonshire language or swallowing Huntingdon, PE29 disorders on an in-patient, out- 6NT patient and domiciliary basis (including telephone advice) and to support their families and carers. Fulbourn JET - Cambridge Admission avoidance, older Sackville House, Hospital persons in the community Sackville Way, Cambourne, Cambridge Fulbourn JET - Huntingdon Admission avoidance, older Hinchingbrooke Hospital persons in the community Hospital, Huntingdon North 12 NT - Wisbech - Community, physical and mental The Bowthorpe Cambridgeshire District Nursing health multi-disciplinary team. Centre, North Hospital (Daytime) Caseload management for a Cambridgeshire defined group of GP practices. Hospital, The Over 18 yrs. for community Park, Wisbech, PE13 3AB

20190830 RT1 Evidence appendix Page 55

physical health. Over 65 yrs. for community mental health. North 12 NT - Wisbech - Community, physical and mental The Bowthorpe Cambridgeshire Community Matron health multi-disciplinary team. Centre, North Hospital Caseload management for a Cambridgeshire defined group of GP practices. Hospital, The Over 18 yrs. for community Park, Wisbech, physical health. Over 65 yrs. for PE13 3AB community mental health. North 12 NT - Wisbech - Community, physical and mental The Bowthorpe Cambridgeshire Community health multi-disciplinary team. Centre, North Hospital Rehabilitation Caseload management for a Cambridgeshire defined group of GP practices. Hospital, The Over 18 yrs. for community Park, Wisbech, physical health. Over 65 yrs. for PE13 3AB community mental health. North District Nursing (Out Community, physical and mental Chesterton Cambridgeshire of Hours) - City, health multi-disciplinary team. Medical Centre, Hospital South & East Caseload management for a 35 Union Lane, Cambs defined group of GP practices. Cambridge, CB4 Over 18 yrs. for community 1PX physical health. Over 65 yrs. for community mental health. North Podiatry - Wisbech Podiatry is a branch of medicine North Cambs Cambridgeshire devoted to the study, diagnosis Hospital, The Hospital and treatment of disorders of the Park, Wisbech, foot, ankle and lower leg. PE13 3AB Cambridgeshire and Peterborough NHS Foundation Trust podiatry services provide care to patients defined as high and medium risk Princess of 10 NT - Isle of Ely - Community, physical and mental Princess of Wales Wales Hospital Community Matron health multi-disciplinary team. Hospital, Lynn Caseload management for a Road, Ely defined group of GP practices. Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Princess of 10 NT - Isle of Ely - Community, physical and mental Princess of Wales Wales Hospital Community health multi-disciplinary team. Hospital, Lynn Rehabilitation Caseload management for a Road, Ely defined group of GP practices. Over 18 yrs. for community

20190830 RT1 Evidence appendix Page 56

physical health. Over 65 yrs. for community mental health. Princess of 10 NT - Isle of Ely - Community, physical and mental Princess of Wales Wales Hospital District Nursing health multi-disciplinary team. Hospital, Lynn (Daytime) Caseload management for a Road, Ely defined group of GP practices. Over 18 yrs. for community physical health. Over 65 yrs. for community mental health. Princess of Podiatry - Ely Podiatry is a branch of medicine Princess of Wales Wales Hospital devoted to the study, diagnosis Hospital, Lynn and treatment of disorders of the Road, Ely, CB6 foot, ankle and lower leg. 1DN Cambridgeshire and Peterborough NHS Foundation Trust podiatry services provide care to patients defined as high and medium risk Princess of JET - Ely and Fens Admission avoidance, older Princess of Wales Wales Hospital persons in the community Hospital, Lynn Road, Ely

Services are provided mostly to men and women over the age of 18, the service supports the transition from children’s services into adult services. Teams within the service include district nursing, therapies, and outpatient clinics, including continence clinics and musculoskeletal physiotherapy and occupational therapy clinics, among others. During the inspection, we visited three locations, as follows: • South Cambridge – Brookfields Hospital • North Cambridge and Villages - Histon • Fenland – Doddington Hospital

During the inspection visit, the inspection team spoke with seven patients who were using the service, and two relatives or carers. We spoke with 23 members of staff including senior managers, clinical and operational service leads, nursing staff, allied health professionals, and support staff. We reviewed 11 patient care records. We also observed patient care, staff handovers and reviewed information including meeting minutes, audit data, action plans and training records.

20190830 RT1 Evidence appendix Page 57

Is the service safe? Mandatory training The service provided mandatory training in key skills to all staff although not everyone completed all components to the trust’s target. The service had a mandatory training programme in place for staff to complete and most staff had met the internal target for completion of 15 out of 24 modules. However, some of the mandatory training modules were role specific and were not completed by all staff. Staff completed both eLearning and face-to-face sessions within their mandatory training programme. Staff we spoke with, told us that mandatory training was easy to access, and they had completed mandatory training. Neighbourhood team leads we spoke with told us that face to face training such as Safeguarding children level three and Mental Capacity Act level two training were difficult to book due to the number of staff that were required to complete this training. Team leads told us that they booked this training in advance to ensure staff completed the required training, however some staff had to wait for session availability when refresher training was due. Mandatory training completion rates Core Service level A breakdown of compliance for mandatory training courses from 1 January 2018 to 31 December 2018 at trust level for all staff in community services for adults is shown below: The trust set a target of 90% for completion of mandatory training.

1 January 2018 to 31 December 2018 Training module name Eligible Completion Trust Met Staff trained staff rate target (Yes/No) Working Safely 413 414 100% 90% Yes Mental Health Act Level 2 1 1 100% 90% Yes PREVENT (Level 2) 1 1 100% 90% Yes Safeguarding Children (Level 3) 2 2 100% 90% Yes Conflict Resolution 411 414 99% 90% Yes PREVENT (Level 1) 407 413 99% 90% Yes Treating People with Respect 410 414 99% 90% Yes Safeguarding Adults 407 415 98% 90% Yes Good Governance 400 414 97% 90% Yes Infection Control (Level 2) 371 390 95% 90% Yes Safeguarding Children (Level 2) 375 393 95% 90% Yes Dementia 367 388 95% 90% Yes Fire Safety 391 414 94% 90% Yes

20190830 RT1 Evidence appendix Page 58

1 January 2018 to 31 December 2018 Training module name Eligible Completion Trust Met Staff trained staff rate target (Yes/No) Basic Life Support (BLS) 324 349 93% 90% Yes Infection Control (Level 1) 23 25 92% 90% Yes Mental Capacity Act Level 1 109 123 89% 90% No Carer Awareness 347 414 84% 90% No Mental Capacity Act Level 2 222 264 84% 90% No Deprivation of Liberty Safeguards 142 180 79% 90% No Manual Handling (Level 2) 189 240 79% 90% No Safeguarding Children (Level 1) 15 19 79% 90% No Smoking Cessation 300 414 72% 90% No Medical Emergency Response 25 35 71% 90% No Course (MERC) Manual Handling (Level 1) 55 100 55% 90% No Safeguarding Children Level 3; 0 2 0% 90% No Mandatory for Role (3hrs) Total 5707 6238 91% 90% Yes

The older people and adult community (OPAC) directorate set out the core mandatory training modules as; basic life support, good governance, infection prevention and control level two, manual handling, safeguarding adults, safeguarding children level two. The directorate set out role specific training modules as; dementia, depravation of liberty safeguards, Mental Capacity Act level one and Mental Capacity Act level two. The OPAC scorecard for December 2018 showed that staff had not completed manual handling, deprivation of liberty safeguards and Mental Capacity Act level two to the trust’s target of 90%. Neighbourhood teams displayed information about core mandatory training modules completion to inform staff. These modules included safeguarding children level one and level two, safeguarding adults and infection prevention and control training. We saw that each of the neighbourhood teams we visited had completed this training to the target set out by the trust. Neighbourhood team leads and managers monitored the completion of mandatory training by staff in their teams. Team leads we spoke with told us that they had monthly one to one meetings with all members of their team where they reviewed mandatory training completion booked staff on to any training that was due to expire. Staff we spoke with within the neighbourhood team confirmed this process took place. All staff we spoke with including neighbourhood care team managers, team leads, specialist nurses and community nurses told us that they were up-to-date with their mandatory training completion.

20190830 RT1 Evidence appendix Page 59

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff who worked within the service were knowledgeable about safeguarding processes and knew when to escalate their concerns. Staff we spoke with gave us examples of the safeguarding concerns they would raise and had access to the safeguarding team for advice and support. However, staff had not always completed training in safeguarding children to level one to meet the provider’s internal training target of 90%.

Safeguarding training completion rates The trust set a target of 90% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from 1 January 2018 to 31 December 2018 at trust level for all staff in community health services for adults is shown below: The table below include prevent training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity.

1 January 2018 to 31 December 2018 Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No) PREVENT (Level 2) 1 1 100% 90% Yes Safeguarding Children (Level 3) 2 2 100% 90% Yes PREVENT (Level 1) 407 413 99% 90% Yes Safeguarding Adults 407 415 98% 90% Yes Safeguarding Children (Level 2) 375 393 95% 90% Yes Safeguarding Children (Level 1) 15 19 79% 90% No

All staff received information and training about female genital mutilation (FGM) within mandatory safeguarding adults and children training levels one and two. This training included the one chance rule and the mandatory reporting to the police, of any cases of FGM in girls under the age of18. All staff received information about sexual exploitation within safeguarding training levels. Staff we spoke with confirmed that they had received training about FGM and sexual exploitation and they knew how to escalate any concerns. The service provided ‘Prevent’ training (this enabled staff to recognise and report vulnerable people from being exploited and drawn into terrorism). Data provided by the trust demonstrated that staff compliance with ‘Prevent’ training met the trust’s target. The trust had a safeguarding children policy in place for staff to follow. The policy set out the responsibility of staff at all levels and referenced relevant legislation and national guidance. The policy was with the review date and had version control.

20190830 RT1 Evidence appendix Page 60

The trust had an adult safeguarding policy and practice guidance procedure in place for staff to follow. The policy set out the responsibility of staff at all levels and referenced relevant legislation and national guidance. The policy was with the review date and had version control. All staff we spoke with gave examples of the types of abuse that they would raise a safeguarding alert for. Staff discussed any concerns about safeguarding during lunch time handovers. We observed a neighbourhood handover which included safeguarding concerns. The safeguarding team was led by the head of safeguarding, supported by the named nurse for safeguarding children and the lead professional for safeguarding adults. All staff we spoke with knew the named safeguarding leads and knew how to contact the safeguarding team to discuss or escalate safeguarding concerns. The trust worked collaboratively with other services, teams, individuals and agencies in relation to all safeguarding matters and had safeguarding policies that were in line with Local Authority policies. The service had systems and processes in place to identify patients at risk of abuse. Staff identified patients at risk of abuse using flags on the electronic records system. All professionals involved in the patient’s care had access to information about safeguarding concerns including their named GP. The service carried out three-yearly Disclosure and Baring Service (DBS) checks on all staff. These checks help to prevent unsuitable people from working with vulnerable groups, including children. The neighbourhood team managers received this information from the human resources team and disseminated it to the team leads as appropriate.

Safeguarding referrals A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. Community services for adults made 283 safeguarding referrals between January 2018 and December 2018, of which 283 concerned adults and none children.

Referrals Adults Children Total referrals

283 0 283

Looking at adult referrals across the 12-month period the highest number of referrals were in January (33) and July 2018 (33). The lowest number of referrals was in February 2018 (12).

20190830 RT1 Evidence appendix Page 61

The trust participated in a multi-agency safeguarding hub (MASH) audit for adult safeguarding in conjunction with the local authority. The audit report was published in October 2018 which found safeguarding concerns had been escalated appropriately and proportionately in line with national guidance. Cleanliness, infection control and hygiene The service controlled infection well and the service had low incidents of infection. Staff kept equipment and their work area visibly clean. Staff used equipment and control measures to protect patients, themselves and others from infection. Staff kept equipment and their work area visibly clean. Although infection prevention and control audit process provided limited assurance about staff practice. The service completed annual hand hygiene audits. All staff were required to participate in hand hygiene audits annually. The hand hygiene audit required staff to demonstrate hand decontamination with the use of ultraviolet light and specialist hand gel to show any areas where hand washing was not effective. Data provided by the trust showed variable compliance with hand hygiene audits conducted since January 2019. We saw that 10 out of 14 neighbourhood teams had a compliance rate of 95% or above. However, the North Cambridge team had a compliance rate of 93% and Isle of Ely team 90%. The Huntington team and St Neots team had not submitted data for this audit. All teams we visited had a compliance rate of 95% or above for hand hygiene. We discussed the assurance process of annual hand hygiene audits with one of the neighbourhood team managers and a team lead, they told us that they reviewed hand hygiene techniques during double visits for additional assurance, however there was no formalised reporting process for this. We raised our concerns with the directorate leadership team, regarding the limited assurance that annual hand hygiene audits provided. The senior leadership team had identified this as an area of concern prior to our inspection and had plans to improve the infection prevention and control audit processes for community teams. All patient facing staff wore uniforms with short sleeves to ensure staff were bare below the elbow to reduce the spread of healthcare associated infections. The trust had a uniform policy in place for staff to follow with specific guidance on infection prevention and control such as uniform washing and jewellery restrictions. We observed the care provided by staff on seven occasions, staff decontaminated their hands appropriately before and after providing care. We observed care provided in people’s own homes and saw that staff decontaminated their hands and used personal protective equipment appropriately. Staff we spoke with knew the measures they needed to take to prevent the spread of healthcare associated infections such as the correct use of personal protective equipment and good hand hygiene. The service had a low number of infection prevention incidents, outbreaks and the results for Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia and Clostridium difficile (C-diff). MRSA and C-diff are healthcare associated infections resistant to some groups of antibiotics. The trust had an infection prevention and control policy in place for staff to follow. The policy was within the review date, with version control and referenced relevant national guidance and legislation. All the clinical areas and integrated care team bases we visited were visibly clean and free from clutter.

20190830 RT1 Evidence appendix Page 62

Within the neighbourhood team bases, staff kept records of equipment used in patient care such as syringe drivers and the hand held doppler. These records detailed the date the item was cleaned and returned to the store cupboard. The provider had an infection prevention and control team to provide advice and support to staff. The infection prevention and control team support neighbourhood and specialist teams with annual hand hygiene audits. Staff completed individual risk assessments where appropriate, if there were concerns about infection prevention and control in a patient’s own home. The risk assessments provided staff with additional information about preventative measures required, such as removing animals from the room while care was provided.

Environment and equipment The design, maintenance and use of facilities, premises and equipment kept people safe. Staff managed clinical waste well. When providing care in patients’ homes staff took precautions and actions to protect themselves and patients. Clinics we visited had wheelchair access for people with reduced mobility. All the clinics we visited at community hospitals signposted patients to the correct area well and had easy access to free car parking nearby. We reviewed equipment used within patient’s own homes such as blood pressure monitoring equipment, syringe drivers and hand held dopplers. We checked 23 items of equipment and of these 19 were up-to-date with electrical servicing and safety testing. We informed senior staff about the equipment that was out of date with servicing. Staff removed this item of equipment from service to ensure that safety testing took place prior to this being used in the care of another patient. The trust had a service level agreement in place with an external organisation for equipment servicing and safety testing. Senior staff we spoke with told us that the engineers were responsive to their needs and arranged annual visits to bases to complete equipment servicing and safety checks. Staff managed the stock of disposable single use items well. We reviewed the storage of single use devices such as wound dressings, urinary catheters and syringes. We found cupboards were well stocked and tidy. We reviewed 97 single use devices and found all devices within their expiry date. The service had a dressings formulary for staff to order and use appropriate dressings in the care of their patients. Nursing staff took dressings from the nursing base to their patients on each visit. This minimised the waste associated with patient held dressings. Staff used special carrying boxes for transporting specimens such as blood samples, from patient’s homes to the laboratory or GP surgery. This meant that the service reduced the risk of contamination from these samples and the spread of healthcare associated infections. The trust had arrangements with the local authority to collect large amounts of contaminated waste where there was a risk of healthcare associated infections. Nurses disposed of small amounts of waste, for example soiled dressings, within the patient’s own domestic waste in line with the trust’s policy.

20190830 RT1 Evidence appendix Page 63

Staff disposed of contaminated used sharps such as needles appropriately. Staff kept sharps containers in patient’s own homes. Staff sealed and removed these containers once they had become full and took them to the nursing base ready for collection. Full sharps containers were collected on a weekly basis from the nursing bases.

Assessing and responding to patient risk Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. The service had processes in place to ensure that patient referrals were assessed and allocated to staff in a safe and timely manner. A senior nurse triaged all new referrals that the single point of contact received. The senior nurses within each neighbourhood team assessed the urgency of the referral and were responsible for the allocation of all electronically tasked referrals to the appropriate team member. The service streamed unplanned work to specifically allocated staff within the neighbourhood teams. The Neighbourhood team managers we spoke with told us that the separation of the planned and unplanned work streams allowed the service to be flexible to the urgent needs of patients. This way of working meant that staff were not allocated extra work causing delays in time sensitive medicine administration such as diabetes medication and prevented staff working late to complete their allocated work. The neighbourhood team managers told us that staff working within the two streams helped each other to complete visits. An example of this was when staff working within the unplanned work stream had a light work load they would take planned visits to help colleagues. Staff used nursing dependency scores to ensure that staffing establishments met the requirements of complex patients. The dependence scores considered a variety of risk assessments to calculate the score for individual patients. The service had various electronic risk assessment tools for example the malnutrition universal screening tool and the Waterlow pressure ulcer risk assessment tool. Each patient admitted to adult community services received a holistic assessment upon their first appointment. Staff assessed patients and undertook appropriate risk assessments during this appointment. We reviewed 11 sets of electronic patient records and found that all records demonstrated a holistic assessment took place on the first appointment. The service undertook individual risk assessments for individual patient circumstances where staff identified concerns about the patient care environment or staff safety. One of the neighbourhood team managers we spoke with told us that the service used individual risk assessments, as it was difficult to identify all risks associated to community care in a standardised risk assessment. This meant risks were identified and assessed on an individual basis for unique patient circumstances. The trust had a joint emergency team (JET), admission avoidance team in place to manage patients with frailty and complex needs in the community and access and flow in the local acute hospitals. The team completed rapid patient assessments to ensure patients could be safely cared for within their own home. The service had systems and processes in place to identify patients with signs of sepsis or deterioration. Staff completed baseline observations on patients which formed part of the holistic assessment process during the first contact visit. The service used the national early warning score (NEWS) which prompted staff to escalate deteriorating patients for medical review. Staff

20190830 RT1 Evidence appendix Page 64

received training in the sepsis six care bundle within the basic life support mandatory training module. The trust had an emergency planning resilience and response (EPRR) and corporate business continuity plan in place which was last updated in November 2018. The plan set out staff roles and responsibilities if a major incident was declared. The plan also defined the types of situations that constituted a major incident. Managers knew how to implement the plan, such as bad weather conditions where staff prioritised the care of the patients with the highest needs. Staff discussed patients on their caseloads every lunchtime. Nursing staff followed the situation, background, assessment and recommendation (SBAR) handover tool this enabled teams to Identify of patients at the end of their life and plan care appropriately. We observed staff discussing end of life care during one of the handover meetings.

Staffing The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix. The service used the Rockwood frailty scoring tool and the Benson tool to plan staffing needs and manage patient dependency for each of the neighbourhood teams. The service collected a range of quality and safety data and used this to identify strain on each of teams such as skill mix issues. This meant that managers had information to implement support for teams with high levels of inexperienced staff. Managers we spoke with told us they moved staff within the neighbourhood teams to maintain a safe skill mix. All neighbourhood teams had a defined team of staff and service leads who were responsible for monitoring and managing caseloads. Within the neighbourhood teams, caseloads were reviewed daily during lunch time handovers using the situation, background, assessment and recommendation (SBAR) handover tool. This ensured that the right care was delivered in the right place at the right time by the appropriately skilled member of staff. It also allowed teams to forward plan and ensure that the correct skill mix of staff was available to meet the needs of patients. The neighbourhood teams used an electronic rostering tool to forward plan staffing. In the South Cambridge neighbourhood team had a business support role, this member of staff had oversight of vacant shifts and staff sickness and communicated with team leads and the area manager about staff sickness. Specialist nursing teams were managed by the lead nurse for the service who completed sickness reviews for staff. Specialist nursing services had a fixed working pattern from Monday to Friday. The continence service lead had two members of staff with long term sickness which had put a strain on their ability to meet the demands of the service. Despite this we saw the service had met the referral to treatment targets. Neighbourhood teams we visited had enough staff to care for patients. We reviewed the electronic staffing rotas for March and April 2019, for each of the neighbourhood team bases we visited. We saw that the South Cambridge team and the North Cambridge and villages team had no unfilled shifts. The fenland had five unfilled nursing shifts out of 627 qualified nursing shifts. The neighbourhood teams did not use agency staff to fill vacant shifts, although they used bank staff to fill these shifts. Staff rotas we reviewed demonstrated that neighbourhood teams only used

20190830 RT1 Evidence appendix Page 65

bank staff to fill vacant shifts. Each bank member of staff had to complete a trust induction and complete mandatory training programme to ensure they were up to date skills and competencies required for their role.

Establishment, Vacancy, Levels of Bank & Agency Usage This core service has reported a vacancy rate for all staff of 10% as of 31 December 2018. This core service reported an overall vacancy rate of 7% for registered nurses at 31 December 2018. This core service reported an overall vacancy rate of 16% for healthcare assistants. Registered nurses Health care Overall staff

assistants figures

Location Team

Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Fulbourn JET - 8.7 33.0 26% 15.9 27.4 58% 23.7 69.4 34% Hospital Cambridge Fulbourn Specialist Hospital Nursing - CFS- 4 13.9 29% 0 0.6 0% 4.6 17.3 27% ME Brookfiel Specialist ds Nursing - Hospital Diabetes - City -2 23.2 -9% 3.4 17.3 20% 8.7 53.1 16% & South Cambs Brookfiel Specialist ds Nursing - Hospital Respiratory - 0.0 13.8 0% 0.6 1.8 33% 2.7 21.6 13% City & South Cambs Fulbourn Specialist Hospital Nursing - Heart Failure - -1 13.3 -8% 0.9 1 90% 1.7 17.1 10% Huntingdonshir e Fulbourn Intermediate Hospital Care Service / 0.0 6.0 0% 6.7 55.0 12% 7 78.4 9% Hospital at Home Service Fulbourn Specialist 0.1 7.2 1% 0 0 0% 0.5 7.6 7% Hospital Nursing -

20190830 RT1 Evidence appendix Page 66

Registered nurses Health care Overall staff

assistants figures

Location Team

Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Tissue Viability - City & South Cambs Brookfiel Neuro - ds Rehabilitation - 1.5 1.5 100% -1.8 8.0 2.1 29.9 7% 23% Hospital Cambridge Fulbourn Specialist Hospital Nursing - Continence - 0.9 7.5 12% 0 0 0% 0.3 7.5 4% City & South Cambs North District Nursing Cambridg (Out of Hours) - 0.4 14.3 3% -1.1 5.6 0.2 21.9 1% eshire - City, South & 20% Hospital East Cambs Brookfiel Speech & ds Language Hospital Therapy - 0 0 0% 0.2 2.3 9% 0.1 16.5 1% Adults - City & South Cambs Fulbourn Podiatry - City Hospital & South 0 0 0% 1.0 4.0 25% -0.5 34.2 -1% Cambs Brookfiel Neuro ds Rehabilitation - -0.8 2 -40% 0.4 5.2 8% -0.8 7.8 -10% Hospital Falls Service Fulbourn District Nursing - Hospital (Out of Hours) -1.5 9.8 -15% -1.8 5.4 -3.3 15.2 -22% 33% - Fenland Fulbourn Nutrition & Hospital Dietetics - City - 0 0 0% -2.2 4.8 -4.6 20.1 -23% & South 46% Cambs Core service total 10.3 145.5 7% 22.2 138.4 16% 42.4 417.6 10%

20190830 RT1 Evidence appendix Page 67

Registered nurses Health care Overall staff

assistants figures

Location Team

Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Trust total 1031. 334. 3984. 164.0 1294 13% 130.6 13% 8% 7 2 1 NB: All figures displayed are whole-time equivalents

Between 1 January 2018 and 31 December 2018, 10510 hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reason for bank and agency usage was vacancies. In the same period, agency staff covered 1572 available hours for qualified nurses and 2862 of available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. Team Bank Usage Agency NOT filled Usage by bank or agency Hrs % Hrs % Hrs % Specialist Nursing - CFS-ME 21 - 0 - 56 - Specialist Nursing - Tissue Viability - City & - - - South Cambs 0 0 23 Specialist Nursing - Diabetes - City & South - - - Cambs 217 0 150 Intermediate Care Service / Hospital at Home - - - Service 201 0 15 Specialist Nursing - Continence - City & - - - South Cambs 12 0 0 District Nursing (Out of Hours) - Fenland 3777 - 148 - 1439 - District Nursing (Out of Hours) - City, South & - - - East Cambs 2328 351 809 Specialist Nursing - Respiratory - City & - - - South Cambs 405 0 157 JET - Cambridge 3549 - 1073 - 214 -

20190830 RT1 Evidence appendix Page 68

Core service total 10510 - 1572 - 2862 - Trust Total 114849 - 42162 - 3142 - 1

Between 1 January 2018 and 31 December 2018, 9519 hours were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reason for bank usage was to fill staff vacancies. In the same period, agency staff covered no available hours and 5211 available hours were unable to be filled by either bank staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling.

Team Bank Usage Agency NOT filled by Usage bank or agency Hrs % Hrs % Hrs % Specialist Nursing - Diabetes - City & South 412 - 0 - 0 - Cambs Intermediate Care Service / Hospital at Home 6775 - 0 - 3782 - Service District Nursing (Out of Hours) - Fenland 912 - 0 - 1235 - District Nursing (Out of Hours) - City, South & 117 - 0 - 26 - East Cambs JET - Cambridge 1303 - 0 - 168 - Core service total 9519 - 0 - 5211 - Trust Total 20249 3183 2575 - - - 5 1 9

Turnover This core service had 42.2 (12%) staff leavers between 1 January 2018 and 31 December 2018.

Location Team Substantive staff Substantive staff Average % staff (at latest month) Leavers over the leavers over the last 12 months last 12 months Fulbourn Podiatry - City & 33.9 7.9 24% Hospital South Cambs

20190830 RT1 Evidence appendix Page 69

Fulbourn Nutrition & Hospital Dietetics - City & 24.7 6.1 24% South Cambs Brookfields Specialist Nursing Hospital - Respiratory - City 19 2.8 14% & South Cambs Brookfields Speech & Hospital Language Therapy - Adults - 16 2 13% City & South Cambs Brookfields Specialist Nursing Hospital - Diabetes - City & 43.6 4.9 12% South Cambs North District Nursing Cambridgeshi (Out of Hours) - 20.5 2.5 12% re Hospital City, South & East Cambs Brookfields Neuro Hospital Rehabilitation - 8.6 0.8 10% Falls Service Brookfields Neuro Hospital Rehabilitation - 27.2 2.4 8% Cambridge Fulbourn District Nursing Hospital (Out of Hours) - 17.8 1.2 7% Fenland Fulbourn Specialist Nursing 13.2 0.8 6% Hospital - CFS-ME Fulbourn Intermediate Care Hospital Service / Hospital 69.4 2.8 5% at Home Service Fulbourn Specialist Nursing Hospital - Tissue Viability - 7.1 0 0% City & South Cambs Fulbourn Specialist Nursing Hospital - Continence - City 7.2 0 0% & South Cambs Fulbourn Specialist Nursing Hospital - Heart Failure - 15.4 0 0% Huntingdonshire

20190830 RT1 Evidence appendix Page 70

Fulbourn JET - Cambridge 46 8 18% Hospital Core service total 369.6 42.2 12% Trust Total 3575.2 446.3 13%

Sickness The sickness rate for this core service was 4.2% between 1 January 2018 and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 5.4%.

Total % staff sickness Ave % permanent staff Location Team sickness (over the past (at latest month) year) Specialist Nursing - Brookfields Respiratory - City & 0.3% 7.5% Hospital South Cambs Brookfields Neuro Rehabilitation - 11.6% 7.0% Hospital Falls Service Intermediate Care Fulbourn Service / Hospital at 4.5% 5.0% Hospital Home Service North District Nursing (Out of Cambridgeshire Hours) - City, South & 2.2% 4.3% Hospital East Cambs Fulbourn District Nursing (Out of 8.8% 3.9% Hospital Hours) - Fenland Specialist Nursing - Fulbourn Continence - City & 13.9% 3.9% Hospital South Cambs Specialist Nursing - Brookfields Diabetes - City & 6.7% 3.8% Hospital South Cambs Speech & Language Brookfields Therapy - Adults - City 8.2% 3.8% Hospital & South Cambs Specialist Nursing - Fulbourn Heart Failure - 7.6% 2.8% Hospital Huntingdonshire Fulbourn Nutrition & Dietetics - 3.9% 2.8% Hospital City & South Cambs

20190830 RT1 Evidence appendix Page 71

Brookfields Neuro Rehabilitation - 5.5% 2.5% Hospital Cambridge Fulbourn Podiatry - City & South 1.4% 2.3% Hospital Cambs Fulbourn Specialist Nursing - 9.7% 1.9% Hospital CFS-ME Specialist Nursing - Fulbourn Tissue Viability - City & 5.5% 1.3% Hospital South Cambs Fulbourn JET - Cambridge 5.7% 6.4% Hospital Core service total 5.4% 4.2% Trust Total 5.3% 4.5%

Suspensions and supervisions During the reporting period from 1 February 2018 to 31 January 2019, community health services for adults reported that there were no cases where staff have been either suspended or placed under supervision. Quality of records Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care. Community adult services used electronic patient records with two-point security access. Staff from different teams had access to one patient record. This meant that information, subject to patient consent, could be shared with all other services that use the system. Staff we spoke with told us that this improved patient care and increased efficiency by ensuring that information was available to the right person at the right time and reduced duplication. Information needed to deliver safe care and treatment was available to relevant staff in a timely and accessible way. Staff were able to access and update electronic patient records remotely. Staff were expected to complete electronic patient records within 24 hours of patient contact. We reviewed 11 sets of patient records, all of which were legible and dated with an electronic staff signature. This meant staff could easily identify the clinician and the date for each entry. All the records we reviewed demonstrated the plan of care and treatment for the patients. We observed staff entering electronic tasks to team members and other professionals such as patient GPs to follow up any concerns or review pain management. The trust had a record a clinical record keeping policy in place which set out the expectations of staff regarding the quality of clinical records. The policy was with the review date and referenced relevant legislation and national guidance. Band six nurses completed an audit of five patient records within their team per month. The service had changed the format of records audits from paper-based audits to electronic audit questionnaires. This process allowed the band six team leads to identify gaps in documentation and assessments within their team and address this with staff.

20190830 RT1 Evidence appendix Page 72

We reviewed the patient records audit conducted in April 2019 for the South Cambridge neighbourhood team which showed 100% of the records reviewed had core care plans in place. The records audit conducted in May 2019 for the Fenland neighbourhood team showed that 93.3% of patients had all core care plans in place. Medicines The service used systems and processes to safely prescribe, administer, record and store medicines. The service had processes in place for the safe administration of medicines to patients. Staff reviewed the medicines administration chart to ensure that the prescriber had fully completed the prescription with a signature. We reviewed four medicines administration directives, and all of these were completed appropriately including information about allergies. Staff administered controlled drugs such as diamorphine (strong pain relief) which is a controlled drug to patients at end of their life. Staff did not convey medicines to patients, the patient’s family collected from a pharmacy or a local pharmacy delivered these medicines. Nursing staff did not routinely transport medicines to patients. However, community nursing staff administered flu vaccines to their patients which they transported from GP surgeries to the patient homes. The vaccines were transported in specialist cool bags with a temperature probe and staff restocked supplies twice daily to prevent vaccines becoming too warm. Staff administered medicines such as insulin to patients in their own homes and within care homes. Insulin is a medicine to regulate blood sugar levels for diabetic patients. We reviewed two medicine administration directives and found that both had recorded patient allergies and sensitivities appropriately. Some of the specialist nurses and community nursing staff were able to prescribe medicines within the scope of their practice. These staff members had completed a specialist university course in order to prescribe medicines and medical devices for their patients. A trust audit for non-medical prescribing showed that all independent non-medical prescribers made prescribing decisions within their scope of practice. We reviewed the non-medical prescribing audit for the joint emergency team undertaken in February 2019. The audit demonstrated that prescribing staff documented allergies, the reason for the prescription and dosage amongst other measure appropriately. The trust had a medicines policy and medicines in domiciliary settings policy in place for staff to follow. Both policies were within the review date and made reference to legislation and national guidance. Safety performance The service used monitoring results well to improve safety. Staff collected safety information and managers shared results with staff. The trust collected information about harms for the NHS safety thermometer and investigated any service acquired harms and shared learning from these incidents with staff. The board reviewed safety information such as the safety thermometer during board meetings every other month. We saw information about harm free care was reported to the board within the meeting minutes for March 2019 and the board report papers for May 2019.

20190830 RT1 Evidence appendix Page 73

The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination. Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date. Community Settings Data from the Patient Safety Thermometer showed that the trust reported 7659 incidences of harm free care, 90 new pressure ulcers, 106 falls with harm and 32 catheter urinary tract infections from March 2018 to March 2019 within community settings.

Prevalence rate (number of patients per 100 surveyed) of harm free care, pressure ulcers, falls and catheter urinary tract infections at Cambridge and Peterborough NHS Foundation Trust – Community settings.

Harm Free Care (7659)

New Pressure ulcers (90)

20190830 RT1 Evidence appendix Page 74

Falls with Harm (106)

Total CUTIs (32)

Incident reporting, learning and improvement The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored. The provider had an electronic incident reporting system in place for staff to report incidents. The system alerted managers when an incident was reported, and the named manager allocated a lead investigator for each incident. Staff received feedback about an incident they had raised through the electronic system once an investigation was completed. Staff we spoke with told us that they received verbal feedback from their managers and shared learning during team meetings and clinical supervision. We observed a group clinical supervision session where staff discussed learning following an incident due to a missed nursing visit. The trust had an Incident reporting policy version four, which was last reviewed in January 2017. Staff could easily access the policy and knew their responsibilities in raising an incident report

20190830 RT1 Evidence appendix Page 75

including how to categorise the incidents. Staff completed e-learning induction training which, included incident reporting. Data provided by the trust showed that the neighbourhood teams within the older people and adult community directorate reported 2,828 incidents from April 2018 to March 2019. We saw that the most common theme was pressure ulcer identification. Staff reported 1,550 incidents for patient with identified pressure ulcers, including deep tissues injuries in line with the trust’s pressure ulcer prevention policy. The second most common theme of incidents staff reported was for slips trips and falls (42). Serious Incidents

From 1 January 2018 to 31 December 2018, trust staff within community health services for adults reported 13 serious incidents.

Of these, one involved the unexpected death of a patient. The most common types of serious incidents were ‘Pressure ulcer’ (six), ‘Apparent/actual/suspected self-inflicted harm (two)’ and ‘Medication incident’ (two). The number of the most severe incidents recorded by the trust incident reporting system is comparable with that reported to Strategic Executive Information System (STEIS). This gives us more confidence in the validity of the data.

Incident Type Number of Incidents

Pressure ulcer 6 Apparent/actual/suspected self-inflicted harm 2 Medication incident 2 Surgical/invasive procedure incident 1 Abuse/alleged abuse of child patient by staff 1 Accident e.g. collision/scald (not slip/trip/fall) 1 Grand Total 13

Managers had received training to investigate serious incidents. Managers we spoke with confirmed they had completed training provided by trust in the investigation of serious incidents. Managers gave examples of serious incidents they had investigated. An example of a recent serious incident was for an insulin administration error which resulted in a patient being admitted to an acute hospital. The had systems and processes in place to apply duty of candour when things went wrong. The duty of candour is a regulatory duty that relates to openness and transparency and requires the providers of health and social care services to notify patients (or other relevant persons) of certain notifiable safety incidents and provide reasonable support to that person.

20190830 RT1 Evidence appendix Page 76

The trust had a policy in place called ‘being open and duty of candour policy. This document set out the responsibilities of staff and referenced relevant legislation and national guidance. The policy was within the review date and had version control. Managers completed thorough serious incident root cause analysis reports and shared the learning with staff. We reviewed two serious incident root cause analysis investigation reports and we found that both serious incident investigations were thorough. One of the investigations related to the administration of the wrong dose of insulin, staff we spoke with during the inspection knew about the incidents and had covered learning from the incident in clinical supervision sessions. Prevention of Future Death Reports The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been no prevention of future death reports sent to Cambridgeshire and Peterborough NHS Foundation Trust.

Is the service effective?

Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence-based practice. Staff protected the rights of patients in their care. The service assessed people’s physical, mental health and social needs holistically and their care and treatment. Staff delivered support in line with legislation, standards and evidence-based guidance including Health and Care Excellence (NICE) and all other expert professional bodies to achieve effective outcomes. Staff adhered to relevant quality standards which we observed during a patient visits. Staff ensured that each individual patient had a plan of care in place. We reviewed patient care plans and we saw these were up to date and in line with relevant good-practice guidance. Staff provided the patient with information relevant to their condition and needs, as well as guidance to support them to manage their condition in between the care visits. The trust had systems and processes in place to ensure that policy documents reflected national guidance and legislation. An example of this process was the new pressure ulcer guidelines from NHS Improvement and the National Pressure Ulcer Advisory Panel (NPUAP). The tissue viability specialists had taken account of and updated the local policy to reflect these changes. Staff we spoke with told us they could easily find policy and pathway information on the trust’s intranet. Staff showed us how they found policies, standard operating procedures, and guidance. The trust developed policies and procedures based on the latest guidance from the NICE. The provider had a quality scorecard for key performance indicators (KPIs) set by local commissioners. The quality scorecard provided information about measures such as the number of patients on the caseload with core care plans. The service conducted regular audits to monitor the compliance of policies and performance measures. An example of this was the monthly documentation audit to monitor compliance with the record keeping policy and the core care plan performance measure.

20190830 RT1 Evidence appendix Page 77

Nutrition and hydration Staff regularly checked if patients were eating and drinking enough to stay healthy and help with their recovery. They worked with other agencies to support patients who could not cook or feed themselves. People’s nutrition and hydration needs were identified and met through a malnutrition universal screening tool (MUST) which was completed for all patients during their initial assessments. Staff completed personal care support plans to identify nutritional care and fluid needs of patients and how they were to be achieved. The service referred patients with swallowing difficulties to the speech and language therapy (SALT) service if they had concerns about a patient’s ability to swallow food or fluids. Staff could refer patients to the dietetics service if a patient required further advice and support with their nutritional needs. Pain relief Staff assessed and monitored patients regularly to see if they were in pain, and requested pain management reviews in a timely way. Staff carried out pain assessments with patients which were demonstrated in the patient records we reviewed. Staff carried out pain assessments with patients which were demonstrated in the patient records we reviewed. Staff told us about how they managed patients’ pain in a person-centred way. For example, if a patient was generally only in pain during a dressing change, the member of staff would call the patient before their appointment and encourage them to take pain relief to ensure their comfort during the delivery of care. Registered nurses regularly assessed the pain experienced by patients at the end of their life. Patient records demonstrated that nurses had completed pain assessments for these patients on each visit. The nursing teams prioritised the visit requests for pain relief, and for palliative care patients. Some nurses were trained to assess and prescribe pain relief to patients. Nurses could request a review of pain relief if required either by a nurse prescriber or the patient’s own GP. The service had positive links with GP services. Staff told us that they were able to contact the patient’s GP to highlight concerns they had about the level of pain patients were experiencing or if they were struggling with pain management. We observed staff discussing pain management with their patients and allocating tasks to the patient’s GP to review pain management medicines. Patient outcomes Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. The service was focused on quality improvement and used patient outcomes and audit data to improve the provision of care. Staff we spoke with told us about quality improvement work teams had in place. An example of the quality improvement work was the management of chronic leg oedema. The tissue viability service had led a pilot project in the management of this long-term condition and had plans to roll out the project across all localities.

20190830 RT1 Evidence appendix Page 78

Specialist teams within the service completed local audits to assess patient outcomes and the quality of care and treatments provided. Managers and staff used this information to improve patient outcomes and the quality of care provide to patients. Neighbourhood teams had internal quality benchmarks which were measure within the trust’s quality improvement evaluation tool (QuIET). An example of the service benchmarking was the number of patients with active care planning in place. Data provided by the trust showed the compliance rate for neighbourhood teams was 92% for this measure. Community services for adults monitored their performance against key performance indicators (KPIs) and commissioning for quality and innovation (CQUIN) measures set out by commissioners. Data provided by the trust demonstrated that teams within the service met the targets for these measures. For example, we saw that the tissue viability service met the CQUIN for the compliance in the wound assessment process. We saw that 94% of patients received a full wound assessment from June to September 2018. Neighbourhood teams and specialist teams four out of five commissioner KPIs from April 2018 to March 2019. The service met the following targets: - % of district nursing (daytime) caseload, with active care plan recorded following initial visit - % of district nursing (out of hours) referrals seen within four hours - % P1 referrals with first contact within three days - % P3 referrals with the first contact within 18 weeks The service did not meet the KPI for the number of patients with the first contact within 28 days. The service achieved 88% for this measure and the commissioner target was 90%. The trust participated in the Sentinel Stroke National Audit Programme (SSNAP). However, the data from December 2017 to April 2018 insufficient to draw conclusion about the quality of the service. Further data was not available at the time of our inspection. Audits The trust has participated in eleven clinical audits in relation to this core service as part of their Clinical Audit Programme. Audit name Area covered Key Successes Key actions Medicines All Community All teams with medicines Each unit has an Management - Services fridges were used solely individual report Community for medicines. All teams with specific have a contingency plan action plans. The in the event of fridge pharmacy team breakdown. All teams will review the have secure medicines audit standards storage areas. All teams ahead of next stocking vaccines round. Pharmacy maintain the appropriate team will contact log. All teams administer non-engaging medicines using Trust teams with advice approved documentation. on how to audit All teams had a legal locally. The authorisation to pharmacy team

20190830 RT1 Evidence appendix Page 79

administer medicines. will expedite the All teams that kept injectable medical gases checked medicines the integrity and expiry of template and the cylinders disseminate to all areas where needed. The pharmacy team will contact all teams with FP10 prescription pads to ensure the correct addresses are recorded. Medical Devices – Trust wide: • 97% (n=229/237) of • Ensure exam Community Adult & Specialist medical devices audited couches have Mental Health were available received planned directorate, • 100% (n=228/228) of maintenance at Children, Young medical devices audited CAMEO and Adult People and Families were clean Locality (Union Directorate, • 99% (n=227/228) of House), Clozapine Older People's and medical devices audited Clinic (Tennyson Adult Community were working Road), CASUS Directorate - All • 99% (n=221/224) of (The Bridge) and community teams Single-Use Items were in CFS/ME (Botolph date Bridge) • Ensure availability of sphygmanometer at District Nurses (Nye Bevan House) and Neighbourhood Team (NCH) • Ensure sphygmanometers have received planned maintenance at CRHTT (Beechcroft), CAMH Core (Newtown Centre), Neighbourhood Team and Tissue Viability (Histon Police Station),

20190830 RT1 Evidence appendix Page 80

CASUS (The Bridge), Neighbourhood Team (Wyboston Lakes), Neighbourhood Team (City Care Centre), First Response (Redshank House), Continence and Tissue Viability (City Clinic), Neighbourhood Team (Botolph Bridge) Hospital at Home (Commerce Road), Memory Clinic (Newtown Centre), Neighbourhood Team (Redshank House), Memory Clinic (The Pines) • Ensure availability of thermometer at District Nurses (Nye Bevan House) and Neighbourhood Team (Wyboston Lakes) • Ensure scales have received planned maintenance at District Nurses (Nye Bevan House), Physiotherapy (Signet Court), IST (Ida Darwin), Clozapine Clinic (Tennyson Road), Neighbourhood Team (Wyboston

20190830 RT1 Evidence appendix Page 81

Lakes), Minor Injuries (PoW), CRHTT (Cavell Centre), CFS/ME (Botolph Bridge), Heart Failure (Commerce Road), Clare Lodge Health Team (Clare Lodge), Podiatry (Oaktree Centre) • Ensure availability of Glucometer at Clozapine Clinic (Tennyson Road) and Neighbourhood Team (Kings Hall) • Ensure availability of Suction Unit at Neighbourhood Team (Sawston Medical Practice) • Ensure dopplers have received planned maintenance at Tissue Viability (Histon Police Station), Neighbourhood Team (NCH), Neighbourhood Teams (Botolph Bridge) and Tissue Viability (City Clinic) • Ensure bladder scanners have received planned maintenance at Neighbourhood Team (Histon Police Station) and

20190830 RT1 Evidence appendix Page 82

Neighbourhood Team (NCH) • Ensure availability of coagulation analysers at Neighbourhood Team (Signet Court) and Neighbourhood Team (Kings Hall) • Ensure coagulation analysers receive planned maintenance at Neighbourhood Team (Wyboston Lakes) • Send quarterly reminder email to all community teams to call in any missed items National Pulmonary Pulmonary CPFT services offer Promote PR Rehabilitation Audit rehabilitation (PR) patients a very provision within services, Older comprehensive range of wider CPFT Peoples & Community tests and measures at services & local initial assessment partners- aim to outperforming the encourage a wider national cohort in all range of referrals areas. These tests are in PR. Review keeping with gold referral process – standards as defined by aim to reduce The British Thoracic assessment to Society (BTS) • treatment waiting Combined data from the times. Discharge 2015 & 2017 audits summary will be suggest that CPFT issued to all provide PR intervention patients and to a broader range of referrers patients with COPD as defined by the MRC dyspnoea score, this includes patients’ groups perceived to have the

20190830 RT1 Evidence appendix Page 83

greatest rehabilitative potential CQUIN 10 Tissue Older People & Adult 96% (155/161) of A dedicated brief Viability Community - patients received a full training session Nurses/wound Neighbourhood Teams wound assessment on re will be delivered to assessment chart Re audit compared to 84.7% the staff/NT Audit Q4 2017/18 in the first round of audit. Teams accounting for the 4% non- concordant full wound assessment cases. Information poster to be disseminated to staff. Produce screen shots ‘guide’ on how and where to access wound care plan and template on SystemOne, distribute to all NT teams. CQUIN 10 Tissue Older People & Adult 94% (144/154) of Training on Viability Community - patients received a full completion of the Nurses/wound Neighbourhood Teams wound assessment on electronic wound assessment chart Re re-audit compared to assessment care Audit Q2 2018/19 96% in Q4 and 84.7% plan and template first round of audit. will be delivered to staff attending the pressure ulcer mandatory training and Continuing Professional Development group meetings. Results shared at -Tissue Viability team meeting, NT meetings, TVN training, inpatient, JET, mental health services. Share results at the Safe to Care

20190830 RT1 Evidence appendix Page 84

group meeting and patient safety. Continuous Older People's and It is possible to state that • Offer subcutaneous insulin Adult Community the current insulin pump questionnaires to infusion service Directorate - Diabetes MDT clinic is well everybody who evaluation to assess Service received, due to the attends an MDT current service majority of respondents insulin pump clinic provision and service scoring 80% for overall development satisfaction with the service. Additional • Increase patient dietetic and consultant contact with appointments will help dietitian and increase the patient consultant rating for their individual satisfaction scores, • Medtronic however DSN input is education already rated at an sessions to be exceptionally high level, adapted e.g. indicating that changes encourage are not required within participants to that area. submit issues for discussion via email prior to attending, as well as set an agenda to ensure the session runs to time.

• Hold an insulin pump event offering different brands for patients to choose their preferred insulin pump option for the diabetes pump team to offer as first line

• Develop a SOP for discontinuing pump therapy

20190830 RT1 Evidence appendix Page 85

Non-Medical Trustwide: Adult & All Independent NMP’s NMP to discuss Prescribing Audit Specialist Mental made prescribing Prescribing (NMP) Health directorate, decisions within their practice at their Children, Young scope of practice appraisal and People and Families In all but one instance, have an objection Directorate, Older NMP’s personally around this People's and Adult assessed their patient discussion. NMP’s Community Directorate before prescribing to complete NMP safe prescribing e Clear evidence of learning. NMP prescriber’s supporting self-audit tool to documentation was fine measure and amongst specialist reflect on safe nurses, MIU’s, Mental prescribing Health services. practice in their All elements of an supervision. accurate prescription Where it is were recorded for the documented as vast majority of MIU, either no or non- mental health and applicable for specialist nurse standards one independent prescribing and two to be episodes. followed up by NMP lead. Sentinel Stroke Older People's Adult & Continuous audit process Participation in National Audit Community Directorate commenced following the SSNAP Audit is Programme (SSNAP) - ESD North successful introduction of ongoing. 12- 2017/18 & Ongoing Community, ESD Early Supported month data South Community, Discharge services summary due end North Inpatients, South during Q4 2017/18. Data Q4 18/19 Inpatients entry for Q4 17-18 insufficient to draw substantive conclusions. Epilepsy and Older People's and •There is clear • To check if Folic pregnancy pathway Is Adult Community documentation is prescribed pre- the service compliant Directorate - Epilepsy demonstrating that pregnancy and with guidance? Service seizure activity is during pregnancy reviewed pre-pregnancy • Lamotrigine and the option to stop levels to check anti-epileptic drugs (AED) baseline pre- is considered. pregnancy levels •Lamotrigine levels are and repeat when checked in majority of the pregnancy is cases and the dose is reported increased during • To discuss pregnancy and reduced teratogenicity risk

20190830 RT1 Evidence appendix Page 86

post pregnancy in line associated with with NICE guidance. AEDs giving •Folic acid use is specific probability discussed in details consultations and • To complete the prescribed pre- MHRA Patient risk pregnancy and during acknowledgement pregnancy in line with form as per the guidance. 2018 MHRA Sodium Valproate guidance to clearly document action taken regarding Sodium Valproate for women who continue to take this whilst pregnant • To complete contraceptive screening for women prescribed Sodium Valproate. Contraceptive should have a failure rate of less than 1% with typical use such as copper intrauterine device, levonorgestrel intrauterine system, and progestogen-only implant and male and female sterilisation • To refer for Vitamin D levels check and suggest that supplements be prescribed for women taking

20190830 RT1 Evidence appendix Page 87

enzyme inducing AEDs. To include on clinic consultation checklist Medical Devices – Older People's and • 94% (n=69/73) of • Ensure that all Podiatry Adult Community medical devices audited CPFT items used Directorate- Podiatry were available at clinics are in • 100% (n=69/69) of date with medical devices audited scheduled were clean maintenance • 100% (n=69/69) of • Request all medical devices audited items used in were working clinics that are non-CPFT owned • 98% (n=205/210) of be kept up to date Single-Use Items were in with scheduled date maintenance • Establish whether availability of drill is applicable at Chesterton, Burwell, Hinchingbrooke and Soham clinics National Diabetes Podiatry Service, Podiatry Service currently Pending review Footcare Audit Older People's & Adult navigating online data (NDFA) 2018/19 Community source

The joint emergency team (JET) undertook urgent patient assessments to prevent unnecessary hospital admissions. The team monitored the admission avoidance rates and the referral to assessment rates. The JET received 1,607 referrals from November to December 2018 of these 86.8% were not admitted to hospital. The trust also participated in one clinical audit in relation to the JET team as part of their Clinical Audit Programme. Audit name Joint Emergency Team (JET) Notes Audit Area covered Older People & Adult Community (OPAC) - JET team Key Successes Clinical electronic notes: • 90% (n=9/10) of staff documented an assessment of Activities of Daily Living (ADLs)

20190830 RT1 Evidence appendix Page 88

• 80% (n=8/10) of staff documented the patients’ personal care needs (Personal Activities of Daily Living (PADLs)) • 100% (10/10) of staff documented the patients’ vital signs (body temperature, pulse rate, respiration rate, blood pressure)

Triage notes:

87% (n=7/8) of staff documented the patients’ medical history • 87% (n=7/8) of staff documented the patients’ living situation • 75% (n=6/8) of staff documented who was present with the patient at the time of the assessment • 100% (n=8/8) of staff documentation had patients registered in the correct location and had language, terminology and appropriate abbreviations approved by the Trust approved throughout Key actions • To review the areas of clinical assessment documentation standards and identify if all areas are appropriate/relevant to the JET team and make necessary changes to the standards for clinical assessment/triage documentation • To identify whether training or educational sessions (specify in what setting/meeting this will be established) are required for practitioners in reference to pain scoring, pressure prevention documentation and electronic discharge template. • Following changes made to the standards for clinical assessment/triage documentation, the audit tool will be reviewed and updated to reflect these changes • For a handover/training session to be given to the JET team about the audit database so that the JET team can take over for monthly rolling audit.

Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Managers maintained regular communication within their teams to ensure that any issues were addressed, and staff were equipped to meet the needs of patients. Managers identified the learning needs of staff through supervision or the appraisal process. Staff felt encouraged and supported to attend additional training in areas they developed an interest in. The trust offered management level staff had been supported to attend leadership training. The provider developed the role of advanced community nurse practitioner to up skill and support junior and senior staff working in a community setting. The practice development nurse worked particularly with newly qualified nurses to ensure that they were sufficiently supported to carry out their role.

20190830 RT1 Evidence appendix Page 89

All new staff received a trust and a local role specific induction. Advance community nurse practitioners were in post to assist staff with skill development and build staff confidence in the community nursing role. The neighbourhood teams held group practice development sessions for nursing staff. We observed a group clinical supervision session which included a presentation from one of the specialist nurses and learning from an incident. During our inspection we reviewed the appraisal completion records for Fenland neighbourhood team, which demonstrated the appraisal completion rate was 100%. The Fenland out of hours nursing service also had an appraisal rate of 100% which met and exceeded the trust’s 95% appraisal target. The South Cambridge neighbourhood team had an appraisal completion rate of 100%. One of the area managers told us that the trust had introduced a new electronic appraisal record in April 2019. This had replaced the old paper-based records and staff were adjusting to this change. All staff we spoke with confirmed they had participated in the appraisal process within the 12 months prior to our inspection. All staff we spoke with told us they had regular one to one meetings with their line manager to discuss any learning needs, education planning and career progression. The trust provided the following information about their clinical supervision process: “The trust, working with colleagues in the Learning and Development department, has developed functionality within their e-Academy System to capture the detailed supervision analysis, whilst staff continue to report through the Quarterly Staff Pulse Survey against a specific metric – ‘having effective supervision,’ which at Dec 18 was over 78%. The compliance rates for Supervision within the e-Academy system are monitored through the Performance & Risk Executive and the compliance rates have been appropriately challenged whilst acknowledging that the Directorates have assured the Executive that staff are receiving supervision and that there is a considerable underreporting, due to late data entry. The Senior leadership team continue to work with clinical and corporate services to ensure compliance is accurately recorded whilst acknowledging that our staff inform us that they are receiving the appropriate supervision.” The trust has not supplied a target for non-medical staff. Between 1 April 2018 and 31 December 2018, the average rate across all fourteen teams for which data was provided in this service was 55%. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision sessions delivered rate (%) required Specialist Nursing - Heart Failure - 142 153 93% Huntingdonshire Podiatry - City & South Cambs 274 320 86% Specialist Nursing - Respiratory - City 145 195 74% & South Cambs

20190830 RT1 Evidence appendix Page 90

Neuro Rehabilitation - Cambridge 207 299 69% District Nursing (Out of Hours) - City, 204 305 67% South & East Cambs Specialist Nursing - CFS-ME 95 152 63% Specialist Nursing - Tissue Viability - 50 83 60% City & South Cambs Nutrition & Dietetics - City & South 153 258 59% Cambs Neuro Rehabilitation - Falls Service 43 78 55% Specialist Nursing - Diabetes - City & 210 393 53% South Cambs Speech & Language Therapy - Adults 117 219 53% - City & South Cambs Specialist Nursing - Continence - City 33 77 43% & South Cambs Intermediate Care Service / Hospital 183 600 31% at Home Service District Nursing (Out of Hours) - 54 237 23% Fenland JET - Cambridge 425 162 38% Core service total 3794 2072 55% Trust Total 31881 15835 50%

From 1 April 2018 to 31 January 2019, 92% of required staff in community health services for adults received an appraisal compared to the trust target of 95%.

Non-Medical staff 1 April 2018 to 31 January 2019 Staff who Staff group Eligible Completion Trust Met received an staff rate target (Yes/No) appraisal Neuro Rehabilitation - Cambridge 32 33 97% 95% Yes District Nursing (Out of Hours) - 24 25 96% 95% Yes Fenland Intermediate Care Service / Hospital 72 75 96% 95% Yes at Home Service

20190830 RT1 Evidence appendix Page 91

Specialist Nursing - CFS-ME 16 17 94% 95% No District Nursing (Out of Hours) - City, 30 32 94% 95% No South & East Cambs Specialist Nursing - Heart Failure - 15 16 94% 95% No Huntingdonshire Speech & Language Therapy - 22 24 92% 95% No Adults - City & South Cambs Podiatry - City & South Cambs 30 33 91% 95% No Nutrition & Dietetics - City & South 26 29 90% 95% No Cambs Specialist Nursing - Continence - 8 9 89% 95% No City & South Cambs Neuro Rehabilitation - Falls Service 7 8 88% 95% No Specialist Nursing - Diabetes - City 34 39 87% 95% No & South Cambs Specialist Nursing - Respiratory - 20 24 83% 95% No City & South Cambs Specialist Nursing - Tissue Viability - 7 9 78% 95% No City & South Cambs

Multidisciplinary working and coordinated care pathways All those responsible for delivering care worked together as a team to benefit patients. They supported each other to provide good care and communicated effectively with other agencies. Staff worked together across multiple health, social and voluntary sector organisations. The trust delivered community adult services through 14 neighbourhood teams (NTs). These teams were responsible for the promotion of health and independence in the community. NTs delivered multi- disciplinary, seamless care closer to a patient’s home. Neighbourhood team included district nurses, staff nurses, health care assistants, occupational therapists, physiotherapist and mental health practitioners. Neighbourhood teams held weekly multidisciplinary team meetings. Team leads, care coordinators, therapists, integrated care workers (ICWs), private care provider (where relevant) attended the MDT meetings. This meant that every patient was discussed at MDT meetings every week to ensure that all actions to support patient flow are completed. Teams used the SBAR tool for each patient discussed. The community teams also held a weekly white board meeting using Red 2 Green tool for discharge planning. Neighbourhood teams worked closely with GPs across Cambridgeshire and Peterborough. Community adult services provided care from a range of specialist teams alongside the neighbourhood teams including dietetics, podiatry, respiratory, continence, tissue viability, speech and language therapy, cardiac service, diabetes, neuro conditions and neuro rehab. Specialist services had specific referral criteria for each of the specialist teams and all referrals were

20190830 RT1 Evidence appendix Page 92

checked and streamed by the single point of contact. During our inspection we spoke with specialist nurses from the respiratory and cardiac specialist teams who confirmed that they accepted referrals from other healthcare professionals for the first referral into the service. They worked with other service such as the joint emergency team (JET) for urgent patient assessments and neighbourhood teams to provide additional support in the management of long-term conditions. Health promotion Staff gave patients practical support and advice to lead healthier lives. During our inspection we observed nursing staff providing health promotion to their patients. An example of this was during a discussion about medicines and why the patient needed to take their medicines regularly. Another member of staff provided health promotion about nutrition and drinking enough to avoid complications of their condition. Staff were able to direct patients to outside organisation for help and support. We observed staff sign posted patients and their relatives to outside organisations for additional social support. Specialist teams provided health promotion advice and support to patients. We observed staff providing information and patient teaching sessions to self-manage condition such as diabetes. The continence service provided information and patient led exercises to improve their continence. The service lead told us that the team had contacted local GPs to refer patient at the earliest opportunity to improve patients daily lives. The tissue viability team had completed a pilot project to improve the outcomes of patients with chronic oedema. Chronic oedema is increased fluid in the legs which causes fluid to leak from the skin or wounds. The tissue viability service had worked with occupational therapists and physiotherapists to educate patients and provide additional equipment to aid patients in self-care, such as bed rest and leg elevation which reduce symptoms of the condition. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff supported patients to make informed decisions about their care and treatment. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Staff completed mental capacity assessments for patients who lacked capacity and were unable to consent to a treatment plan to enable the core components of care to take place. This was completed in the patient’s best interests and enabled staff to undertake a range of interventions that patients had been unable to provide informed consent for. Staff could access support and advice about mental capacity assessments from mental health community nursing staff within the neighbourhood team. Staff provided end of life care and followed do not attempt cardio-pulmonary resuscitation DNACPR directives in place. Managers and staff we spoke with told us patients often had DNACPR directives in place when they were referred to the service. If staff identified a patient in the last year of their life, they worked with local hospice teams, patient GPs and the trust’s palliative care team to ensure patients had a plan of care in place including DNACPR directives. Staff under stood their responsibilities in relation to gaining patient consent to provide care and treatment. During our inspection we observed seven nurse patient interactions, nurses gained consent from patients and documented the verbal consent in the patient record. Staff we spoke knew.

20190830 RT1 Evidence appendix Page 93

The trust set a target of 90% for completion of Mental Capacity Act / deprivation of liberty standards training. From 1 January 2018 to 31 December 2018 the trust reported that Mental Capacity Act (MCA) Level 1 training had been completed by 87% of staff within community health services for adults and Mental Capacity Act Level 2 training was completed by 86% of eligible staff. Deprivation of Liberty training had been completed by 78% of staff. A breakdown of compliance for MCA/DOLS courses from 1 January 2018 to 31 December 2018 for all community services for adults is shown below:

Number Number of of staff Completion Target Target met Training module name eligible trained (%) (%) (Yes/No) staff (YTD) (YTD) Mental Capacity Act Level 1 93 107 87% 90% No Mental Capacity Act Level 2 207 240 86% 90% No Deprivation of Liberty Safeguards 121 156 78% 90% No

Staff received training about the Mental Capacity Act and Deprivation of Liberty Safeguards, which formed part of their mandatory training programme. Although the community adult service had not always completed this training in line with the trust’s internal target for the completion of this training. Managers and team leads, we spoke with, told us staff found face to face training difficult to book due to the high demand and limited places for each session. This meant some staff were out of date with this training. Managers had escalated the issues with face to face training to the senior leadership team and extra training had been arranged. From 1 January 2018 to 31 December 2018 the trust reported that 142 Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority. None of which were pertinent to community health services for adults. Staff did not complete deprivation of liberty safeguards for their patients as care was provided in patients own homes or within clinics. Staff we spoke with had know about deprivation of liberty safeguards, however they told us that they had not been involved in the application process within their role.

Is the service caring? Compassionate care Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff demonstrated strong, caring, respectful and supportive relationships with their patients and those close to them. We observed staff delivering care in patients’ homes. Their interactions were professional, friendly, and kind. Staff demonstrated an understanding of the importance of treating patients and those who were important to them in a caring and sensitive manner.

20190830 RT1 Evidence appendix Page 94

Staff treated patients with privacy, respect, and dignity and we saw this when they protected patients from cold and exposure, using blankets to cover exposed parts of the body whilst administering physical and or intimate care whilst in their own homes. The staff respected the confidentiality of patients and did not discuss or display confidential information in the hearing of others. Staff shared information appropriately with each other either during handover or within the secure electronic records systems. Feedback from people who used the service was continuously positive about the way staff treated people. Patients consistently praised the care they received from staff. Patients and their carers we spoke with told us “the team are very helpful and easy to contact” and staff were “very helpful and knowledgeable” one patient told us that staff “treat me like a person not my illness” another patient told us staff were “helpful and always with a smile”. The service participated in the NHS friends and family test. Data provided by the trust showed that 99.4% of patients would recommend the service provided by the neighbourhood teams, to friends and family from April 2018 to March 2019. Emotional support Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. We observed staff providing emotional support to patients during their care. We saw staff reassuring an anxious patient with a complex diagnosis staff explored the cause of their distress and provided reassurance. Staff could signpost patients or their relatives to other service such as bereavement counselling and patient support groups when they required additional support emotional with their condition or situation. The trust had a service called ‘heart and soul’ which included spiritual wellbeing for patients and carers. The trust had changed the name of this service which was previously the chaplaincy service. Managers we spoke with told us that the heart and soul service was aimed to be inclusive to all people regardless if they had religious beliefs or not. Understanding and involvement of patients and those close to them Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Staff took the time to explain and interact with patients, they were sensitive to patients’ needs offering explanations and being supportive when patients expressed concerns. We observed staff providing care to patients and explaining the care they were providing to patients in a way they understood. We observed staff taking time to explain the care and treatment with patients and their carers. One example of this was during a home visit with the diabetes team where staff spoke with the patient and their relative and answered their questions. We saw that staff involved patients and their families in planning care and treatment. Staff explained procedures in a manner that was easily comprehensible and took the time to ensure that patients understood explanations, so that patients knew what they were consenting to. The trust had implemented the triangle of care initiative to increase patient and carer involvement in the care they received. The triangle of care helped staff to promote safety, support on-going recovery and improve the well-being of both the carer and the person they care for. Staff we spoke with knew about the triangle of care and integrated this into the care they provided to patients. 20190830 RT1 Evidence appendix Page 95

Is the service responsive?

Planning and delivering services which meet people’s needs The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. The design of buildings met the needs of people using the service. The design of the building we visited, which held patient clinics met the needs of patients. All buildings used for patient clinics we visited, could be accessed by patients using mobility aids. The trust worked together with commissioners and other organisations across Cambridgeshire and Peterborough to plan and meet the needs of the local population. The service planned and provided services, delivered by district nursing teams, specialist nursing teams and therapists. The trust worked with other NHS organisations within the local sustainability and transformation partnership (STP) to develop new services to help keep patients well at home. The trust worked with the local STP to provide services such as respiratory, stroke and diabetes to provide person- centred care. Managers for the service met with their commissioners regularly. The service had action plans in place extend or improve the provision of care and treatment. Managers worked in collaboration with their stakeholders and commissioners to extend the service provision where the service did not meet the needs of local people. The service had identified unmet care needs within community adult services such as patients with chronic leg oedema and completed a pilot for the effective management of this condition. The pilot had demonstrated an improvement in symptom management in 13 patients out of 20 patients where interventional treatment was used. The tissue viability service had plans in place to upskill community nurses in the management of chronic leg oedema. Another project had reduced the number of patients in the community with long-term urinary catheters in place following discharge from hospital without a clear treatment plan. The trust had identified the rapid growth of the older population and used population forecasts to plan and develop services for an increasing aging population in the local area. The trust provided care areas of significant deprivation such as Fenland (ranking as 94th most deprived authority out of 326 nationally). One of the advanced community nurse practitioners we spoke with had plans to strengthen links with migrant families and support groups for these families to meet the needs of older patients who were more isolated. Meeting the needs of people in vulnerable circumstances The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. The main functions of the neighbourhood teams were, care co-ordination, integrated physical health, mental health care and social care, including treatment, admission avoidance, palliative care, rehabilitation and recommendations for provision of equipment and adaptations Staff had access to interpreters when their patient’s first language was not English. The service had access to translation services to ensure staff had effective communication with their patients.

20190830 RT1 Evidence appendix Page 96

The trust had identified the ten commonly used languages in Cambridgeshire and Peterborough and used an external interpreting and translation service. The translation service provided face to face spoken language interpreting, telephone interpreting, British sign language Interpreting, document translation & proofreading, deaf Blind Manual and reader/speaker services. Staff we spoke with knew how to access this service. Managers understood the population of their locality and the nationalities of their patients. Dementia training formed part of mandatory training for clinical staff. Information provided by the trust showed that 95% of staff had completed this training. All staff we spoke with told us that they had completed dementia training. The community nurses worked closely with the wider multidisciplinary team for example social workers and GPs to ensure patients in vulnerable circumstances had support to remain independent or stay in their own homes. The community service for adults supported patients with frailty in their own homes. Physiotherapists and occupational therapists provided care and treatment in patients their own homes in falls prevention and aid rehabilitation. Community adult services had a joint emergency team (JET). This was a rapid response service staffed by nurse and paramedic practitioners. The team provided an acute health response supporting people over 65 to stay at home safely who were otherwise at risk of being admitted to an acute hospital unnecessarily. The service operated seven days a week from 7am to 9.30pm. The service had a clinical telephone triage function and response times were agreed with the referring clinician for patients reviews within 2 hours, 4 hours, same day or next day. The trust worked with other organisations such as hospices and local NHS hospital to provide patient centred end of life care. The trust participated in work to develop an end of life dashboard and a template within electronic patient records to capture the preferred place of death. The trust was in the process of implementing the recommended summary plan for emergency care and treatment (ReSPECT) end of life advanced decision-making care plans. Access to the right care at the right time People could access the service when they needed it and received the right care in a timely way. All referral to the services went to the single point of access. The service received patient referrals, electronically, by telephone or by fax. Each team had a referral criteria and senior nurses triaged all referrals and allocated to the appropriated team according to the referral criteria. Staff prioritised the patients with the greatest need within each team. Patients we spoke with told us that they found it easy to contact the service in the event of changes to their condition. Accessibility2 The largest ethnic group within the trust catchment area is White with 90.8% of the population.

Ethnic minority group Percentage of catchment population (if known)

2 P48. Accessibility 20190830 RT1 Evidence appendix Page 97

First largest White 90.8% Second largest Asian/Asian British 4.8% Third largest Black/African/ Caribbean/ 2.0% Black British Fourth largest Mixed/ Multiple Ethnic Groups 1.9%

Referrals3 The information submitted showed that the service had met all national targets for 18 weeks and commissioners’ local targets for referral to treatment times. The national target was set to prevent treatment delays from initial referral to the first appointment. Community adult services met and exceeded referral to treatment targets (RTT). Patients referred to Parkinson’s disease specialist nurse had the longest waiting time of 116 days, however this was below the target of 126 days. The trust has identified the below services in the table as measured on ‘referral to initial assessment’ and ‘assessment to treatment’. The trust met the referral to assessment target in all the targets listed The trust did not provide targets for the assessment to treatment. The trust informed us that ‘median results based on referral to first contact, then first to second contact, where either took place in 2018.

Name of Name of in- Service Type Days from referral Days from hospital site patient ward or to initial assessment to or location unit assessment treatment National Actual National Actual / Local (median) / Local (median) Target Target

Brookfields Speech & SALT - Adults 126 65 - 13 Hospital Language Therapy - Adults - City & South Cambs Fulbourn Speech & SALT - Adults 126 18 - 13 Hospital Language Therapy - Adults - Ely & The Fens Fulbourn Speech & SALT - Adults 126 49 - 16 Hospital Language Therapy - Adults

3 CHS10. Referrals 20190830 RT1 Evidence appendix Page 98

- Huntingdonshire City Care Speech & SALT - Adults 126 14 - 11 Centre Language Therapy - Adults - Peterborough Fulbourn Specialist Specialist 126 11 - 14 Hospital Nursing - Tissue Nursing - Viability - City & Tissue South Cambs Viability Fulbourn Specialist Specialist 126 12 - 14 Hospital Nursing - Tissue Nursing - Viability - Ely & Tissue The Fens Viability Fulbourn Specialist Specialist 126 12 - 9 Hospital Nursing - Tissue Nursing - Viability - Tissue Huntingdonshire Viability Fulbourn Specialist Specialist 126 9 - 17 Hospital Nursing - Tissue Nursing - Viability - Tissue Peterborough Viability Fulbourn Specialist Specialist 126 21 - 14 Hospital Nursing - TB Nursing - TB Brookfields Specialist Specialist 126 10 - 9 Hospital Nursing - Nursing - Respiratory - Respiratory City & South Cambs Fulbourn Specialist Specialist 126 4 - 7 Hospital Nursing - Nursing - Respiratory - Ely Respiratory & The Fens Fulbourn Specialist Specialist 126 12 - 8 Hospital Nursing - Nursing - Respiratory - Respiratory Huntingdonshire Fulbourn Specialist Specialist 126 6 - 6 Hospital Nursing - Nursing - Respiratory - Respiratory Peterborough

20190830 RT1 Evidence appendix Page 99

Fulbourn Specialist Specialist 126 66 - 41 Hospital Nursing - CFS- Nursing - ME CFS-ME Fulbourn Specialist Specialist 126 21 - 9 Hospital Nursing - Nursing - Continence - City Continence & South Cambs Fulbourn Specialist Specialist 126 36 - 34 Hospital Nursing - Nursing - Continence - Ely Continence & The Fens Fulbourn Specialist Specialist 126 26 - 38 Hospital Nursing - Nursing - Continence - Continence Huntingdonshire Fulbourn Specialist Specialist 126 30 - 37 Hospital Nursing - Nursing - Continence - Continence Peterborough Brookfields Specialist Specialist 126 14 - 8 Hospital Nursing - Nursing - Diabetes - City & Diabetes South Cambs Fulbourn Specialist Specialist 126 14 - 14 Hospital Nursing - Nursing - Diabetes - Ely & Diabetes The Fens Fulbourn Specialist Specialist 126 8 - 12 Hospital Nursing - Nursing - Diabetes - Diabetes Huntingdonshire Fulbourn Specialist Specialist 126 6 - 12 Hospital Nursing - Nursing - Diabetes - Diabetes Peterborough Fulbourn Specialist Specialist 126 54 - 34 Hospital Nursing - Nursing - Epilepsy Epilepsy Fulbourn Specialist Specialist 126 2 - 5 Hospital Nursing - Heart Nursing - Failure - Heart Failure Huntingdonshire

20190830 RT1 Evidence appendix Page 100

Fulbourn Specialist Specialist 126 5 - 8 Hospital Nursing - Heart Nursing - Failure - Ely & Heart Failure The Fens Fulbourn Specialist Specialist 126 5 - 5 Hospital Nursing - Heart Nursing - Failure - Heart Failure Peterborough Fulbourn Specialist Specialist 126 14 - 42 Hospital Nursing - Nursing - Multiple Multiple Sclerosis Sclerosis City Care Specialist Specialist 126 63 - 35 Centre Nursing - Nursing - Parkinson’s - Parkinson’s North Disease Brookfields Specialist Specialist 126 116 - 28 Hospital Nursing - Nursing - Parkinson’s - Parkinson’s South Disease North District Nursing District 0 0 - 0 Cambridgeshire (Out of Hours) - Nursing (Out Hospital City, South & of Hours) East Cambs Fulbourn District Nursing District 0 0 - 0 Hospital (Out of Hours) - Nursing (Out Fenland of Hours) Fulbourn District Nursing District 0 0 - 1 Hospital (Out of Hours) - Nursing (Out Huntingdonshire of Hours) -City Care - District Nursing District 0 0 - 1 Centre (Out of Hours) - Nursing (Out Peterborough of Hours) Fulbourn - Intermediate Intermediate 126 4 1 Hospital Care Service / Care Service Hospital at Home Service Brookfields Neuro Neuro 126 8 - 7 Hospital Rehabilitation - Rehabilitation Cambridge Fulbourn Neuro Neuro 126 8 - 8 Hospital Rehabilitation - Rehabilitation

20190830 RT1 Evidence appendix Page 101

East Cambs, Ely and Fenland Brookfields Community Neuro 126 5 - 7 Hospital Rehabilitation - Rehabilitation Falls Service Fulbourn Neuro Neuro 126 18 - 7 Hospital Rehabilitation - Rehabilitation Huntingdon City Care Neuro Neuro 126 4 - 5 Centre Rehabilitation - Rehabilitation Peterborough Fulbourn Nutrition & Nutrition & 126 32 - 49 Hospital Dietetics - City & Dietetics South Cambs Fulbourn Nutrition & Nutrition & 126 34 - 42 Hospital Dietetics - Ely & Dietetics The Fens Fulbourn Nutrition & Nutrition & 126 35 - 53 Hospital Dietetics - Dietetics Huntingdonshire Fulbourn Nutrition & Nutrition & 126 34 - 42 Hospital Dietetics - Dietetics Peterborough Fulbourn Podiatry - City & Podiatry 126 47 - 46 Hospital South Cambs Fulbourn Podiatry - Podiatry 126 27 - 27 Hospital Doddington Princess of Podiatry - Ely Podiatry 126 37 - 48 Wales Hospital Fulbourn Podiatry - Podiatry 126 35 - 35 Hospital Huntingdonshire Fulbourn Podiatry - Podiatry 126 41 - 42 Hospital Peterborough North Podiatry - Podiatry 126 35 - 38 Cambridgeshire Wisbech Hospital Fulbourn 01 NT - Community 126 3 - 8 Hospital Cambridge East Rehabilitation - Community Rehabilitation

20190830 RT1 Evidence appendix Page 102

Fulbourn 01 NT - District 3 2 - 3 Hospital Cambridge East Nursing - District Nursing (Daytime) (Daytime) Fulbourn 02 NT - District 3 2 - 4 Hospital Cambridge City Nursing North - District (Daytime) Nursing (Daytime) Fulbourn 02 NT - Community 126 7 - 9 Hospital Cambridge City Rehabilitation North - Community Rehabilitation Fulbourn 04 NT - District 3 3 - 5 Hospital Cambridge North Nursing Villages - District (Daytime) Nursing (Daytime) -Fulbourn - 04 NT - Community 126 5 - 8 Hospital Cambridge North Rehabilitation Villages - Community Rehabilitation -Brookfields - 05 NT - District 3 3 - 3 Hospital Cambridge City Nursing South - District (Daytime) Nursing (Daytime) -Brookfields 05 NT - Community 126 3 - 7 Hospital Cambridge City Rehabilitation South - Community Rehabilitation Fulbourn 07 NT - District 3 2 - 4 Hospital Huntingdon Nursing Central - (Daytime) Community Rehabilitation Fulbourn 07 NT - Community 126 5 - 7 Hospital Huntingdon Rehabilitation Central - District Nursing (Daytime)

20190830 RT1 Evidence appendix Page 103

Fulbourn 08 NT - St Ives - District 3 3 - 3 Hospital District Nursing Nursing (Daytime) (Daytime) Fulbourn 08 NT - St Ives - Community 126 3 - 9 Hospital Community Rehabilitation Rehabilitation Fulbourn 09 NT - St Neots Community 126 5 - 8 Hospital - Community Rehabilitation Rehabilitation Fulbourn 09 NT - St Neots District 3 3 - 4 Hospital - District Nursing Nursing (Daytime) (Daytime) Princess of 10 NT - Isle of Community 126 8 - 8 Wales Hospital Ely - Rehabilitation Community Rehabilitation Princess of 10 NT - Isle of District 3 1 - 3 Wales Hospital Ely - District Nursing Nursing (Daytime) (Daytime) Fulbourn 11 NT - Fenland District 3 2 - 3 Hospital - District Nursing Nursing (Daytime) (Daytime) Fulbourn 11 NT - Fenland Community 126 7 - 7 Hospital - Community Rehabilitation Rehabilitation North 12 NT - Wisbech District 3 3 - 4 Cambridgeshire - District Nursing Nursing Hospital (Daytime) (Daytime) North 12 NT - Wisbech Community 126 4 - 6 Cambridgeshire - Community Rehabilitation Hospital Rehabilitation -City Care - 13 NT - Community 126 4 - 6 Centre Peterborough Rehabilitation City 1 - Community Rehabilitation -City Care 13 NT - District 3 3 - 3 Centre Peterborough Nursing City 1 - District (Daytime) Nursing (Daytime)

20190830 RT1 Evidence appendix Page 104

City Care 14 NT - Community 126 5 - 5 Centre Peterborough Rehabilitation City 2 - Community Rehabilitation City Care 14 NT - District 3 3 - 4 Centre Peterborough Nursing City 2 - District (Daytime) Nursing (Daytime) Fulbourn 15 NT - Community 126 3 - 6 Hospital Borderline - Rehabilitation Community Rehabilitation Fulbourn 15 NT - District 3 3 - 4 Hospital Borderline - Nursing District Nursing (Daytime) (Daytime) Fulbourn 16 NT - Community 126 3 - 5 Hospital Borderline Rehabilitation Central - Community Rehabilitation Fulbourn 16 NT - District 3 3 - 4 Hospital Borderline Nursing Central - District (Daytime) Nursing (Daytime)

Learning from complaints and concerns It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. The trust had an up to date complaints, concerns and compliments policy, which was last reviewed January 2017. Staff followed the complaints policy, which provided guidance on how to manage complaints efficiently. Team leads managed complaints and resolved concerns at the earliest opportunity. An appointed named member of staff dealt with a complaint where the service was not able to resolve the concern. This member of staff was the lead investigator for the complaint response. The trust displayed information about how to make a complaint on their public website. We saw that the trust provided information to make a complaint by telephone, email and by letter. The web page also provided information about escalating concerns to the parliamentary and health service ombudsman.

20190830 RT1 Evidence appendix Page 105

Board reports provided complaints information and the main themes of complaints and concerns received by the older people and adult community directorate. The board report from the directorate for May 2019 showed the three main themes for patients raising concerns to PALS about community adult services were, visits by community staff that did not take place as expected, issues for ordering or delivery of continence products and delays in receiving podiatry service appointment. Team leads and managers discussed complaints during monthly service line reporting meetings. We reviewed service line reporting minutes from March 2019 to May 2019 which evidenced this was a regular agenda item although the teams had not received any complaints during this period. Staff discussed complaints with neighbourhood team meetings. We reviewed team meeting minutes for all the neighbourhood teams we visited from February 2019 to May 2019 which showed complaints was a rolling agenda item. The minutes showed that the teams had no complaints during this period. Staff we spoke with told us that learning following complaints was shared during team meetings. Staff gave an example of a complaint about wound care that a patient had a deterioration in the wound. Staff were reminded about the importance of wound documentation and ensuring this was completed. From 1 January 2018 to 31 December 2018 the service received 17 complaints about community health services for adults (8% of total complaints received by the trust). The trust took an average of 14 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be dealt with within 30 working days. A breakdown of complaints by subject and site is shown below: CHS - Community Adults Total Team Access to Quality of Care Staff Equipment Total Services Attitude Parkinson's Disease 2 1 3 Service Intermediate Care Team, 1 1 1 3 Cambridge OOH Ely and 1 1 2 Fens Hinchingbrooke Hospital - Front 1 1 2 of House Team Podiatry 1 1 2 Service OPAC Admin Hub - 1 1 Cambridge

20190830 RT1 Evidence appendix Page 106

Respiratory 1 1 Service Intermediate Care Team, 1 1 Huntingdon Discharge Planning Team 1 1 - Peterborough Multiple Sclerosis 1 1 Service Total 8 6 2 1 17

From 1 January 2018 to 31 December 2018 this service received 1504 compliments for community health services for adults, which accounted for 23% of all compliments received by the trust as a whole (6654).

Name of hospital site or Team Number of location compliments

Fulbourn Hospital Podiatry - City & South Cambs 227 Brookfields Hospital Specialist Nursing - Parkinson’s - South 185 Fulbourn Hospital Specialist Nursing - Heart Failure - 184 Huntingdonshire Fulbourn Hospital Neuro Rehabilitation – Huntingdon 171 Brookfields Hospital Neuro Rehabilitation – Cambridge 135 Fulbourn Hospital Specialist Nursing - Respiratory - 73 Huntingdonshire Fulbourn Hospital Specialist Nursing - Tissue Viability - City 66 & South Cambs Fulbourn Hospital Specialist Nursing - Epilepsy 61 Brookfields Hospital Specialist Nursing - Diabetes - City & 60 South Cambs North Cambridgeshire Hospital District Nursing (Out of Hours) - City, 58 South & East Cambs Fulbourn Hospital Specialist Nursing - Diabetes - 54 Peterborough Fulbourn Hospital Specialist Nursing - CFS-ME 52

20190830 RT1 Evidence appendix Page 107

Brookfields Hospital Speech & Language Therapy - Adults - 42 City & South Cambs Fulbourn Hospital Nutrition & Dietetics - City & South Cambs 38 Fulbourn Hospital Intermediate Care Service / Hospital at 31 Home Service Fulbourn Hospital Specialist Nursing - Continence - City & 25 South Cambs Fulbourn Hospital Specialist Nursing - Multiple Sclerosis 22 Fulbourn Hospital Specialist Nursing - Diabetes - Ely & The 10 Fens Fulbourn Hospital Specialist Nursing - Diabetes - 7 Huntingdonshire Brookfields Hospital Neuro Rehabilitation - Falls Service 3 Total 1504

Is the service well-led?

Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Clinical directors supported the board of directors in the oversight and decision making for integrated community services within the older people and adult community directorate. Staff at all levels understood their responsibilities within their roles. Locally, staff told us their managers were routinely visible and approachable. We observed strong leadership at a local level with staff praising their local managers regarding their support and communication. Staff felt they could raise concerns without the fear or reprimand and they were confident action would be taken as result. A team of dedicated and proactive managers supported the services who received a high amount of praise from the staff they managed. Each manager was fully versed in the challenges and areas of good practice in their individual areas and committed to making positive change. Staff stated that they felt valued and supported in their role. The senior leaders for the service had mapped the age of the community workforce and identified skilled staff nearing retirement age. The service had strategies in place for succession planning and to increase the skill of junior staff. The role of advance community nurse practitioner had been developed within the neighbourhood teams to provide coaching and facilitate the development of newly qualified nurses.

20190830 RT1 Evidence appendix Page 108

Vision and strategy The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The vision of community adult services was for patient care to become further integrated, by ensuring teams are worked closer together and they worked more closely with partner organisations in the local area for the benefit of patients and their carers. The adult community service had a 10-point strategy in place and aligned these objectives with the trust’s broader objectives. The service had a workable strategy in place to turn their vision into a reality. The 10- point strategy included the following goals: • Promote a culture where improving the population’s health is a core component of the practice of all nursing, midwifery and care staff. • Increase the visibility of nursing and midwifery leadership and input in prevention. • Work with individuals, families and communities to equip them to make informed choices and manage their own health. • Centred on individuals experiencing high value care. • Work in partnership with individuals, their families, carers and others important to them • Actively respond to what matters most to our staff and colleagues. • Lead and drive research to evidence the impact of what we do. • Have the right education, training and development to enhance our skills, knowledge and understanding. • Have the right staff in the right places at the right time. • Champion the use of technology and informatics to improve practice, address unwarranted variations and enhance outcomes. The trust had a three-year strategy published in 2018. The trust’s strategy was underpinned by four strategic goals. The trust had a set of five core values of professionalism, respect, innovation, dignity and empowerment. Staff we spoke with know the organisation core values and demonstrated in their work. We saw posters in all the bases we visited which displayed the organisational values. Culture Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The trust encouraged staff to demonstrate candour, openness and honesty at all levels. The trust had a policy in relation to duty of candour and this was readily available to staff via the provider intranet. Staff reported an open and honest culture and said they felt able to raise any concerns with their managers. All the staff we spoke with confirmed that the needs and experience for their patients was at the centre of the service. Staff had access to independent speak up guardian to concerns outside of their immediate teams.

20190830 RT1 Evidence appendix Page 109

Staff morale was good and staff we spoke with during the inspection confirmed that they felt valued and well supported by colleagues and managers within their roles. The trust had staff awards called the ‘pride awards’. Staff members and teams could be nominated for an award by patients and other staff members for going the extra mile in care delivery. The awards were bases around the trust’s values of professionalism, respect, innovation, dignity and empowerment with the acronym of pride. Adults community services required staff to be lone workers. The service had processes in place for staff safety in lone working. Staff we spoke with told us that they had a buddy system to communicate the start of a visit and when this was completed via mobile text message. Staff also had a code word to alert buddies or managers they were in danger. Governance The service used a systematic approach to continually improve the quality of its services. Although the service did not have robust assurances in relation to infection prevention and control audits. The service had effective data collection processes which provided the management team with service level assurance. However, the infection prevention and control (IPC) audits were only completed annually to provide board level assurance regarding staff compliance with the IPC policy. We raised our concerns with the directorate leadership team at the time of our inspection. The senior leaders we spoke with told us that they had identified infection prevention and control audits as an area of improvement and planned to include IPC in the quality improvement evaluation tool (QuIET) audits. The service set out clear roles, responsibilities, and systems of accountability to support good governance and management of the service. Staff we spoke with described the service’s management structure and their specific roles and responsibilities. The community adults service was part of the older people and adult community (OPAC) directorate. Team leads reported to the directorate management team through service line reporting meetings. The directorate had a set agenda for service line reporting meetings. We reviewed service line reporting minutes from March 2019 to May 2019 which demonstrated that quality, safety and performance were discussed. For example, the tissue viability team reported that staff completion of mandatory training was 100%, there were no staff vacancies and performance measures were met. The minutes also demonstrated that incidents and risks were discussed. Team leads and locality managers attended monthly quality and safety meetings chaired by the senior leadership of the directorate. We reviewed the meeting minutes from January to March 2019 which showed that the meetings followed the Care Quality Commission key lines of enquiry. The minutes evidence that managers discussed incidents, complaints risks and performance. The directorate held monthly performance and risk executive meetings, where managers monitored progress on achieving strategic aims, performance against quality and safety measures. The senior managers submitted monthly directorate reports to the board for review. The service had mechanisms to escalate information to executive team meeting and other committees such as quality, safety and governance committee. The service had processes to share information within team meetings. Each team had monthly team meeting to share key messages from the senor leadership team and to discuss learning following incidents and complaints. We reviewed team meeting minutes from March 2019 to May

20190830 RT1 Evidence appendix Page 110

2019 for neighbourhood team located in South Cambridge, North Cambridge and villages and Fenland. The meeting minutes evidenced that managers shared learning from incidents and team performance. There was a range of policies, which underpinned the governance structure. The organisation reviewed policies in line with expected review dates. These included but was not limited to, the incident reporting and the safeguarding policies. Management of risk, issues and performance The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The service had clear processes for managing risks issues and performance. The service had an electronic trust wide risk register linked to the incident reporting system. The trust used risk registers based on the potential consequence of the risk and the likelihood of the risk happening again. The trust used a red, amber, green risk rating system, to denote the high, medium and low. Each risk had a rating on entry to the register and a rating once mitigation was in place. All risks had a review date, a named owner, and an action plan. The service had local risk registers and a directorate risk register. Leaders at all levels knew the service risks in their area of responsibility and they had plans in place to mitigate these risks. Senior managers for the directorate knew the risks to the service and had mitigated these risks appropriately. Senior managers we spoke with told us that the top risks were, staffing, sustainability and transformational partnership (STP) and achieving the cost improvement programme savings. We reviewed the risk register actions which demonstrated that leaders had taken mitigating actions to reduce the impact of the risks. Example of action taken for staffing, the service had ongoing advertisements to fill staff vacancies. The senior leadership team took immediate action to address skill mix issues within the neighbourhood teams. The top risks on neighbourhood team risk register was staffing and the skill mix of the team. Team leads and area managers escalated risks appropriately to the directorate senior management team. The service used electronic reporting for key performance indicators, monitor quality and safety measures. Staff at all levels had access to this information that was updated every week to increase staff engagement and ownership of quality and safety improvement. Senior managers accessed this information to identify any risks to care quality and safety and apply measures to mitigate these risks. An example of this process was staff skill mix, where performance deterioration was identified. Managers moved staff to support teams with less experienced staff to mitigate any risks to quality and safety of care. Staff completed individual risk assessments in circumstances such as, where patients had poor living conditions, or they had animals which posed additional risks. Staff we spoke with told us the individual risk assessments were attached to the patient records with a flagging system to alert staff a risk assessment was in place. The risk assessments provided information to mitigate any risks such as staff calling the patient prior to the visit to ensure animals shut out of the areas where staff completed dressings or similar procedures. Information management The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

20190830 RT1 Evidence appendix Page 111

Staff across the trust could access information from the intranet, including policies and national guidance. Staff knew how to access information through the intranet and through paper documentation available at main sites across the trust. Staff used electronic patient records and staff we spoke with, told us that they did not have any issues with areas with poor connectivity. The service used the electronic records system to compile reports as evidence to their commissioners and for internal and external KPI monitoring. The service utilised a dashboard for oversight of KPIs and other quality and performance indicators such as service acquired pressure ulcer reduction. The service used the data collected to monitor information on a weekly basis and identified areas of stress within neighbourhood and specialist teams to take immediate remedial action. Staff accessed all electronic records via a two-point security log in process to prevent inappropriate access to sensitive information. The board papers from May 2019 showed that the trust had no reported breaches of information governance from April 2018 to March 2019. This meant that staff protected information they held about people and kept this information securely. Engagement The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively. Managers we spoke with had regular meetings with the local clinical commissioning group to discuss performance and key performance indicators. Staff had an opportunity to provide feedback about working for the organisation. Staff participated in the NHS staff survey undertaken in 2018. The service had an action plan in place to act on feedback from staff. An example actions taken by the service was to focus on staff wellbeing this linked in with the trust’s heart and soul strategy to improve staff wellbeing. The service held team meetings monthly and staff confirmed that there was good teamwork and engagement. We reviewed team meeting minutes for North Cambridge and villages, South Cambridge and Fenland neighbourhood teams, which demonstrated that line managers updated their staff with information such as but not limited to, audits, and social events. The trust had staff awards where staff and patients could nominate individual staff members or teams for going the extra mile. Staff we spoke with told us about these awards and several staff members told us their team had been nominated for an award. The trust had a participation and partnership forum where the patients and members of the local community were consulted on service improvement and development. The trust also provided a range information through their website about the services provided. The trust website had a link for patients to provide feedback about the services they received. The service participated in the friends and family test and had an additional patient survey to gain feedback from patients that did not have access to the internet. Team meeting minutes we reviewed demonstrated that feedback from patients was discussed. Learning, continuous improvement and innovation The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

20190830 RT1 Evidence appendix Page 112

The service had developed a patient streaming pathway. An example of this was, the neighbourhood teams had split planned and unplanned workload to improve caseload management to reduce interruptions to unplanned care. The joint emergency team (JET) provided urgent assessments for patients with long term conditions such as diabetes, heart failure and respiratory diseases to prevent hospital admissions. The team worked well with specialist teams to provide urgent care and transfer patients to the specialist nursing teams for long term management. The trust had a strong focus on quality improvement. We saw staff from specialist nursing teams and neighbourhood teams had embraced opportunities to develop quality improvement strategies locally. We saw examples of quality improvement projects such as the chronic leg oedema management pilot and the community nursing catheter clinic. NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. The trust did not provide details of any teams which had received accreditations.

20190830 RT1 Evidence appendix Page 113

Urgent care

Facts and data about this service

Information about the sites and teams, which offer community urgent care services at this trust, is shown below: Location / site Team/ward/satellite Services Address (if applicable) name name provided Fulbourn MIU - Doddington Conditions that Doddington Hospital, Benwick Hospital Hospital can be treated at Road, Doddington, March the Minor Injuries Units include: wounds – cuts and bruises (Tetanus immunisation can also be given) bites – human, insect and animal minor burns and scalds, muscle and joint injuries – strains, sprains, limb fractures North MIU - North Conditions that North Cambridgeshire Hospital, Cambridgeshire Cambridgeshire can be treated at The Park, Wisbeach Hospital Hospital the Minor Injuries Units include: wounds – cuts and bruises (Tetanus immunisation can also be given) bites – human, insect and animal, minor burns and scalds, muscle and joint injuries – strains, sprains, limb fractures

20190830 RT1 Evidence appendix Page 114

Princess of MIU - Princess of Conditions that Princess of Wales Hospital, Lynn Wales Hospital Wales Hospital can be treated at Road, Ely, CB6 1DN the Minor Injuries Units include: wounds – cuts and bruises (Tetanus immunisation can also be given) bites – human, insect and animal, minor burns and scalds, muscle and joint injuries – strains, sprains, limb fractures

Is the service safe?

Mandatory training The service provided mandatory training in key skills to all staff and made sure most staff had completed it. The service provided mandatory training to staff via e-learning and face-to-face sessions. Managers had a record of which staff had completed their mandatory training, and they discussed gaps in training at service leads meetings and governance meetings. At the time of our inspection, mandatory training completion at the service was 89%, which is close to the trust target of 90%. However, according to the training records for April 2019, not all staff had completed training across all the mandatory modules. Three of 18 eligible staff had not completed Mental Capacity Act Level Two; and four of 18 eligible staff had not completed Safeguarding Children Level Three (Mandatory for Role). Managers told us this was on the risk register, and they had plans in place for staff to complete their outstanding mandatory training modules. Core Service level A breakdown of compliance for mandatory training courses from 1 January 2018 to 31 December 2018 at trust level for all staff in community urgent care services is shown below: 1 January 2018 to 31 December 2018 Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No) Infection Control (Level 2) 26 26 100% 90% Yes Basic Life Support (BLS) 1 1 100% 90% Yes Conflict Resolution 35 35 100% 90% Yes

20190830 RT1 Evidence appendix Page 115

Treating People with Respect 35 35 100% 90% Yes Mental Capacity Act Level 1 8 8 100% 90% Yes Infection Control (Level 1) 9 9 100% 90% Yes Safeguarding Children (Level 1) 1 1 100% 90% Yes Working Safely 34 35 97% 90% Yes Good Governance 34 35 97% 90% Yes Fire Safety 34 35 97% 90% Yes PREVENT (Level 1) 34 35 97% 90% Yes Dementia 25 26 96% 90% Yes Safeguarding Children (Level 2) 16 17 94% 90% Yes Deprivation of Liberty Safeguards 17 18 94% 90% Yes Safeguarding Adults 33 35 94% 90% Yes Manual Handling (Level 2) 21 26 81% 90% No Safeguarding Children (Level 3) 11 14 79% 90% No Carer Awareness 25 35 71% 90% No Medical Emergency Response Course 90% No (MERC) 5 8 63% Smoking Cessation 20 35 57% 90% No Safeguarding Children Level 3; 90% No Mandatory for Role (3hrs) 8 17 47% Mental Capacity Act Level 2 8 18 44% 90% No Immediate Life Support (ILS) 2 17 12% 90% No Total 442 521 85% 90% No

Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Most staff had training on how to recognise and report abuse, and they knew how to apply it. Staff could identify possible safeguarding concerns, knew the process for raising and escalating concerns and could give examples of when they had done this. Contact details for the safeguarding team were displayed and staff knew how to contact them for advice and support. Staff at the service completed a safeguarding note for every patient on the electronic records system, whether they were raising a safeguarding or not. This ensured that staff considered possible safeguarding concerns for every patient. Staff flagged safeguarding concerns on the electronic records system, which fed into an NHS-wide safeguarding system. Staff also completed incident reports after they raised a safeguarding.

20190830 RT1 Evidence appendix Page 116

Staff were aware of recent safeguarding incidents that had been reported locally, and service leads discussed safeguarding at team meetings. In addition to completing mandatory training in safeguarding, staff took part in safeguarding group supervision every three months. However, not all eligible staff were compliant in Safeguarding Children Level Three training. The completion rate had improved in the first months of 2019. By end of April 2019, four members of staff had not completed the module mandatory for role, and one member of staff had not completed the core module. The service manager had a plan in place for these staff members to undertake their outstanding training modules within the next two months. The trust set a target of 90% for completion of safeguarding training. A breakdown of compliance for safeguarding training courses from 1 January 2018 to 31 December 2018 at trust level for all staff in community urgent care services is shown below: The tables below include prevent training as a safeguarding course. Prevent works to stop individuals from getting involved or supporting terrorism or extremist activity. 1 January 2018 to 31 December 2018 Training module name Staff Eligible Completion Trust Met trained staff rate target (Yes/No) Safeguarding Children (Level 1) 1 1 100% 90% Yes PREVENT (Level 1) 34 35 97% 90% Yes Safeguarding Children (Level 2) 16 17 94% 90% Yes Safeguarding Adults 33 35 94% 90% Yes Safeguarding Children (Level 3) 11 14 79% 90% No Safeguarding Children Level 3; 8 17 47% 90% No Mandatory for Role (3hrs)

All staff received information and training about female genital mutilation (FGM) within mandatory safeguarding adults and children training levels one and two. This training included the one chance rule and the mandatory reporting to the police, of any cases of FGM in girls under the age of18. All staff received information about sexual exploitation within safeguarding training levels. The service provided ‘Prevent’ training (this enabled staff to recognise and report vulnerable people from being exploited and drawn into terrorism). Data provided by the trust demonstrated that staff compliance with ‘Prevent’ training met the trust’s target. The trust had a safeguarding children policy in place for staff to follow. The policy set out the responsibility of staff at all levels and referenced relevant legislation and national guidance. The policy was within the review date and had version control. The trust had an adult safeguarding policy and practice guidance procedure in place for staff to follow. The policy set out the responsibility of staff at all levels and referenced relevant legislation and national guidance. The policy was within the review date and had version control.

20190830 RT1 Evidence appendix Page 117

The adult safeguarding team is led by a head of safeguarding. Children's safeguarding is led by the named nurse. Both teams have lead professionals to support. All staff we spoke with knew how to contact the safeguarding team to discuss or escalate safeguarding concerns. The trust worked collaboratively with other services, teams, individuals and agencies in relation to all safeguarding matters and had safeguarding policies that were in line with Local Authority policies. Staff at the service gave examples of when they had raised safeguarding alerts and had liaised with Local Authority contacts, acute services and GP services about the patient(s) concerned. Social services representatives attended quarterly safeguarding team meetings. The service had contacts for escalation of safeguarding concerns outside the trust, for example the CCG safeguarding lead. A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. Community urgent care services made three safeguarding referrals between 1 January 2018 and 31 December 2018, all of which were for children.

Referrals Adults Children Total referrals 0 3 3

20190830 RT1 Evidence appendix Page 118

agreement with the landlords. However, the service had a process in place for the isolation of patients in the outpatient’s department of the Princess of Wales Hospital site, and staff could access the guidelines via the intranet. Health Care Assistants cleaned and checked the site according to a weekly cleaning schedule, which included equipment, dressing trolleys, children’s toys, fridges and clinic room surfaces. Local leads sent copies of this log to the central infection prevention and control team. However, parts of the cleaning schedule we saw were not dated and signed in several instances. We saw annual environmental infection prevention and control audits that had been completed at the MIUs in Wisbech (2018), Doddington and Ely (2019). Staff wore uniforms with short sleeves and were bare below the elbows. The trust had a uniform policy in place for staff to follow with specific guidance on infection prevention and control such as uniform washing and jewellery restrictions. We observed good hygiene practices and saw staff washing their hands. There were hand washing facilities in clinical rooms. Staff had access to antibacterial gel, antibacterial surface wipes and personal protective equipment such as gloves. A member of the local team, usually the Infection Prevention and Control link nurse, completed monthly hand hygiene audits at each site. These were sent to the trust Infection Prevention and Control Team. Hand hygiene audits had been completed for Doddington every month since November 2018, and for Wisbech since December 2018. The audits had been completed for Ely from December 2018 to March 2019. However, we did not see any completed hand hygiene audits for the Ely site for April or May 2019. We were not given information on hand hygiene audits at the MIUs prior to November 2019. Environment and equipment The design, maintenance and use of facilities, premises and equipment kept people safe. Staff managed clinical waste well. The MIU site we visited at Ely was rented by the trust and based within a hospital. Therefore, the facilities were managed by another party, with oversight from the trust estates team. The corridor, clinical rooms and waiting area were a suitable size, and were tidy and well-lit. However, at the MIU at Ely there was no staff room, only a small office behind reception. Staff and patients had to use toilets around the corner from the MIU area itself. Parts of the corridor and waiting areas were worn and needed refurbishment. The service at Ely no longer had a decontamination room due to a change in the agreement with the landlords. The trust was planning to make changes to the layout of the MIU at Ely and we saw a business case for this, submitted in June 2019. The plan proposed moving the reception area and creating a new waiting area for children and adding vinyl flooring to the triage room so that will be fully infection control compliant. The service had arrangements for managing waste, with separate domestic waste and clinical waste bins. Disposable items of equipment were discarded appropriately in clinical waste bins. Bins were not overfilled, and sharps bins were lidded, labelled and dated. The service had a dirty utility with key pad entry, which was locked. Hazardous chemicals were kept in a locked cupboard. Fire extinguishers were all tested, in date and stored safely on corridor walls.

20190830 RT1 Evidence appendix Page 119

The storage cupboard was tidy with all items stored on shelves. We checked single use sterile items, such as sterile swabs and disposable scalpels, all were in date and unopened. The trust had a service level agreement in place with an external organisation for equipment servicing and safety testing. Equipment had undergone recent safety checks and services. We checked 5 items of equipment and all had an in-date safety test. The deep vein thrombosis (DVT) D-dimer machine was checked daily, and this was logged and dated correctly except on one occasion. The resuscitation trolley was fully stocked, with all equipment in date and tested. However, the weekly resuscitation trolley check record was not signed and dated in several instances. Assessing and responding to patient risk Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. Reception staff met patients on their arrival at the MIU, received an overview of the issue and put this data into the electronic records system against a list of conditions. Nursing staff then assessed and triaged patients according to need, using a red, amber, green (RAG) rating system. Patients would then wait for a full clinical assessment. Reception staff could see the RAG rating of each patient in the waiting area. The waiting area was close to reception and staff told patients to notify a member someone if they felt their symptoms were worsening. Staff used their clinical judgement, and additional tools where appropriate, to assess patients and record observations. We saw printed notes and posters detailing different assessments, for example a Lund and Browder chart for assessing burns, and copies of up-to-date National Early Warning Score (NEWS) and Paediatric Early Warning Score (PEWS) information. When staff added patient observations into the electronic records, the system would trigger screening tools where needed. For example, specific National Early Warning Scores (NEWS) or Paediatric Early Warning Scores (PEWS) would trigger the electronic sepsis screening tool. The trust had a major incident plan and staff undertook major incident training. The trust had a deteriorating patient policy that was issued in January 2018. This was displayed in the staff office and staff knew how to access it on the intranet. If a patient attended the MIU with concerning symptoms, these were automatically flagged by the electronic system and clinical staff would prioritise their assessment and treatment. In the event of a patient presenting with chest pain, staff would complete observations including an Electrocardiogram (ECG) test. Staff would call 999 if the patient needed immediate treatment, so that they could be quickly transferred to a local accident and emergency department. The trust had a Management of Medical Emergencies Policy, which incorporated resuscitation and Do Not Attempt Resuscitation (DNAR), which was issued in November 2016 and due for review in November 2019. The resuscitation trolley was easily accessible and nursing staff had undertaken Immediate Life Support (ILS) training. The service did not have a separate crash team. Paramedic staff could support with Advanced Life Support (ALS) training, however the service did not have equipment appropriate to ALS such as blood gas machines, so the trust did not require ALS as part of mandatory training for all staff.

20190830 RT1 Evidence appendix Page 120

Adrenaline was available on site and the service had patient group directions (PGDs) and prescribers in place for adrenaline. Each morning the service leads asked a relevant member of staff if they consented to prescribe adrenaline that day, in the event of a patient having a cardiac arrest. Staffing This core service has reported a vacancy rate for all staff of -4% as of 31 December 2018. This core service reported an overall vacancy rate of 13% for registered nurses at 31 December 2018. This core service reported an overall vacancy rate of -31% for healthcare assistants. Registered Health care assistants Overall staff

nurses figures

Location Ward/Team

Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Vacancies Establishment Vacancy rate (%) Fulbourn MIU - Hospital Doddington 2.5 19.5 13% -1.5 4.9 -31% -1.1 30.4 -4% Hospital Core service total 2.5 19.5 13% -1.5 4.9 -31% -1.1 30.4 -4% Trust total 164.0 1294 13% 130.6 1031.7 13% 334.2 3984.1 8% NB: All figures displayed are whole-time equivalents Between 1 January 2018 and 31 December 2018, 182 hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reason for bank and agency usage was vacancies. In the same period, agency staff covered 536 available hours for qualified nurses and 1923 of available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. Wards Bank Usage Agency NOT filled Usage by bank or agency Hrs % Hrs % Hrs % MIU - Doddington Hospital 182 - 536 - 1709 - Core service total 182 - 536 - 1709 - Trust Total 114849 - 42162 - 3142 - 1

20190830 RT1 Evidence appendix Page 121

Between 1 January 2018 and 31 December 2018, there was no bank or agency usage for nursing assistants, 156 available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. Wards Bank Usage Agency NOT filled Usage by bank or agency Hrs % Hrs % Hrs % MIU - Doddington Hospital 0 - 0 - 156 - Core service total 0 - 0 - 156 - Trust Total 3183 2575 202495 - - - 1 9

This core service had 5.5 (19%) staff leavers between 1 January 2018 and 31 December 2018. Substantive staff Average % staff Substantive staff Location Ward/Team Leavers over the leavers over the (at latest month) last 12 months last 12 months Fulbourn MIU - Doddington 31.1 5.5 19% Hospital Hospital Core service total 31.1 5.5 19% Trust Total 3575.2 446.3 13%

The sickness rate for this core service was 7% between 1 January 2018 and 31 December 2018. The most recent months data (December 2018) showed a sickness rate of 9.4%.

Total % staff sickness Ave % permanent staff Location Ward/Team sickness (over the past (at latest month) year) Fulbourn MIU - Doddington 9.4% 7.0% Hospital Hospital Core service total 9.4% 7.0% Trust Total 5.3% 4.5%

During the reporting period from 1 February 2018 to 31 January 2019, community services for adults reported that there were no cases where staff have been either suspended or placed under supervision. Quality of records

20190830 RT1 Evidence appendix Page 122

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to most staff providing care. However, the service had not fully embedded a records audit. The service stored patient records securely on an electronic system. The system allowed staff to write free text notes, complete scoring tools such as NEWS and PEWS, and rate patient risk on a RAG scale. Each record included a note on safeguarding, whether there was a concern or not. The system could also link up with patients’ GP records, where the GP practice had the same electronic system. Staff could set up ‘tasks’ to complete and refer patients on for further treatment. Service leads told us that agency staff would have relevant experience on the electronic records system or be shown how to use it as part of induction. The service would usually give agency staff a smart card for short-term access to the system. However, if the service did not give agency staff the card, they would take paper notes which would be scanned in. This meant that agency staff might not have access to patients’ GP notes, would not be automatically prompted to escalate a high NEWS or PEWS score, and would not be prompted to make a safeguarding note. We viewed 5 patients records and all staff had taken a patient history, noted their assessments, and included appropriate treatment plans and onward referrals where needed. Staff completed safeguarding assessments and noted whether any other people attended with the patient. Staff scored patients’ pain when necessary, checked patients’ allergies and prescribed appropriate medication via a patient group direction (PGD). The service lead at Ely told us that they were making changes to the records system, including the use of referral ‘tasks’, which would be checked as part of records audits. We saw a recent records audit for the MIU in Ely. The lead scored patient notes on a numbered scale and, where the record was not completed sufficiently, made a note to discuss this with the staff member. However, not all the MIU sites had undertaken regular records audits and this was not on the risk register. The service manager had recently begun to implement a monthly records audit, which would be completed by local leads at each MIU site, however this was not yet embedded. Medicines The service used systems and processes to safely prescribe, administer, record and store medicines. Staff at the MIUs in Wisbech and Doddington ordered medicines through the trust central office. Staff at the MIU in Ely ordered medicines from an agreed stocklist through the local acute NHS trust, under the Service Line Agreement. Staff told us they had pharmacy support on all medicine- related questions and issues. The service had a robust patient group directions (PGD) system in place for staff prescribing drugs to take out. New PGDs were developed by a group including the medical director, director of nursing and a pharmacist, and discussed at conferences before they were approved. We saw a dated overview of all the PGDs relating to the service and we checked specific PGDs. All were completed, dated and had a record of the health professionals’ agreement to practice. Staff signatures for approval were completed by email and kept separately under a password protected electronic record, and we saw evidence of this. Prescribing updates were displayed in the staff office.

20190830 RT1 Evidence appendix Page 123

The service stored medicines appropriately in locked cupboards and fridges, and at the MIU in Ely we saw that they were kept locked. Prescription pads were also kept in a locked cupboard. The keys to these were kept in key-coded safes, and the codes were changed every six months or when a member of staff left the service. At the MIU we visited in Ely, the medicine storage room temperatures were checked daily and this was logged and dated. The medicines fridge was checked daily and this was logged and dated. However, in one of the clinical rooms at the MIU in Ely, we found a nitrous oxide cylinder with a demand valve attached. After highlighting this with the manager, we were assured that the service had a system for storing nitrous oxide safely. In clinical rooms, nitrous oxide cylinders were secured to the wall to prevent them from falling or being removed, and the doors were locked by staff when not in use. The demand valves were stored in a locked cupboard overnight. Safety performance The MIU service does not currently use the Safety Thermometer. However, the service completes a QEWTT (Quality Early Warning Trigger Tool) based around a red, amber, green (RAG) rating. This is a self-assessment tool, produced by the National Patient Safety Agency and adapted by the trust to suit community services. The service had assessed itself in the range of 12 to 14 (amber), for the months February to April 2019. This was an improvement on its higher scores of 17 to 19 (red) in October to November 2018 and January 2019. Incident report, learning and improvement The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored. Staff completed an e-learning induction which included incident reporting training. The trust had an incident reporting policy, which was last reviewed in January 2017. Staff could easily access the policy and knew their responsibilities in raising an incident report, including how to categorise the incidents. The trust had an electronic incident reporting system in place for staff to report incidents. The system alerted managers when an incident was reported, and the named manager allocated a lead investigator for each incident. Staff received feedback about any incidents they had raised through the electronic system once an investigation was completed. Staff we spoke to knew the process for logging and escalating incidents. Managers gave examples of when learning from incidents was shared with staff across all three sites at team meetings. We reviewed data on the National Reporting and Learning System (NRLS) relating to safety incidents at the service from May 2018 to May 2019. We saw that incidents were logged appropriately, and actions were taken by staff and managers. The trust had a policy in place called ‘being open and duty of candour’. This document set out the responsibilities of staff and referenced relevant legislation and national guidance. The policy was within the review date and had version control.

20190830 RT1 Evidence appendix Page 124

From 1 January 2018 to 31 December 2018, trust staff within community urgent care reported no serious incidents. The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there have been no prevention of future death reports sent to Cambridgeshire and Peterborough NHS Foundation Trust.

Is the service effective?

Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients’ subject to the Mental Health Act 1983. The trust had systems and processes in place to ensure that policy documents reflected national guidance and legislation. The trust developed policies and procedures based on the latest guidance from the (National Institute for Clinical Evidence) NICE. The service had up-to-date clinical guidelines in place based on NICE guidelines and other best- practice guidelines. Staff could access these guidelines through the trust intranet. Clinical pathways were available via the intranet and were displayed in staff areas. Staff at the service used relevant guidelines to asses and treat patients, for example asthma, chest pain and sick child guidelines. Staff we spoke with told us they could easily find policy and pathway information on the trust’s intranet. Specific guidelines were attached to patient group directions (PGDs). Nutrition and hydration (only include if specific evidence) Drinking water was available for people awaiting assessment. There were cafés where people could purchase food, close to the MIUs at the hospital sites in Ely and Doddington. Staff assessed the nutrition and hydration needs where appropriate and advised patients and those close to them on these needs. Pain relief (only include if specific evidence) Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and prescribed pain relief to ease pain. When patients were waiting after initial assessment, they were advised to speak to a member of staff if their pain worsened. Staff recorded pain scores where needed and had access to adapted pain scoring tools for children and people with sensory disabilities. Staff prescribed patients suitable pain relief via a PGD, where it was assessed as required. Alternatively, staff advised patients to ask for pain relief after their referral to another service such as the local accident and emergency department, or their GP. Patient outcomes 20190830 RT1 Evidence appendix Page 125

Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. Lead managers helped to monitor audits locally, disseminated the results to staff and discussed the results in team meetings. Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. However, Managers maintained regular communication within their teams to ensure that any issues were addressed, and staff were equipped to meet the needs of patients. Managers identified the learning needs of staff through supervision or the appraisal process. Staff felt encouraged and supported to attend training, There were effective supervision arrangements in place for all staff, which included one to one meetings, team meetings and shadowing opportunities. All staff members had a competencies folder so that they could track their progress and keep a copy of training certificates. We saw a competencies folder which included a log of which competencies and training the staff member had completed, and which they were yet to complete. However, at the time of our inspection 6 members of staff had not fully completed their appraisals for 2018, out of 25 applicable members of staff at the service. This meant appraisals were at 76%, which was below the trust’s target of 95%. Managers told us that this was in part due to members of staff having been off for long-term sickness and maternity leave. The missed appraisals meant that managers could not be assured that they had supported staff to complete their competencies and develop in their roles. All new staff received a trust and a local role-specific induction. Staff were given inductions at all three MIU sites to ensure that they could work safely at a different location, if this was ever necessary. The trust had plans in place for a Band 5-7 Development Programme, which will provide training days and shadowing opportunities for staff. The trust offered leadership training to managers. 20 members of staff had completed paediatric training and shadowing relevant to their roles, including training on Illness & Injury, Recognition of / Spotting the sick child, and Paediatric Immediate Life Support (PILS). However, of the five staff at the Wisbech MIU who had relevant paediatric training, three did not have up-to-date PILS training. The trust provided the following information about their clinical supervision process: The Trust working with colleagues in the Learning and Development department, have developed functionality within our e-Academy System to capture the detailed supervision analysis, whilst staff continue to report through the Quarterly Staff Pulse Survey against a specific metric – ‘having effective supervision,’ which at Dec 18 was over 78%. The compliance rates for Supervision within the e-Academy system are monitored through the Performance & Risk Executive and the compliance rates have been appropriately challenged whilst acknowledging that the Directorates have assured the Executive that staff are receiving supervision and that there is a considerable underreporting, due to late data entry. The Senior leadership team continue to work with clinical

20190830 RT1 Evidence appendix Page 126

and corporate services to ensure compliance is accurately recorded whilst acknowledging that our staff inform us that they are receiving the appropriate supervision. The trust has not supplied a target for non-medical staff. Between 1 April 2018 and 31 December 2018, the average rate across all fourteen teams for which data was provided in this service was 14%. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision sessions delivered rate (%) required MIU - Doddington Hospital 291 42 14% Core service total 291 42 14% Trust Total 31881 15835 50%

From 1 April 2018 to 31 January 2019, 50% of permanent non-medical staff within the community urgent care services core service had received an appraisal compared to the trust target of 95%. Community urgent care total Team Number of Sum of Appraisal Trust Target staff Individuals rate (%) target (%) met appraised required (Yes/No)

MIU - Doddington Hospital 17 34 50% 95% No

Multidisciplinary working and coordinated care pathways All those responsible for delivering care worked together as a team to benefit patients. They supported each other to provide good care and communicated effectively with other agencies. Staff told us they had strong relationships with radiographers working within the MIU at Ely. Paramedic, nursing and HCA staff worked well alongside each other. We saw reception staff and nursing staff working closely to assess patients as they entered the service. The service worked closely with local GPs to ensure that patients went to the right service for their assessment and treatment. As part of the LUCS pilot, patients could access advice from a GP on site at Ely, or via the phone at Wisbech. Staff recorded GP referrals in the electronic notes system. The lead at Ely had recently brought in a ‘tasks’ prompt to ensure that GP referrals were followed up. Staff knew how to assess the needs of patients and could access information on care pathways. Staff knew how to contact specialist healthcare teams and services in the region, and refer patients where needed. For example, the service liaised with local acute hospitals, reablement teams, mental health crisis teams and community (Joint Emergency Team) JET services. Staff told us they could contact local urgent and emergency care services or ambulance crews for acute

20190830 RT1 Evidence appendix Page 127

clinical advice, to ensure they made appropriate referrals to acute settings. Patients at the service were given information on how to self-refer to physiotherapy, where needed. Health promotion Staff gave patients practical support and advice to lead healthier lives. The service displayed health information in waiting areas and corridors. This included posters and leaflets on sepsis, Lyme disease, asbestosis, and local mental health services Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Staff recorded consent in patient notes and were also able to note if a treatment or referral was declined by a patient. The service displayed leaflets on making treatment decisions, and the trust website had information leaflets on shared decision making. Mandatory training including training on the Mental Capacity Act (2005) and staff could access mental capacity guidance on the intranet. Staff told us they were aware of how to assess mental capacity and gave examples of when they had considered the mental capacity of a patient. However, three members of staff did not have up-to-date training on the Mental Capacity Act (Level two). The service had arranged further MCA training and managers told us that the training would be completed by all staff within the next few months. The trust set a target of 90% for completion of Mental Capacity Act / deprivation of liberty standards training. From 1 January 2018 to 31 December 2018 the trust reported that Mental Capacity Act (MCA) Level 1 training had been completed by 100% of staff within community urgent care services, Mental Capacity Act Level 2 training had been completed by 44% of eligible staff. Deprivation of Liberty training had been completed by 94% of staff. A breakdown of compliance for MCA/DOLS courses from 1 January 2018 to 31 December 2018 for community urgent care services is shown below:

Number Number of of staff eligible trained staff Completion Target Target met Training module name (YTD) (YTD) (%) (%) (Yes/No) Deprivation of Liberty Safeguards 17 18 94% 90% Yes Mental Capacity Act Level 1 8 8 100% 90% Yes Mental Capacity Act Level 2 8 18 44% 90% No

From 1 January 2018 to 31 December 2018 the trust reported that 142 Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority. None of which were pertinent to community urgent care services.

20190830 RT1 Evidence appendix Page 128

Is the service caring?

Compassionate care Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. We observed patients being treated with respect and kindness by staff including reception staff and nurses. A patient told us that staff were ‘lovely’ and that they were told what to do if they needed more attention while waiting for treatment. There were signs telling patients that they could discuss their illness or injury with staff elsewhere if they wanted more privacy. Patients were taken to private rooms for assessment and treatment. Thank-you cards were on display in the staff office at the MIU in Ely. Patients wrote that staff were ‘helpful, kind, courteous, caring and very professional’, and that they received ‘excellent care’. We saw comment cards from patients attending the MIU in Wisbech. Patients wrote that the MIU was ‘very clean and tidy’ and that there was ‘great service’. They also wrote that staff were ‘welcoming’ and ‘attentive’. The service participated in the NHS friends and family test. Trust data showed that an average of 95.6% of patients would recommend the service to friends and family, from a total of 6,508 responses for the year April 2018 to March 2019. The friends and family test results for each site in March 2019 were 98.6% at Doddington, 93.4% at Ely and 100% at Wisbech. At the MIU in Ely we saw data from patient experience surveys, which was largely positive, with no complaints made from February to April 2019. 98% of the feedback was complimentary in February; 97% in March and 99% in April. Emotional support Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. Staff showed awareness of the different needs of patients, including elderly patients, patients with dementia, patients with mental health needs and patients with physical or sensory disabilities. Mandatory training at the service included Treating People with Respect, Dementia training, and Carer Awareness. There were signs informing patients that they could request a chaperone. However, staff told us that on some days low staffing levels meant that they could not always offer a chaperone, and this was on the risk register. Understanding and involvement of patients and those close to them Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Patients told us that staff gave them clear information about their treatment. Patient comment cards at Wisbech said that staff were ‘always listening and trying to help’. Patients were able to bring a relative or friend with them into the treatment rooms and we heard staff informing patients of this. Staff recorded information about people who accompanied the patients, for example parents attending with a child, or carers attending with an adult who lived in a care home.

20190830 RT1 Evidence appendix Page 129

We observed staff speaking clearly to people for whom English was a second language, and saw staff establishing that the patient understood the process for assessment. Is the service responsive?

Planning and delivering services which meet people’s needs The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. The MIU sites were located in rural areas in North Cambridgeshire, allowing local people to receive assessment without having to travel to acute trust accident and emergency departments. The sites were all based within larger hospital premises, which were accessible by car or a short walk from local bus stops. The MIU at Ely was signposted and the building was accessible to wheelchair users. The trust website showed the locations of the MIUs, opening times, a list of the injuries and illnesses that staff could assess and treat there, and information on x-ray services. There were also leaflets with this information in the reception and waiting areas. The service was commissioned by the regional NHS acute trauma centre. Managers at the service had monthly meetings with the acute trust and we saw minutes from these meetings. The service manager produced monthly reports for the meeting, which covered staffing levels, mandatory training levels, patient waiting times and breaches. Managers at the trust and the service had regular meetings with the local Clinical Commissioning Group (CCG). At the time of the inspection, several of the MIU sites were part of a Local Urgent Care Services (LUCS) Hub pilot implemented by the local CCG. The MIU at Ely had been part of the pilot since May 2017. The MIU at Wisbech joined the pilot in January 2019, and Doddington is expected to join later in 2019. As part of the pilot, a local GP is now available for clinical advice at the services, based in-house at the Ely MIU and contactable by phone at the Wisbech MIU. This aims to allow a wider range of treatments at the MIUs and reduce the need for patient referral to an ED or GP service. Diagnostic imaging was provided by another local acute NHS trust via the local clinical commissioning group (CCG). Local people could have input into the service via the Local Urgent Care group, which had a patient representative and a Healthwatch representative. Staff encouraged patients, relatives and carers to give feedback about the service by completing the NHS friends and family test. Signs around the reception and waiting area encouraged patients to complete experience surveys. As well as offering paper surveys, the signs included a QR code and short web link to the online survey. Meeting the needs of people in vulnerable circumstances The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. The service took account of the language needs of service users. Interpretation services were available to support service users who did not speak English. We observed staff speaking clearly

20190830 RT1 Evidence appendix Page 130

to people for whom English was a second language, and saw staff establishing that the patient understood the process for assessment. At the MIU in Ely all areas of the hospital were accessible for patients who used mobility aids. The reception desk had a lowered section so that wheelchair users could be seen and there was an accessible toilet along the corridor from the MIU entrance. The MIU had hearing loops in place for patients and visitors to use. However, the service did not have any specialist bariatric chairs or equipment such as wheelchairs and beds. This was on the risk register and the service had ordered the equipment. Staff completed a dementia training session as part of their mandatory training and could give examples of how they used this training in practice, when treating a patient with dementia. They were aware of the individual needs, for example communication needs, of patients with dementia and the relatives or carers. Staff showed good awareness of patients with mental health needs, who might attend the MIU for physical health treatment. They gave examples of seeing patients who had self-harmed and how they had considered safeguarding concerns. They knew how to liaise with GPs and mental health teams regarding a patient’s mental health, or drug and alcohol misuse, and knew how to access further information on the staff intranet. There was a process in place for escalating mental health concerns to crisis teams by calling 111. The MIU at Ely had an area in the waiting room designed for children, with a smaller table and chairs. There was a children’s trolley with books, colouring books and stationary, toys and teddy bears. The service had picture charts that helped clinical staff to assess children’s symptoms, including pain, more easily. The trust had two-star accreditation from the Carers Trust, awarded in 2016. The trust had implemented the ‘triangle of care’ initiative to increase patient and carer involvement in the care they received. There was a Carer programme board, which had oversight of the triangle of care initiative, worked on improving carer pathways, and published a carer’s handbook in 2017. The carer’s handbook was available on the trust website along with information leaflets and links to local and national associations for carers. Access to the right care at the right time People could access the service when they needed it and received the right care in a timely way. However, diagnostic imaging support was not available during opening hours every day across all sites. We viewed six records and saw that staff assessed patients appropriately, in line with national guidance. Patients whose needs were most urgent were prioritised, and people told us they were informed of waiting times. The service met the 95% target for patients to receive an initial assessment within 15 minutes of arrival. From January to April 2019, the overall service and the individual sites were consistently between 98-100% for this target. The service met the 95% target for patients to receive assessment and treatment within four hours of arrival. From January to April 2019, the overall service and the individual sites were consistently between 97-100% for this target.

20190830 RT1 Evidence appendix Page 131

Staff at the MIU in Ely told us that the service would not close if there were patients waiting to receive assessment, and that the service occasionally had to stay open after 6pm. Managers ensured that any late-running days were noted and escalated. Managers said that low staffing levels occasionally meant that the service had to reduce to only streaming patients. These occasions were escalated by staff and logged as incidents. The three MIU sites were open Monday to Friday, 8:30am to 6pm, with x-ray services available 9am to 4:45pm (5:45pm in Doddington). The MIU at Wisbech was closed on weekends. Doddington was open on weekends 9am to 5pm, with x-ray services available 1pm to 4:45pm. Ely was open on weekends 8:30am to 6pm, with no x-ray services available. However, X-ray services were not available at every MIU site, during all service opening times. Diagnostic imaging was provided by another local acute NHS trust via the local clinical commissioning group (CCG). The gap in diagnostic imaging support had been raised by managers and was on the risk register. Staff at the MIU in Ely told us that if a patient presented on a weekend and needed an x-ray, they would be given the option of going to Doddington MIU, or the local acute trust accident and emergency department. Alternatively, the patient would be given the option of having a soft-cast put on and returning to the Ely MIU the following week for a scan. This would be offered only if the patient’s injury was assessed as non-urgent and stable. Patients of higher risk, for example children or elderly patients, would be referred to the acute trust in the case of a suspected fracture.

The largest ethnic group within the trust catchment area is White with 90.8% of the population.

Ethnic minority group Percentage of catchment population (if known) Largest White 90.8% Second largest Asian/Asian British 4.8% Third largest Black/African/ Caribbean/ Black 2.0% British Fourth largest Mixed/ Multiple Ethnic Groups 1.9%

The trust has identified the below services in the table as measured on ‘referral to initial assessment’ and ‘assessment to treatment’. The trust met the referral to assessment target in all of the targets listed. The trust informed us that ‘median results based on referral to first contact, then first to second contact, where either took place in 2018.

Name of hospital Name of in- Service Days from referral to Days from site or location patient ward or Type initial assessment assessment to unit treatment

National / Actual National / Actual Local (median) Local (median) Target Target Fulbourn Hospital MIU - Doddington Minor Hospital Injuries 0 0 - 2 Unit service

20190830 RT1 Evidence appendix Page 132

North MIU - North Minor Cambridgeshire Cambridgeshire Injuries 0 0 - 2 Hospital Hospital Unit service Princess of Wales MIU - Princess of Minor Hospital Wales Hospital Injuries 0 0 - 2 Unit service

Learning from complaints and concerns It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. The trust had an up-to-date complaint, concerns and compliments policy, which was last reviewed January 2017. The trust website had information on how to give feedback and make complaints, through the NHS friends and family test (FFT), patient experience surveys and the trust Patient Advice and Liaison Service (PALS). The service displayed posters and leaflets on how to give feedback and make complaints. Signs were put on the reception desk and in the waiting area to encourage patients and carers to complete experience surveys. As well as offering paper surveys, the signs included a QR code and a short web link to the online version of the survey. There were also leaflets for the trust Patient Advice and Liaison Service (PALS). Managers and staff discussed recent complaints and negative comments at service lead meetings and team meetings, and shared any lessons learned. From 1 January 2018 to 31 December 2018 the trust received three complaints about community urgent care services (1.5% of total complaints received by the trust). The trust took an average of 54 days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be dealt with within 30 working days.

A breakdown of complaints by subject and site is shown below:

Community Urgent Care Services Total Access to Team Staff Attitude Total Services Doddington Hospital - 1 1 Minor Injuries Unit Princess of Wales Hospital - Minor Injuries 1 1 2 Unit Total 1 2 3

From 1 January 2018 to 31 December 2018 the trust received 333 compliments for community urgent care services, which accounted for 5% of all compliments received by the trust as a whole.

Team Number of compliments MIU - Doddington Hospital 189 MIU - Princess of Wales Hospital 128

20190830 RT1 Evidence appendix Page 133

MIU - North Cambridgeshire Hospital 16 Total 333

Is the service well-led?

Leadership Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. The service had appointed a new operational and clinical manager for the MIU sites in 2018. Staff and service leads told us that the manager had made positive changes to the service, for example by bringing in a weekly phone calls for the location leads to look at staffing levels across the following week. Leads said this helped them to deal with issues around low staffing. Since the manager had been in post, rates for mandatory training and appraisal completion had gone up, and they were expanding the service audit programme. The service had an organisational structure which described staff roles. Staff knew who they reported to and what they were accountable for. Service leads, and staff told us they felt supported by their managers and were clear about their key priorities. Staff told us that management were communicative, visible and approachable. The MIU manager said they had good support in their role and regularly spoke with area managers face to face or on the phone. The staff knew who they could contact if a team lead or the manager was on leave or sick, and who to contact when escalating a major issue at the service. Staff told us that they had opportunities to develop in their roles and that they were usually given time to complete additional training, where staffing levels allowed it. The trust had plans in place for a Band 5-7 Development Programme, which will provide training days and shadowing opportunities for staff. The trust offered leadership training to managers. Vision and strategy The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress. Managers at the service and in the wider division (OPAC) understood the trust’s vision for the MIU as part of the provision plans of the local clinical commissioning group. The service had been working closely with the CCG, local acute trusts, GP services and other stakeholders to plan, implement and monitor the Local Urgent Care Services pilots in Ely and Wisbech. The pilot was due to be expanded to Doddington. The service manager and local service leads held weekly telephone conferences to plan and coordinate the day-to-day running of services and ensure that all three MIU sites had sufficient staff to provide a good service. We saw minutes from monthly meetings between the manager and team leads where they discussed wider and local service issues.

20190830 RT1 Evidence appendix Page 134

Managers had mitigated issues such as staffing shortages and were making improvements to mandatory training and appraisal completion rates. The trust had a three-year strategy published in 2018. The trust’s strategy was underpinned by four strategic goals. The trust had a set of five core values of professionalism, respect, innovation, dignity and empowerment. During our inspection, managers and staff at the service showed the trust values in their attitude and approach to their work. Culture Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. There was a good working culture within the service. Staff were kind and respectful towards patients and relatives and were focussed on providing excellent care. Staff were positive about their work and felt valued and supported by managers. The trust encouraged staff to demonstrate candour, openness and honesty at all levels. The trust had a policy in relation to duty of candour and this was readily available to staff via the provider intranet. Staff morale was good and staff we spoke with during the inspection confirmed that they felt valued and well supported by colleagues and managers within their roles. The trust had staff awards called the ‘pride awards’. Staff members and teams could be nominated for an award by patients and other staff members for going the extra mile in care delivery. The awards were based around the trust’s values of professionalism, respect, innovation, dignity and empowerment with the acronym of pride. Governance Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. The MIU service was part of the older people and adult community (OPAC) directorate. Team leads reported to the directorate management team through service line reporting meetings. The directorate had a set agenda for service line reporting meetings. We reviewed service line reporting minutes from March 2019 to May 2019 which demonstrated that quality, safety and performance were discussed. The minutes also demonstrated that incidents and risks were discussed. Team leads, and locality managers attended monthly quality and safety meetings chaired by the senior leadership of the directorate. We reviewed the meeting minutes from January to March 2019 which showed that the meetings followed the Care Quality Commission key lines of enquiry. The minutes evidence that managers discussed incidents, complaints risks and performance. The directorate held monthly performance and risk executive meetings, where managers monitored progress on achieving strategic aims, performance against quality and safety measures. The senior managers submitted monthly directorate reports to the board for review. The service had mechanisms to escalate information to executive team meeting and other committees such as quality, safety and governance committee.

20190830 RT1 Evidence appendix Page 135

There were a range of policies, which underpinned the governance structure and the organisation reviewed policies in line with expected review dates. These included but were not limited to the incident reporting and safeguarding policies. Management of risk, issues and performance Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care. Management kept risk registers at division level (OPAC) and location level, and there was a mix of new and ongoing risks. Risks were given a red, amber, green (RAG) rating and were rated in terms of consequence and likelihood, at the time they were raised and again after review or actions were taken. The service manager had good oversight of the risks at each MIU site and discussed these at governance meetings. Managers and team leads went over any local or wider service risks at meetings, and took on actions as needed. The service had local risk registers and a directorate risk register. Leaders at all levels knew the service risks in their area of responsibility and they had plans in place to mitigate these risks. Senior managers for the directorate knew the risks to the service and had mitigated these risks appropriately. Senior managers we spoke with told us that the top risks were, staffing, sustainability and transformational partnership (STP) and achieving the cost improvement programme savings. We reviewed the risk register actions which demonstrated that leaders had taken mitigating actions to reduce the impact of the risks. Information management The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required. Information was collected to monitor the performance of the MIU service, including the targets for triage (less than 15 minutes) and treatment (less than four hours). The information the trust gathered was communicated to staff and used to make changes and improve services. We saw evidence of discussions about performance and outcomes from board level to team meetings. Staff across the trust could access information from the intranet, including policies and national guidance. Staff knew how to access information through the intranet and through paper documentation available at main sites across the trust. Staff accessed all electronic records via a two-point security log in process to prevent inappropriate access to sensitive information. The board papers from May 2019 showed that the trust had no reported breaches of information governance from April 2018 to March 2019. This meant that staff protected information they held about people and kept this information securely. Engagement Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

20190830 RT1 Evidence appendix Page 136

The service worked closely with the local clinical commissioning group, local acute trusts and local GP services to plan and coordinate care across the region. Service area managers attended meetings with relevant stakeholders and were part of a group which had specific oversight of the Local Urgent Care Services pilot. Representatives from Healthwatch and patient groups attended these meetings to give feedback about the services. The service collected feedback from patients, their relatives and carers, provided physical comments cards and links to online questionnaires, and encouraged people to complete the friends and family test (FFT) forms. Managers at the service circulated this feedback to staff via email or at face to face meetings and worked closely with the trust PALS team to ensure that patients’ feedback was responded to. The MIU service had recently worked with the trust communications team on health promotion campaigns in the region. This included creating and displaying new posters on chest pain, and distributing information on winter slips, trips and falls, including via social media. One of the team leads had recently given a demonstration of MIU equipment as part of a local Science for Schools week. Staff felt that they could raise issues or concerns directly with the team leads or service manager and knew how to access intranet information on Freedom to Speak Up guardians. The manager was encouraging Band 7 staff to attend wider leadership meetings, for example Service Line Reporting meetings, in order for them to become more involved in shaping the service. Learning, continuous improvement and innovation NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. The trust did not provide any details of teams within this service which had been awarded accreditation.

20190830 RT1 Evidence appendix Page 137

Mental health services

Acute wards for adults of working age and psychiatric intensive care units

Facts and data about this service

Location site name Ward name Number of beds Patient group (male, female, mixed) Fulbourn Hospital Mulberry 1 AAU 11 Mixed

Fulbourn Hospital Mulberry 1 Detox 3 Mixed

Fulbourn Hospital Mulberry 2 16 Mixed

Fulbourn Hospital Mulberry 3 16 Mixed

Cavell Centre Oak 1 Treatment 16 Mixed

Cavell Centre Oak 3 AAU 13 Mixed

Cavell Centre Oak 4 Recovery 18 Mixed

Cavell Centre Poplar (PICU) 6 Male

Fulbourn Hospital Springbank 12 Female

Is the service safe?

Safe and clean environment Managers had completed environmental risk assessments of all ward areas including a foot print of the ward areas which highlighted areas of the ward considered higher risk of incidents occurring. The assessments were on display to staff in ward offices and contained both written and pictorial detail of risk areas including ligature risks. However, we identified ventilation grills on the ceilings of bathrooms on Mulberry 1 and Mulberry 2 wards which could have been used to ligate. We raised this with managers during the inspection and managers immediately added these risks to the environmental risk assessment and made staff aware of the additional risk. We found that bedroom floors on Poplar psychiatric intensive care unit (PICU) were dirty with rubber marks and in need of cleaning. Other ward areas were clean and well maintained. Staff had easy access to alarms and patients had access to nurse call systems in assisted bathrooms.

20190830 RT1 Evidence appendix Page 138

Over the 12-month period from 1 January 2018 to 31 December 2018 there were no same sex accommodation breaches within this service. There were no same sex breaches reported at the last inspection. On Mulberry 1 and Mulberry 2 the wards had been designed to allow for flexibility of male and female beds. Each ward had a male and a female corridor of bedrooms with en-suite facilities. In addition to this there was an interlinking corridor of bedrooms which could be used for either male or female beds as need demanded. There were ligature risks on eight wards within this service. All wards had updated ligature risk assessments in the last 12 months, two wards had a high level of risk identified. Ward / unit Briefly describe risk - one High level of risk? Summary of actions taken name sentence preferred Yes/ No Detailed audit report available on Springbank Moderate Service User Risk No request. Detailed audit report available on Oak 3 AAU Moderate Service User Risk No request. Detailed audit report available on Poplar PICU High Service User Risk Yes request. Oak 4 Recovery Detailed audit report available on Moderate Service User Risk No Ward request. Detailed audit report available on Mulberry 1 High Service User Risk Yes request. Detailed audit report available on Mulberry 2 Moderate Service User Risk No request. Detailed audit report available on Mulberry 3 Moderate Service User Risk No request. Detailed audit report available on Oak 1 Treatment Moderate Service User Risk No request.

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), the locations scored higher than similar trusts for cleanliness and scored higher than similar trusts for condition, appearance and maintenance.

Site name Core services) Cleanliness Condition appearance and maintenance Fulbourn MH - Acute wards for adults of working age and 100% 99.3% Hospital psychiatric intensive care units MH - Eating Disorders MH - Forensic inpatient MH - Other Specialist Services MH - Wards for older people with mental health problems Cavell Centre MH - Acute wards for adults of working age and 99.7% 99.2% psychiatric intensive care units

20190830 RT1 Evidence appendix Page 139

Site name Core services) Cleanliness Condition appearance and maintenance MH - Wards for older people with mental health problems MH - Wards for people with learning disabilities or autism Trust overall 99.6% 98.7% England 98.4% 95.4% average (Mental health and learning disabilities)

As part of the trust’s policy on reducing the use of restrictive interventions, none of the acute wards had dedicated seclusion rooms. The only seclusion room was on the Poplar unit. Staff told us that if seclusion was necessary patients were escorted to the de-escalation area on Mulberry 2 or to quiet rooms. On Poplar psychiatric intensive care unit (PICU), the risks we found at our last inspection of 2018 remained. Managers had included risks such as handrails in toilets, toilet seats, door closures in garden area, fire detectors in various places on the environmental risk assessment. However, there also were multiple environmental risks with the seclusion room including; no observation hatch to the room, meaning that staff needed to open the door to perform seclusion reviews and pass food and drink to patients, putting staff at increased risk of assault. The door to the bathroom on the seclusion suite could not be opened remotely meaning that staff needed to enter the room to ensure patients could safely use the toilet. This put staff at risk of assault and compromised patient’s privacy, dignity and respect. Closed circuit television (CCTV) was used to monitor the seclusion suite. However, the monitor for the CCTV was installed in the visitor’s room meaning that if the seclusion room was in use the visitor’s room could not be used. Staff managed this by using the quiet lounge for visitors at these times. In the PICU garden area, there was a point where patients had been able to climb onto the fence and jump off using a nearby window ledge. The trust had identified this on their risk register and had a business case to address the issue but there was no date for the completion of works to make the area safe.

Clinic rooms and treatment rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff maintained equipment well and kept it clean. Clean stickers on equipment were visible and in date.

20190830 RT1 Evidence appendix Page 140

Safe staffing This core service has reported a vacancy rate for all staff of 16% as of 31 December 2018. This was lower than the 30% reported at the last inspection (September 2017) This core service reported an overall vacancy rate of 13% for registered nurses at 31 December 2018. The vacancy rate for registered nurses was lower than the 36% reported at the last inspection. This core service reported an overall vacancy rate of -8% for health care assistants, which indicated they were over-established. The vacancy rate for health care assistants was lower than the 31% reported at the last inspection.

Registered nurses Health care assistants Overall staff figures

Location Ward/Team

(%) (%) (%)

Vacancies Vacancies Vacancies

Vacancy rate rate Vacancy rate Vacancy rate Vacancy

Establishment Establishment Establishment Cavell Oak 4 3.7 14 26% -4.8 6.2 -77% 2.9 26.2 11% Centre Recovery Cavell Poplar 4.1 16.5 25% 0.2 9.6 2% 8.3 30.1 28% Centre (PICU) Fulbourn Mulberry 2 3.4 15.2 22% -0.3 7.3 -4% 2.9 22.8 13% Hospital Fulbourn Mulberry 3 1.8 14 13% -6.4 6 -107% 0.4 26 2% Hospital Fulbourn Springbank 2 15 13% 7 17 41% 8.9 33.8 26% Hospital Cavell Oak 1 1 14 7% -0.4 6.3 -6% 5.6 26.3 21% Centre Treatment Cavell Oak 3 AAU 0.6 13 5% 1.7 8.5 20% 5.5 26.7 21% Centre Fulbourn Mulberry 1 -2.1 10 -21% -2.6 5.4 -48% 0.5 20.6 2% Hospital AAU Core service total 14.5 111.7 13% -5.6 66.3 -8% 35.0 212.5 16% Trust total 164.0 1294 13% 130.6 1031.7 13% 334.2 3984.1 8% NB: All figures displayed are whole-time equivalents

Between 1 January and 31 December 2018, 31608 hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reasons for bank and agency usage for the wards were vacancies and the acuity of patients. In the same period, agency staff covered 15924 of available hours for qualified nurses and 7478 of available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that

20190830 RT1 Evidence appendix Page 141

they record this information based on the number of hours used and not the number of available hours that need filling. Wards Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Mulberry 3 4893 n/a 1889 n/a 1158 n/a Mulberry 1 AAU 4611 n/a 1200 n/a 1519 n/a Mulberry 2 3242 n/a 4961 n/a 1557 n/a Springbank 3287 n/a 1397 n/a 741 n/a Oak 1 Treatment 5062 n/a 3402 n/a 951 n/a Oak 4 Recovery 4681 n/a 1376 n/a 530 n/a Poplar (PICU) 3106 n/a 944 n/a 401 n/a Oak 3 AAU 2727 n/a 755 n/a 622 n/a Core service total 31608 n/a 15924 n/a 7478 n/a Trust Total 114849 n/a 42162 n/a 31421 n/a

Between 1 January and 31 December 2018, 68087 hours were filled by bank staff to cover sickness, absence or vacancy for health care assistants. The main reasons for bank and agency usage for the wards were vacancies and the acuity of patients. In the same period, agency staff covered 5525 of available hours and 4979 of available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. Wards Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Mulberry 3 2259 n/a 390 n/a 602 n/a Mulberry 1 AAU 8602 n/a 477 n/a 759 n/a Mulberry 2 7093 n/a 1568 n/a 1086 n/a Springbank 1814 n/a 242 n/a 579 n/a Oak 1 Treatment 14899 n/a 829 n/a 513 n/a Oak 4 Recovery 10283 n/a 365 n/a 369 n/a Poplar (PICU) 12575 n/a 935 n/a 558 n/a Oak 3 AAU 10563 n/a 721 n/a 514 n/a Core service total 68087 n/a 5525 n/a 4979 n/a Trust Total 202495 n/a 31831 n/a 25759 n/a

Managers could adjust staffing levels daily to take account of patient acuity. When necessary managers deployed agency and bank staff to maintain safe staffing levels, however managers told us that agency use was rarely necessary, the majority of shifts were covered by staff who knew the ward. Qualified staff were present in communal areas of the ward at all times.

20190830 RT1 Evidence appendix Page 142

Staffing levels allowed patients to have regular one -to-one time with their named nurse. There were enough staff to carry out ward activities, escorted leave and physical interventions such as observation and restraint when necessary. This core service had 21.8 (13%) staff leavers between 1 January and 31 December 2018. This was higher than the 12% reported at the last inspection (from 1 October 2016 and 30 September 2017).

Location Ward/Team Substantive Substantive staff Average % staff leavers staff (at latest Leavers over the over the last 12 months month) last 12 months Fulbourn Mulberry 3 23.6 5.2 23% Hospital Cavell Centre Oak 4 Recovery 24.9 5.8 22% Fulbourn Mulberry 1 AAU 18.1 3.0 17% Hospital Oak 1 Cavell Centre 19.8 2.0 11% Treatment Fulbourn Mulberry 2 17.9 2.0 10% Hospital Fulbourn Springbank 26.3 1.8 7% Hospital Cavell Centre Poplar (PICU) 21.2 1.0 5% Cavell Centre Oak 3 AAU 19.8 1.0 5% Core service total 171.6 21.8 13% Trust Total 3575.2 446.3 13%

The sickness rate for this core service was 7.8% between 1 January and 31 December 2018. The most recent month’s data (31 December 2018) showed a sickness rate of 9.7%. This was higher than the sickness rate of 6% reported at the last inspection in September 2017. Location Ward/Team Total % staff sickness Ave % permanent staff sickness (at latest month) (over the past year)

Fulbourn Hospital Mulberry 2 11.2% 12.9%

Cavell Centre Oak 3 AAU 12.8% 10.2%

Fulbourn Hospital Springbank 7.7% 10.2%

Cavell Centre Poplar (PICU) 16.1% 8.0%

Fulbourn Hospital Mulberry 3 6.7% 7.1%

Cavell Centre Oak 4 Recovery 9.8% 5.7%

Oak 1 Cavell Centre 11.6% 5.6% Treatment

Fulbourn Hospital Mulberry 1 AAU 2.2% 2.1%

20190830 RT1 Evidence appendix Page 143

Location Ward/Team Total % staff sickness Ave % permanent staff sickness (at latest month) (over the past year) Core service total 9.7% 7.8% Trust Total 5.3% 4.5%

The below table covers staff fill rates for registered nurses and care staff during November, October and September 2018. Springbank ward had below 90% of the planned registered nurses for day shifts in two of the three months and below 90% of the planned care staff for all three months. Mulberry 1 (AAU) ward had below 90% of the planned registered nurses for night shifts in all three months and above 125% of the planned care staff for all three months. Oak 1 ward had above 125% of the planned care staff for night shifts for all three months. Oak 3 ward had below 90% of the planned registered nurses for night shifts and above 125% for care staff in all three months. Oak 4 ward had below 90% of the planned care staff for day shifts for all three months. Key:

> 125% < 90%

Day Night Day Night Day Night

Care Care Care Care Care Care Nurses Nurses Nurses Nurses Nurses Nurses staff staff staff staff staff staff (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%)

Nov-18 Oct-18 Sep-18 Mulberry 1 99.44 97.50 78.33 133.33 98.39 95.16 64.52 164.52 105.56 98.33 80.00 133.33 (AAU Detox) Mulberry 2 111.67 103.33 95.00 100.00 104.30 111.29 96.77 138.71 102.22 113.33 95.00 100.00

Mulberry 3 94.76 105.00 100.00 110.00 90.78 112.10 96.77 103.23 91.43 92.50 95.00 113.33

Springbank 95.00 75.83 98.33 96.67 82.80 69.35 93.55 96.77 85.56 73.33 95.00 90.00

Oak 1 103.19 113.33 98.33 200.00 105.73 125.00 98.39 206.45 96.30 123.33 101.67 203.33

Oak 3 (AAU) 112.22 124.17 71.67 170.00 102.69 103.23 79.03 141.94 96.11 120.83 71.67 146.67

Oak 4 111.11 75.00 98.33 100.00 106.99 72.04 100.00 100.00 100.56 69.44 100.00 100.00

Poplar 121.67 101.67 98.33 111.67 116.13 114.52 100.00 140.32 115.83 129.44 98.33 158.33

The trust has not supplied any medical locum usage for this core service. Each ward had a consultant and associate specialist doctor. The trust also operated an on-call rota which ensured that a doctor was always available in an emergency including out of hours.

The compliance for mandatory and statutory training courses at 31 December 2018 was 91%. Of the training courses listed eleven failed to achieve the trust target and of those, three failed to score above 75%. The trust set a target of 90% for completion of mandatory and statutory training.

20190830 RT1 Evidence appendix Page 144

The trust has stated that the training data is reported as a final figure at year end (where applicable). The training compliance reported for this core service during this inspection was higher than the 90% reported in the previous year. The training compliance reported for this core service during this inspection was higher than the 89% reported in the previous inspection (September 2017). Key: Not met trust Met trust target Higher No change Lower Below CQC 75% target ✓  ➔  

Training Module Number Number YTD Trust Compliance of eligible of staff Compliance Target change staff trained (%) Met when compared to previous year Working Safely 159 159 100% ✓  Conflict Resolution 159 159 100% ✓  PREVENT (Level 1) 3 3 100% ✓ n/a Safeguarding Adults 159 159 100% ✓  Infection Control (Level 1) 3 3 100% ✓ n/a Safeguarding Children (Level 1) 3 3 100% ✓  Deprivation of Liberty Safeguards 87 86 99% ✓ n/a Good Governance 159 157 99% ✓  Treating People with Respect 159 158 99% ✓  PREVENT (Level 2) 156 153 98% ✓ n/a Safeguarding Children (Level 2) 62 60 97% ✓  Mental Health Act Level 1 62 60 97% ✓  Dementia 156 150 96% ✓  Infection Control (Level 2) 156 148 95% ✓ n/a Fire Safety 159 151 95% ✓  Mental Capacity Act Level 1 62 59 95% ✓  Carer Awareness 159 140 88%  n/a Mental Capacity Act Level 2 89 77 87%   Safeguarding Children (Level 3) 94 82 87%   Basic Life Support (BLS) 7 6 86%   Physical Interventions 149 127 85%   Mental Health Act Level 2 94 75 80%   Medical Emergency Response 149 118 79%  n/a Course (MERC) Manual Handling (Level 2) 155 119 77%  n/a Smoking Cessation 159 118 74%  n/a Safeguarding Children Level 3; 94 65 69%  n/a Mandatory for Role (3hrs) Manual Handling (Level 1) 1 0 0%  n/a Total 2854 2595 91% ✓ 

20190830 RT1 Evidence appendix Page 145

Assessing and managing risk to patients and staff We reviewed 37 care records. Staff completed a risk assessment for every patient on admission and updated them regularly. Risk assessments were generally detailed and of good quality. However, for one patient who was being cared for on Poplar PICU had a historical risk of harm to others. This was not reflected in the risk assessment. Staff were aware of and dealt with specific risk issues. Risks were documented on the electronic record system and handed over at the beginning and end of the shift and at a daily multidisciplinary handover meeting. The trust had a policies and procedures for use of observation and searching patients. However, staff did not effectively implement these policies. At the Acute Assessment Unit at Cavell Centre inspectors saw that a patient had cigarettes and a lighter on his bedside table. Inspectors raised this with managers and the lighter was removed. The trust’s smoke free policy was that patients needed to leave the hospital grounds if they wanted to smoke. At Fulbourn hospital site patients from Mulberry 2 were smoking directly outside the ward, in a non-smoking area. Staff applied blanket restrictions on people’s freedom only when justified. Staff told us informal patients could leave at will, however the admission booklet for assessment wards asked informal patients to stay on the acute wards for 72 hours in order that staff could assess their mental state. We reviewed six care records on each acute assessment unit. Two patient records on Mulberry 1 recorded in the risk assessment that staff should consider application of the Mental Health Act 1983 if patients tried to leave. This service had 391 incidences of restraint (176 different service users) and 38 incidences of seclusion between 1 January and 31 December 2018. The below table focuses on the last 12 months’ worth of data: 1 January to 31 December 2018.

Ward name Seclusions Restraints Patients Of restraints, Of restraints, restrained incidents of prone incidences of restraint rapid tranquilisation Poplar 18 106 37 15 (14%) 40 (38%) (PICU) Oak 1 10 63 32 5 (8%) 28 (44%) Treatment Mulberry 2 4 90 42 7 (8%) 22 (24%) Mulberry 1 1 21 13 0 (0%) 7 (33%) AAU Oak 3 AAU 0 44 27 12 (27%) 7 (16%) Mulberry 3 4 57 17 1 (2%) 5 (9%) Oak 4 1 5 4 0 1 (2%) Recovery Springbank 0 5 4 1 (20%) 1 (20%) Core service 38 391 176 41 (10%) 111 (28%) total

20190830 RT1 Evidence appendix Page 146

There were 41 incidences of prone restraint, which accounted for 10% of the restraint incidents. Over the 12 months, incidences of restraint on each ward ranged from five to 106. The number of incidences (391) had increased from the previous 12-month period (251). There were 111 (28%) incidences of rapid tranquilisation over the reporting period. Incidences resulting in rapid tranquilisation on each ward, over 12 months ranged from one to 40 (1 January to 31 December 2018). The number of incidences (111) had increased from the previous 12-month period (72). There have been no instances of mechanical restraint over the reporting period. The number of restraint incidences reported during this inspection was higher than the 244 reported at the time of the last inspection (1 October 2016 – 30 September 2017). Staff used restraint only after de-escalation had failed. Staff were trained in conflict resolution and used correct restraint techniques. Staff understood and worked within the Mental Capacity Act (2005) definition of restraint. Staff informed us that acuity at Fulbourn hospital site had peaked in January and there were two restraints during which staff were injured one of these incidents had been reported to the Health and Safety Executive as staff had sustained significant injury meaning that they were away from work for longer than 7 days. We saw evidence in care records that staff followed National Institute for Health and Care Excellence (NICE) guidance when using rapid tranquilisation. There have been 38 instances of seclusion over the reporting period. Over the 12 months, incidences of seclusion ranged from 0 to 18. The number of incidences (38) had increased from the previous 12-month period (six). The number of seclusion incidents reported during this inspection was higher than the four reported at the time of the last inspection.

Staff used seclusion as a last resort and followed best practice when they did so. Poplar PICU ward had a dedicated staff seclusion lead who led audits of seclusion practice across the trust and had developed a seclusion grab and go pack to support staff in recording interventions used during seclusion. However, there was only one seclusion room within the trust. Staff at Cavell Centre told us patients had been moved across the hospital in restraint holds to access the seclusion room at Poplar PICU putting patients and staff at increased risk of injury. There have been no instances of long-term segregation over the 12-month reporting period.

A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made 149 safeguarding referrals between 1 January and 31 December 2018, of which 138 concerned adults and 11 children.

20190830 RT1 Evidence appendix Page 147

The data reported during this inspection was not reported at core service level at the last inspection so is not comparable. Number of referrals Core service Adults Children Total referrals MH - Acute wards for adults of working age 138 11 149 and psychiatric intensive care units

The number of adult safeguarding referrals per month ranged from three to 19. The number of child safeguarding referrals per month ranged from 0 to three. Staff were trained in safeguarding, knew how to make a safeguarding alert and did so when appropriate. Staff gave examples of how they had protected patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of significant harm and gave us examples of where they had worked in partnership with other agencies. The trust had safe procedures for children to visit patients on the ward in visitor’s rooms away from the main ward areas. There were no serious case reviews commenced or published in the last 12 months (1 January and 31 December 2018) that relate to this service. All information needed to deliver care was stored on electronic patient records system and was available to all relevant staff when they needed it including when patients moved between teams. Staff followed good practice in medicines management and did so in line with national guidance. Staff on Mulberry three told us they worked in collaboration with community mental health teams to ensure patients had medication at home when on leave from the hospital. Staff reviewed the effects of medication on patient’s physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance. Doctors had worked with the trust information technology department to produce a comprehensive dashboard of physical health monitoring and potential side effects of antipsychotic medication. The system flagged when patients were at increased risk and enabled doctors to revise the prescribing accordingly. We reviewed 36 prescription charts and found that all patient medications were prescribed within British National Formulary limits.

Track record on safety Between 1 January and 31 December 2018 there were six serious incidents reported by this service. Of the total number of incidents reported, the most common type of incident was ‘Apparent/actual/suspected self-inflicted harm’ with four. All three of the unexpected deaths were instances of ‘Apparent/actual/suspected self-inflicted harm’. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with six reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service reported no never events during this reporting period.

20190830 RT1 Evidence appendix Page 148

The number of serious incidents reported during this inspection was lower than the 16 reported at the last inspection. Number of incidents reported

Type of incident reported (SIRI) Apparent/actual/ Major incident/ Medication Total suspected self- emergency incident inflicted harm preparedness. meeting SI criteria meeting SI resilience and

criteria response/ suspension of services Mulberry 1 Ward 1 1 Mulberry 2 Ward 1 1 Oak 3 Ward 1 1 2 Poplar Ward 1 1 2 Total 4 1 1 6

Reporting incidents and learning from when things go wrong The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there has been no ‘prevention of future death’ reports sent to Cambridgeshire and Peterborough Trust. Staff described to us the types of incidents that should be reported and told us that these would be reported to their line manager and recorded on the trust electronic incident reporting system. However, there was an incident of self harm on the acute assessment unit at Cavell Centre in May 2019 involving an informal patient who had wanted to leave. The patient had been discouraged from doing so and then subsequently self harmed. The incident had not been handed over to the next shift and had not been reported on the electronic reporting system. Inspectors raised this with staff during inspection who then recorded the incident within the trust 24-hour time frame for reporting incidents. Staff were able to describe their responsibilities in respect of duty of candour. Staff told us they were open and transparent giving patients and their families a full explanation when things went wrong. Staff told us that they received feedback from investigation of incidents both internal and external to the service. Staff met to discuss feedback and there was evidence that changes had been made as a result of feedback.

Is the service effective?

Assessment of needs and planning of care We reviewed 37 care records. Staff completed mental health assessments at or soon after admission. Staff assessed patient’s physical health needs in a timely manner, we saw that where patients declined physical health intervention this was clearly documented, and staff made

20190830 RT1 Evidence appendix Page 149

repeated attempts to follow up physical health priorities. Care plans were personalised holistic and recovery orientated, and staff updated care plans regularly.

Best practice in treatment and care Staff provided a range of care and treatment interventions recommended by the National Institute for Health and care Excellence. Interventions included medication, psychological therapies, occupational activities and daily activities provided by activities coordinators. Staff ensured patients had good access to physical healthcare, including access to specialists when needed. Staff assessed and met patient’s nutrition and hydration needs for food and drink and for specialist nutrition and hydration. There was evidence in care records that staff used food and fluid balance charts to monitor food and fluid intake. Staff supported patients to live healthier lives for example the trust had appointed a wellbeing practitioner who visited the wards regularly and supported staff to promote healthy lifestyle choices for patients. The trust’s smoking cessation programme included offering nicotine replacement therapy and promoting the use of e-cigarettes, dieticians provided healthy eating advice, doctors monitored cardiovascular risks and dealt with issues relating to substance misuse. Staff used recognised rating scales to assess and record severity of outcomes for example the health of the Nation Outcome Scales and clustering tool. On Mulberry three, doctors had worked with the trust IT department to devise an electronic dashboard which monitored physical health outcomes including side effects of medication. Staff developed care plans that met needs identified at assessment. This service participated in ten clinical audits as part of their clinical audit programme 2018.

Audit name Audit scope Core service Audit type Date Key actions completed following the audit National Early All Inpatient MH - Acute Clinical 01.02.18 Individual ward Warning Score Units wards for areas to spot check (NEWS) Audit adults of NEWS forms in the working age next 8 weeks to and check completion psychiatric and action from a intensive care sample of units completed NEWS forms. NEWS form has been revised this should improve recording and actions, Non-touch observations have been included, clinical escalation using SBAR tool is more clearly defined, Red flag Sepsis symptoms

20190830 RT1 Evidence appendix Page 150

Audit name Audit scope Core service Audit type Date Key actions completed following the audit are on the front of the NEWS chart and on the reverse. Re audit following the revised NEWS form rollout. Projects 4-6 Medical Trust wide: Various Clinical 31/10/2018 • Ensure exam Devices – Inpatient Adult & couches have Units Specialist received planned Mental Health maintenance at AAU directorate, and S3 wards Children, • Ensure Young sphygmanometers People and have received Families planned Directorate, maintenance at Older Mulberry 1 and People's and Treatment wards Adult • Ensure availability Community of tympanic Directorate - thermometers at All inpatient Welney and units Springbank wards • Ensure tympanic thermometers have received planned maintenance at Maple and Treatment wards • Ensure scales have received planned maintenance at Mulberry 1 and Mulberry 2 wards • Ensure availability of ophthalmoscope at Mulberry 2 and Springbank wards • Ensure ophthalmoscopes have received planned maintenance at Croft and ICU • Ensure wheelchairs have received planned maintenance at ICU,

20190830 RT1 Evidence appendix Page 151

Audit name Audit scope Core service Audit type Date Key actions completed following the audit Maple, Trafford and Hollies wards • Ensure availability of ECG at Phoenix ward • Ensure availability of Nebuliser at Welney ward • Ensure Nebuliser has received planned maintenance at ICU • Ensure availability of Pulse Oximeter at Mulberry 3 ward • Ensure Pulse Oximeter has received planned maintenance at Mulberry 1 ward • Ensure Treatment cylinder is replaced at Mulberry 2 • Revisit all wards to ensure weekly check list is in place Eliminating Mixed Trust wide: Various Clinical/env 05/06/2018 The Sex Adult & ironment Communications Accommodation Specialist Team have Mental Health refreshed the directorate, bespoke CPFT Children, posters and these Young have been issued to People and wards requesting Families them. Directorate, Older People's and Adult Community Directorate Capacity to Consent Various Various Clinical 08/01/2018 (Inpatient MH Wards) to Inpatient Care Develop a dashboard Mi report to and Treatment monitor compliance Audit with capacity assessment to consent to admission, care and treatment. (Physical Health Wards)

20190830 RT1 Evidence appendix Page 152

Audit name Audit scope Core service Audit type Date Key actions completed following the audit Include in the admission check list – the need to seek valid informed consent from the patient (including checking for LPA and Advance Decisions) Provide additional ‘practice based’ training for ward staff (including doctors) Develop and disseminate additional SOPs, check-lists and posters to aid staff in the process (MCA/DoLS ward packs) Develop local MCA/DoLS Champions (bespoke training) MH Law Manager to join Directorate Development Meetings fortnightly and provide legal update/support practice related issues. Monitor the legal status of patients admitted to MH Wards weekly (Capacity to consent, Capacity assessments & Best interest decisions, Referral to IMHA for MHA Patients) Monitor the legal status of patients admitted to Physical Health Wards weekly (Capacity to consent, Capacity assessments & Best interest decisions, DoLS) Include a section to cover capacity & consent in the CQC Compliance dashboard, as well as a new Quality & Safety Assessment Tool (QuSAT).

20190830 RT1 Evidence appendix Page 153

Audit name Audit scope Core service Audit type Date Key actions completed following the audit The tool will include monthly ward reviews of the quality of the care plans, in line with CQC standards. The outcome of the reviews (in line with the newly approved Governance & Compliance Assurance Framework) will be fed via the DMT meetings to the PREs and the Board. CQUIN 3b Adult & MH - Acute Clinical 01.06.18 Presentation with Improving physical Specialist wards for Exec Physical healthcare to Mental Health adults of Health Lead, reduce premature (ASMH) working age Physical Health in mortality in people Teams, and Mental Health with Severe Mental Inpatient & psychiatric Strategy Group, Illness (SMI): Community intensive care Directorate specific Collaborating with units action plan to be primary care agreed clinicians Medicines Children, MH - Acute Clinical 31/10/2018 • Take report to Management – Young wards for Medicines Inpatients People and adults of Governance Group Families working age for approval Directorate, and • Pharmacy leads to Older psychiatric disseminate to Ward People's and intensive care Managers / Clinical Adult, units Leads Community • Pharmacy team to Directorate - develop injectable all inpatient risk assessment units MMSOP040 Pharmacy • Ward managers & clinical leads to implement injectable risk assessments • Ward managers & clinical leads to complete individual action plans for their unit (see separate action plan summary & individual unit action plans ) • Pharmacy team to

20190830 RT1 Evidence appendix Page 154

Audit name Audit scope Core service Audit type Date Key actions completed following the audit review data collection tool • Pharmacy team to re-audit medicines management on wards & units Medicines Trust wide: MH - Acute Clinical/me 01/03/2018 In collaboration with Management - All Inpatient wards for dicines pharmacy leads, Prescription Units adults of individual wards to working age create specific plan. and Pharmacy team to psychiatric review MMSOP016 intensive care Medicines units reconciliation. Create a specific medicines information bulletin to share learning from this audit. Re- audit in 12 months. POMH 16b: Rapid Adult & MH - Acute Clinical/ 31/12/2018 Audit was discussed tranquillisation in Specialist wards for medicines final local at PPC & Q&S the context of the Mental Health adults of report still meeting, currently pharmacological directorate - working age in progress being discussed at management of inpatient and ward level before acutely-disturbed wards psychiatric final focus on behaviour intensive care improvements units agreed. Use of Seclusion - A PICU, AAU, MH - Acute Service 06/02/2019 Both units are Qualitative Service Treatment wards for Evaluation actively sharing this Evaluation Ward, Adult & adults of information with staff Specialist working age teams, a clear plan Mental Health and of action is pending. psychiatric intensive care units Patient Involvement Adult and MH - Acute Clinical Due: Not • SDM policy to be in Shared Decision Specialist wards for Supplied discussed in one of Making Mental Health adults of the initial clinical Directorate - working age supervision all inpatient and sessions for new units psychiatric trainees in the ward. intensive care This would enable units on-going bilateral awareness among medical staff and subtly adjust MDT reviews to ensure this aspect of clinical practice is

20190830 RT1 Evidence appendix Page 155

Audit name Audit scope Core service Audit type Date Key actions completed following the audit implemented and appropriately captured in electronic notes. • For the Trust SDM policy be made part of induction pack for all new staff in the wards including trainee doctors • Wider circulation of Trust SDM to all ward-based staff including senior clinicians. During the study, it was felt anecdotally, the awareness of the said policy is limited • To conduct a more robust study (re- audit) with agreed data set for patient surveys and review of clinical notes for same cohort would provide better reliability of results. • Inpatient units will share learning from the audit and agreed upon local action plans

Skilled staff to deliver care The team included the full range of specialists required to meet the needs of patients. The multi- disciplinary team consisted of nurses, health care assistants, doctors, occupational therapists, and assistant occupational therapists, clinical psychologists and assistant psychologist, dieticians, activities coordinators, and pharmacists. Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group. New staff told us that experience of trust induction was mixed. Most staff told us that they received an appropriate trust induction. However, three staff told us that they had a three-day induction but had not received training in how to keep themselves safe on the ward which had left them feeling vulnerable to assault.

20190830 RT1 Evidence appendix Page 156

The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for non-medical staff within this service was 64%. This year so far, the overall appraisal rates was 77% (as at 1 January 2019). The wards with the lowest appraisal rate at 31 January 2019 were Mulberry 1 AAU with an appraisal rate of 63%, Oak 4 (Recovery) with an appraisal rate of 68% and Springbank at 68%. The rate of appraisal compliance for non-medical staff reported during this inspection was lower than the 88% reported at the last inspection. Ward name Total number of Total number of % % appraisals permanent non- permanent non- appraisals (previous year 1 medical staff medical staff (as at 31 April 2017-31 requiring an who have had January March 2018) appraisal an appraisal 2019)

Mulberry 3 22 22 100% 74% Oak 1 Treatment 20 18 90% 67% Oak 3 AAU 19 15 79% 83% Poplar (PICU) 23 17 74% 54% Mulberry 2 15 11 73% 47% Springbank 25 17 68% 70% Oak 4 Recovery 28 19 68% 71% Mulberry 1 AAU 16 10 63% 38% Core service total 168 129 77% 64% Trust wide 3503 2807 80% 76%

The trust has not supplied any details of appraisals for medical staff relating to this core service. The trust has not supplied a target for non-medical staff. Between 1 April 2018 and 31 December 2018, the average rate across all eight teams in this service was 51%. The rate of clinical supervision reported during this inspection was lower than the 72% reported at the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) Poplar (PICU) 204 127 62%

Springbank 232 140 60%

Oak 1 Treatment 187 103 55%

Oak 4 Recovery 225 123 55%

Oak 3 AAU 168 85 51%

Mulberry 1 AAU 137 62 45% Mulberry 3 206 78 38%

Mulberry 2 144 53 37%

20190830 RT1 Evidence appendix Page 157

Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) Core service total 1503 771 51% Trust Total 31881 15835 50%

The trust has not supplied any clinical supervision data for medical staff in this core service. Managers provided staff with supervision, however supervision data did not reflect the amount of supervision staff told us they received. Staff told us they received supervision monthly and were happy with the quality of supervision they received. In addition to supervision, Managers ensured staff had access to regular team meetings, daily handovers and monthly reflective practice meetings. Managers ensured that staff had the necessary specialist training for their roles. Managers dealt with poor performance promptly and effectively.

Multi-disciplinary and interagency team work Staff held regular multidisciplinary meetings, we observed three nursing handovers and two multidisciplinary meetings. Staff held multidisciplinary meetings every morning Monday to Friday, and daily handovers at the beginning and end of each shift. Staff spoke passionately about patients and handed over essential information. There was evidence of effective working relationships with other care teams. Staff spoke about joint working with community mental health teams to support patients on leave and on community treatment orders. Care co-ordinators and crisis teams-maintained communication with patients on the ward and worked with staff and patients to facilitate discharge. Teams had effective relationships with teams outside of the organisation including GPs, the local authority and advocacy. Staff told us it was easy to access support of approved mental health practitioners when necessary.

Adherence to the Mental Health Act and the Mental Health Act Code of Practice

As of 31 December 2018, 97% of the workforce in this service had received training in the Mental Health Act L1 and 80% in the Mental Health Act L2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed yearly. The training compliance reported during this inspection was higher than the 95% reported at the last inspection for MHA L1 and higher than the 65% for MHA L2. Staff had easy access to mental health act administrators and legal advice on administration of the Mental Health Act and its Code of Practice. Staff knew who mental health act administrators were. The trust had relevant policies and procedures that reflected most recent guidance, and staff had easy access to these and the Code of Practice.

20190830 RT1 Evidence appendix Page 158

Patients had easy access to information about independent mental health advocacy and advocates regularly visited wards. There was evidence in care records that staff explained to patients their rights under the Mental Health Act and repeated it as required and recorded that they had done this. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. Staff requested an opinion from a second opinion appointed doctor when necessary. Staff stored copies of patient’s detention papers electronically and in paper format so that they were available to all staff that needed to access them. Care plans referred to identified section 117 aftercare to be provided for patient’s subject to section 3 authorising admission to hospital for treatment. Staff conducted regular audits to ensure that the Mental Health Act was being applied correctly. However, we conducted review of seclusion records in relation to incidents of seclusion between 1 February and 31 May 2019 where patients were secluded on wards without seclusion rooms. We found 11 incidents where patients were secluded on wards without a seclusion room. There were nine incidents on Mulberry 2, one incident on Oak treatment ward and one incident on Mulberry three ward. In the weeks following our site visit we had asked the trust to submit information about the number and details of such incidents. One of the incidents we looked at was not included in information the list provided by the trust. For ten out of 11 incidents of seclusion, the seclusions we looked at, the reason given for seclusion met the Code of Practice: Mental Health Act 1983. There was a lack of clarity in five of 11 records as to whereabouts on the ward the patient was secluded, the remainder showed the patients were secluded in the low stimulus area, intensive nursing area or the patient’s bedroom. In seven records there was evidence of a medical review within the first hour. The remaining records were unclear. Four patients’ records did not contain the trust’s seclusion document and information was gathered from the patients’ progress notes. Seclusion records were not contemporaneous. For example, we found; the time seclusion started and terminated was not always clear, the name(s) and roles of staff authorising the start and termination of seclusion was often unclear, there were no records of 15-minute observations, the times and outcomes of nursing and medical reviews were unclear. Where there were seclusions documents, they did not contain all of the information recommended in the Code of Practice 26.149, for example, the seclusion documents included the signatures of nurses and doctors carrying out reviews but there were not always records of the assessment of the patient or the care plan following the incident. Transfer to Psychiatric Intensive Care Unit was considered as an alternative to continued seclusion in 8 incidents and transfers were arranged as needed. However, this necessitated secure transport from Fulbourn hospital. The time patients waited for transport were not recorded in the notes. There were two incidents at Fulbourn hospital where staff had been injured by patients who were awaiting transfer to psychiatric intensive care units.

20190830 RT1 Evidence appendix Page 159

The training compliance reported during this inspection was higher than the 90% reported at the last inspection for MCA L1 and higher than the 63% for MCA L2. The trust told us that 18 Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority for this service between 1 January to 31 December 2018. The greatest number of DoLS applications were made in February with four. The trust stated that CQC received 16 standard direct notifications from the trust between 1 January to 31 December 2018. The number of DoLS applications made during this inspection was lower than the 22 reported at the last inspection. The trust had a policy on the Mental Capacity Act including deprivation of liberty safeguards. Staff were aware of the policy and had access to it. Staff knew where to get advice regarding the Mental Capacity Act including deprivation of liberty safeguards. For patients who might have impaired capacity, staff had assessed and recorded capacity to consent appropriately. This was done on a decision specific basis. When patients lacked capacity, staff made decisions in their best interests recognising the importance of the person’s wishes and feelings, culture and history. The trust had arrangements to monitor adherence to the Mental Capacity Act, staff audited the application of the Mental Capacity Act and took action on any learning that resulted from it.

Number of ‘Standard’ DoLS applications made by month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 2018 Standard applications 1 4 1 1 1 0 1 1 3 2 3 0 18 made Standard applications 0 2 0 0 0 0 0 0 1 1 0 0 4 approved

Is the service caring?

Kindness, privacy, dignity, respect, compassion and support We observed staff attitudes and behaviours when interacting with patients to be discreet, respectful and responsive, providing patients with help and emotional support and advice at the time they needed it. Staff supported patients to understand and manage their care treatment or condition. Staff signposted patients and carers to other services when appropriate and if appropriate supported them to access those services. We spoke with 23 patients. Patients said that staff treated them well and behaved appropriately towards them. Staff understood the individual needs of patients including their personal, cultural, social and religious needs. staff said they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients without fear of consequences. Staff maintained the confidentiality of information about patients. The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at two service locations scored higher than similar organisations.

20190830 RT1 Evidence appendix Page 160

Site name Core services provided Privacy, dignity and wellbeing Fulbourn Hospital MH - Acute wards for adults of working age 93.7% and psychiatric intensive care units MH - Eating Disorders MH - Forensic inpatient MH - Other Specialist Services MH - Wards for older people with mental health problems Cavell Centre MH - Acute wards for adults of working age 91.1% and psychiatric intensive care units MH - Wards for older people with mental health problems MH - Wards for people with learning disabilities or autism Trust overall 91.6%

England average (mental 91.0% health and learning disabilities)

Involvement in care Staff used the admission process to inform and orientate patients to the ward and the service. Each ward had devised additional written patient information about what to expect whilst staying on the ward. Mulberry three ward had devised a recovery pack to give to patients on admission containing information about the service and additional information that may be useful upon discharge. The information was contained in a useful shopping bag which also contained a small pack of toiletries that patients could use during their stay. Staff involved patients in care planning and risk assessment, care plans were written in patient focused language and evidence the patient voice. However, none of the patients we spoke with had not been given copies of their care plans. Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with those who experienced communication difficulties. Staff involved patients in decisions about the service. Each ward held daily community meetings. The trust also collated patient and carer feedback on the service via a survey. Staff ensured patients could access advocacy. Staff informed and involved families and carers appropriately and provided them with support when needed. The service facilitated a monthly carer’s group and encouraged carers mutual support. Staff also provided carers with information about how to access a carer’s assessment.

Is the service responsive?

Access and discharge The trust provided information regarding average bed occupancies for nine wards in this service between 1 January to 31 December 2018.

20190830 RT1 Evidence appendix Page 161

Eight of the wards within this service reported average bed occupancies ranging above the nationally recommended minimum benchmark of 85%, over this period. Ward name Average bed occupancy range (1 January – 31 December 2018) (current inspection) Mulberry 1 AAU 69% - 94% Mulberry 1 Detox 48% - 91% Mulberry 2 82% - 97% Mulberry 3 89% - 100% Oak 1 Treatment 84% - 98% Oak 3 AAU 60% - 80% Oak 4 Recovery 89% - 100% Poplar (PICU) 58% - 94% Springbank 50% - 96%

Bed management meetings took place Monday to Friday to review bed pressures, availability of beds and options for patient transfers. Two wards Mulberry 2 and three had a bed occupancy rate above 85%. This is above the average recommended by the Royal College of Psychiatrists for an acute ward. This meant that patients would not always have a bed to come back to if they returned from community leave Managers reported that when patients went on leave from wards their beds were not used for other patients needing admission to hospital. However, staff from all wards said there was often pressure to admit to beds when patients went on leave. The trust provided information for average length of stay for the period 1 January to 31 December 2018. Ward name Average length of stay range (1 January – 31 December 2018) (current inspection) Mulberry 1 AAU 6-14 Mulberry 1 Detox 6-13 Mulberry 2 21-41 Mulberry 3 28-298 Oak 1 Treatment 13-36 Oak 3 AAU 5-8 Oak 4 Recovery 32-146 Poplar (PICU) 14-26 Springbank 198-440

The trust operated a ‘3-3-3’ pathway model of assessment, treatment and recovery. The model consists of three stages of care, namely three days of assessment, three weeks of treatment and three months of recovery. Staff told us the model was used as a guide. Average length of stay data indicates variation from the model, which staff also confirmed in their interviews. This service reported 53 (ten received in and 43 placed with another provider) out of area placements between 1 January to 31 December 2018. As of 31 December 2018, this service had ten (three received in and seven placed with another provider) ongoing out of area placements.

20190830 RT1 Evidence appendix Page 162

There were no placements that lasted less than one day, and the placement that lasted the longest amounted to 440 days. 43 out of 43 out of area placements, where patient was placed with another provider, were due to ‘this better suiting their care or personal needs’. The number of out of area placements reported during this inspection was higher than the 35 reported at the time of the last inspection.

Number of out of Number due to Number due to Range of lengths Number of area placements specialist needs capacity (completed ongoing placements) placements 53 43 0 2 – 440 days 10

The Poplar PICU ward was for male patients. Female patients needing PICU would be admitted to other providers in the adjacent counties. On the Oak acute assessment unit at Cavell Centre the Ministry of Defence Commissioned 4 beds for service personnel. This service reported 154 readmissions within 28 days between 1 January to 31 December 2018. Of the 154 readmissions (82, 53%) were readmissions to the same ward as discharge. The average number of days between discharge and readmission was 11 days. There were no instances whereby patients were readmitted on the same day as being discharged and four instances where patients were readmitted the day after being discharged. At the time of the last inspection, for the period September 2016 to 30 October 2017, there were a total of 187 readmissions within 28 days. Of these, 112 were readmissions to the same ward (60%) and the average number of days between discharge and readmission was 11 days. Therefore, the number of readmissions within 28 days has decreased between the two periods and the average time between discharge and readmission has remained static. Ward name Number of Number of % Range of Average days readmissions readmissions readmissions days between discharge (to any ward) (to the same to the same between and readmission within 28 ward) within ward discharge days 28 days and readmission Mulberry 1 46 33 72% 2-23 10 AAU

Mulberry 2 25 9 36% 2-25 13

Mulberry 3 2 1 50% 4-20 12

Oak 1 22 15 68% 1-28 10 Oak 3 49 24 49% 1-28 12 Oak 4 4 0 0% 2-23 11 Poplar 6 0 0% 2-28 17

Between 1 January to 31 December 2018 there were 78 discharges within this service. This amounted to 5% of the total discharges from the trust overall (1582).

20190830 RT1 Evidence appendix Page 163

There were eight delayed discharges in this core service, ranging from 0 to one over the 12 month period. The proportion of delayed discharges reported during this inspection was not comparable with the data reported at the last inspection. Facilities that promote comfort, dignity and privacy The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at the Cavell centre scored higher similar trusts. There was one location, Fulbourn Hospital (83.2%) that scored lower than other similar trusts for ward food. Site name Core services provided Ward food

Fulbourn Hospital MH - Acute wards for adults of working age 83.2% and psychiatric intensive care units MH - Eating Disorders MH - Forensic inpatient MH - Other Specialist Services MH - Wards for older people with mental health problems Cavell Centre MH - Acute wards for adults of working age 100% and psychiatric intensive care units MH - Wards for older people with mental health problems MH - Wards for people with learning disabilities or autism Trust overall 89.4%

England average (mental 92.2% health and learning disabilities)

Although patients had their own bedrooms across all seven wards with toilet facilities Mulberry 1 ward bedrooms did not have enlowersuite shower facilities. On Mulberry 3 male patients did not have ensuite facilities. Patients were able to personalise their bedrooms, for example with artwork and photographs.

Poplar psychiatric intensive care unit’s seclusion room had a separate toilet room. It was locked as staff could not clearly observe the patient in the area. Staff were required to enter the seclusion room to unlock the door and hold open the toilet door to enable observations. Staff had to enter the room to open and close the window blind. This posed a privacy and dignity issue to the patient.

The seclusion room was located outside of the main ward area near the ward entrance opposite the visitors’ room. Staff said the area could be used for de-escalation or segregation of patients. This could affect a patient’s privacy and dignity if seclusion was needed when the area was being used by visitors.

Staff used Closed Circuit Television to observe patients using the seclusion room. However, the monitor screen was situated within visitor’s room. This meant that the visitor’s room could not be used if the seclusion room was in use, however there was a quiet room that could be used for visitors to the ward.

Wards had enough rooms for patients to access individual sessions with nursing staff, to receive visitors or to participate in ward-based activities.

20190830 RT1 Evidence appendix Page 164

Patients had use of their mobile phones across all wards. The trust provided information on accessing telephone calls and the internet in patient welcome packs. Patients on all wards had access to outside space. Patients could store their valuables in lockers either within locked cabinets in their bedrooms or locked containers within rooms only accessible by staff. Staff accessed valuables on behalf of patients, subject to risk assessment, when requested. Patients had access to ward kitchens to make hot and cold drinks and snacks 24 hours a day, except on the Psychiatric Intensive Care Unit, where staff facilitated access to drinks and snacks.

Staff supported patients to maintain contact with their families and carers and invited them to attend ward reviews where appropriate. Staff also encouraged patients to attended education and work opportunities where they had capacity to do so. Meeting the needs of all people who use the service For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018) the locations scored higher than similar trusts for the environment being dementia friendly and scored higher than similar trusts for the environment supporting those with disabilities.

Site name Core services provided Dementia Disability friendly Fulbourn Hospital MH - Acute wards for adults of working age and 96.3% 96.2% psychiatric intensive care units MH - Eating Disorders MH - Forensic inpatient MH - Other Specialist Services MH - Wards for older people with mental health problems Cavell Centre MH - Acute wards for adults of working age and 96.8% 97.3% psychiatric intensive care units MH - Wards for older people with mental health problems MH - Wards for people with learning disabilities or autism Trust overall 92.9% 95.0% England average 88.3% 87.7% (Mental health and learning disabilities)

Staff could access information leaflets in a variety of languages for patients whose first language was not English, and some information was in pictorial form. Patients had access to a wide range of information leaflets in ward areas. For example, information of advocacy, patients’ rights, how to complain and local services. Staff had access to interpreters to enable communication with patients, as needed. However, staff had not detailed in one patient’s care plan their need for this.

There was a multi-faith room, The Sanctuary, available to patients and staff situated at the Cavell Centre, and a chaplaincy service at Fulbourn hospital.

20190830 RT1 Evidence appendix Page 165

Wards had assisted bathrooms or shower rooms for patients and we saw examples where staff had gained aids and adaptations to increase patient’s independence. Staff told us they had processes for supporting transgender patients.

Listening to and learning from concerns and complaints This service received 12 complaints between 1 January to 31 December 2018. One of these was upheld, three were partially upheld, three were not upheld, two were under investigation and three were withdrawn. None were referred to the Ombudsman.

Ward name

Total Total

Under Under

upheld

Partially Partially

Withdrawn

Not upheld Not

Complaints

Fully upheld Fully Investigation Cavell Centre - Poplar Ward (PICU) 3 1 1 1 Cavell Centre - Recovery Ward / Oak 4 2 2 Cavell Centre - Treatment Ward / Oak 1 3 1 1 1 Fulbourn Hospital - Mulberry 2 3 1 1 1 Fulbourn Hospital - Mulberry 3 1 1 Total 12 1 3 3 2 3

This service received 419 compliments during the last 12 months from 1 January to December 2018 which accounted for 6% of all compliments received by the trust as a whole (6654). Patients had access to information on how to make a complaint. Wards had information on the complaints process and this was displayed to patients on ward notice boards and in leaflets. The trust had systems for the recording and management of complaints. We saw minutes of team meetings where the outcomes and learning from complaints was discussed. Patients raised concerns and provided feedback about the wards at daily community meetings. Staff encouraged completion of an online patient feedback survey on discharge. Is the service well-led?

Leadership Leader’s said that the trust provided them with opportunities to develop their own and their team’s skills. Managers told us that senior managers were visible on the wards and they knew who senior staff were. However, managers and staff both told us that senior board members rarely visited the wards. Vision and strategy Staff knew and understood the trust’s vision and values and how they applied in the work of their team. Managers displayed posters displaying the values of professionalism, respect, innovation, dignity and empowerment in ward areas and on the intranet. Staff told us that their appraisal was based on these values.

20190830 RT1 Evidence appendix Page 166

Culture Staff said they felt respected and supported by their managers and that morale was good. Staff we spoke with said they felt able to raise concerns without fear of retribution and knew the trust had a whistle blowing policy which they would use if they needed to. Staff said they could access the trust occupational health service for support with both physical and mental health issues. Staff told us they felt positive and proud about working for the trust and their team and described supportive relationships with colleagues and managers. Governance We saw minutes of the monthly governance meetings which included a standard agenda including for example, safeguarding, incidents, staffing, risk register, environment, training, patient experience and audits. We saw local risk registers were in place across all seven wards. Managers and staff could identify new risks. These were updated regularly and contained action plans. Staff understood the arrangements for working with other teams, both with in the trust and with external providers to meet the needs of patients. Management of risk, issues and performance Staff maintained and had access to the risk register at ward level. Staff told us they could escalate concerns when necessary. Staff told us that they were able to raise risk and performance issues in their supervision, via ward meetings. Managers held monthly governance meetings. Managers updated clinical dashboards for their wards in relation to key performance indicators. Targets included ensuring incidents were recorded with 24 hours, supervision of staff, staff mandatory training, follow up of patients within 7 days of discharge and physical health checks for patients. Information management The trust collected data from wards to produce a performance dashboard which monitored for example: sickness levels, turnover, complaints, incidents, restraints, audits and patient experience. Managers used information and technology to assist them in their role; they described how they looked at trends in the types of incidents on the wards. Staff told us they had enough technology and equipment to do their role. Engagement We saw evidence that wards were engaging with each other through regular managers and governance meetings at a location level. There was evidence of good engagement with community mental health teams and other providers external to the service. Learning, continuous improvement and innovation NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.

20190830 RT1 Evidence appendix Page 167

The table below shows which services within this service have been awarded an accreditation together with the relevant dates of accreditation where available. Accreditation scheme Core service Service accredited Comments

MH - Acute wards for adults Oak 1 (Treatment of working age and ward) reviewed psychiatric intensive care units 04.10.18 MH - Acute wards for adults Poplar ward, of working age and 14.12.17, reviewed psychiatric intensive care August 2018 units MH - Acute wards for adults Accreditation for Inpatient of working age and Oak 3 (AAU) Mental Health Services psychiatric intensive care (AIMS) units MH - Acute wards for adults of working age and Mulberry 1 psychiatric intensive care units Submission of actions MH - Acute wards for adults of working age and for accreditation Mulberry 2 psychiatric intensive care 21.01.19, awaiting units outcome

Managers at Mulberry 1 and Oak 3 wards had implemented an “open door” policy. The policy enables previous patients to access the service informally. The aim is to support patients before crisis and therefore reduce the workload of the crisis team. We saw on Mulberry 1 ward that a cardio-wall had been installed to help improve physical fitness of patients.

20190830 RT1 Evidence appendix Page 168

Community-based mental health services for adults of working age

Facts and data about this service

Location site name Team name Number of clinics Patient group (male, female, mixed) Fulbourn Hospital Darwin Nurseries Not provided Not provided

Fulbourn Hospital Dual Diagnosis Street Team Not provided Not provided (DDST) Fulbourn Hospital Liaison and Diversion Not provided Not provided

Fulbourn Hospital Adult ADHD Not provided Not provided

Fulbourn Hospital Cambridge North Affective Not provided Not provided Disorder Pathway Fulbourn Hospital Cambridge North Assessment Not provided Not provided Pathway Fulbourn Hospital Cambridge North Others Pathway Not provided Not provided

Fulbourn Hospital Cambridge North Personality Not provided Not provided Disorder Pathway Fulbourn Hospital Cambridge North Psychosis Not provided Not provided Pathway Fulbourn Hospital Cambridge South Affective Not provided Not provided Disorder Pathway Fulbourn Hospital Cambridge South Assessment Not provided Not provided Pathway Fulbourn Hospital Cambridge South Others Not provided Not provided Pathway Fulbourn Hospital Cambridge South Personality Not provided Not provided Disorder Pathway Fulbourn Hospital Cambridge South Psychosis Not provided Not provided Pathway Fulbourn Hospital CAMEO Not provided Not provided

MH Services (CPFT) CUH - LPS - OPMH - IP Not provided Not provided at Addenbrookes MH Services (CPFT) CUH – LPS – Adults - ETDMHS Not provided Not provided at Addenbrookes MH Services (CPFT) CUH - LPS - Adults - OP Not provided Not provided at Addenbrookes MH Services (CPFT) CUH – LPS – Adults - PSYONC Not provided Not provided at Addenbrookes MH Services (CPFT) CUH - LPS - Adults - IP Not provided Not provided at Addenbrookes MH Services (CPFT) CUH - LPS - CSMHS - OP Not provided Not provided at Addenbrookes MH Services (CPFT) CUH - LPS - OPMH - OP Not provided Not provided at Addenbrookes

20190830 RT1 Evidence appendix Page 169

MH Services (CPFT) CUH - LPS - Therapy Not provided Not provided at Addenbrookes MH Services (CPFT) CUH - LPS D + A - OP Not provided Not provided at Addenbrookes MH Services (CPFT) CUH - LPS D + A - IP Not provided Not provided at Addenbrookes North Cambridgeshire Fenland Affective Disorder Not provided Not provided Hospital Pathway North Cambridgeshire Fenland Assessment Pathway Not provided Not provided Hospital North Cambridgeshire Fenland Other Pathway Not provided Not provided Hospital North Cambridgeshire Fenland Personality Disorder Not provided Not provided Hospital Pathway North Cambridgeshire Fenland Psychosis Pathway Not provided Not provided Hospital MH Services (CPFT) Huntingdon - LPS - Adults - IP Not provided Not provided at Addenbrookes MH Services (CPFT) Huntingdon - LPS - OPMH - IP Not provided Not provided at Addenbrookes Fulbourn Hospital Huntingdon Affective Disorder Not provided Not provided Pathway Fulbourn Hospital Huntingdon Assessment Pathway Not provided Not provided

Fulbourn Hospital Huntingdon Other Pathway Not provided Not provided

Fulbourn Hospital Huntingdon Personality Disorder Not provided Not provided Pathway Fulbourn Hospital Huntingdon Psychosis Pathway Not provided Not provided

Fulbourn Hospital IST Not provided Not provided

MH Services (CPFT) Peterborough - LPS - Adults - IP Not provided Not provided at Addenbrookes MH Services (CPFT) Peterborough - LPS - OPMH - IP Not provided Not provided at Addenbrookes Fulbourn Hospital Peterborough Affective Disorder Not provided Not provided Pathway Fulbourn Hospital Peterborough Assessment Not provided Not provided Pathway Fulbourn Hospital Peterborough Other Pathway Not provided Not provided

Fulbourn Hospital Peterborough Personality Not provided Not provided Disorder Pathway Fulbourn Hospital Peterborough Psychosis Pathway Not provided Not provided

Is the service safe?

Safe and clean environment

20190830 RT1 Evidence appendix Page 170

Staff assessed the care environment annually for potential risks. Whilst the environments on each site had potential ligature anchor points, staff risk assessed individual patients and put in plans to mitigate any risks. Patients who were high risk were supervised at all times in the clinical areas. Staff had access to personal alarms on site in the clinical rooms. All clinical areas were clean, furnishings were in good repair, and décor on all sites was maintained to a high standard. Hand rub was available at the entrance of each site and all clinic rooms had handwashing facilities. The clinic rooms were fully equipped with everything needed for monitoring patients’ physical health. Each community team had access to resuscitation equipment and emergency drugs. Staff had a procedure for checking this equipment and kept clear records. Staff maintained equipment well and kept it clean. Safe staffing Nursing staff The Fenland team had a staffing establishment of three nurses and three support workers with one vacancy. The Cambridge North team had a staffing establishment of five nurses and four support workers with three vacancies. The Cambridge South team had a staffing establishment of six nurses and four support workers with no vacancies. The Peterborough team had a staffing establishment of six nurses and two support workers with no vacancies. The Huntingdon team had a staffing establishment of six nurses and three support workers with one vacancy. Two services, Peterborough and Huntingdon were experiencing longer wait times of up to four months for psychological treatments due to staffing vacancies. Managers had calculated the number and type of staff required according to their service user need. The provider decided staff levels according to the number of cases which each team held, however, managers were able to request additional staff should individuals hold a caseload which was more complex. The managers at Fenland highlighted that it was difficult to recruit and retain staff in this area. In the case of Fenland this was due to the remoteness of the service. The average caseload across all teams was 25. Managers monitored caseload for each staff member in supervision meetings and adjusted numbers according to the complexity of the cases. Where necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. The teams were using agency staff due to sickness and vacancies. Agency staff were booked for long periods of time and given appropriate inductions and training. Patients had an allocated psychiatrist and could contact the duty staff member at the community teams should they need additional support. Patients were given contact details for the trust crisis team who could support patients in the case of a decline in their mental health. Staff had received, and were up to date with, appropriate mandatory training including safeguarding, the mental health act and the mental capacity act. Overall, staff in this service had undertaken 91% of the 25 elements of training that the trust had set as mandatory. Fewer than 75% of staff had completed mandatory training the Mental Health Act level 1, smoking cessation, manual handling level 2 and safeguarding children level 3.

20190830 RT1 Evidence appendix Page 171

This core service has reported a vacancy rate for all staff of 7% as of 31 December 2018. This was lower than the rate of 15% reported at the last inspection (between 1 October 2016 and 31 September 2017). This core service reported an overall vacancy rate of 18% for registered nurses at 31 December 2018. The vacancy rate for registered nurses was higher than the 23% reported at the last inspection. This core service reported an overall vacancy rate of -5% for nursing assistants. The vacancy rate for nursing assistants was lower than the 25% reported at the last inspection.

Registered nurses Health care assistants Overall staff figures

Location Ward/Team

Vacancies Vacancies Vacancies

Establishment Establishment Establishment

Vacancy (%) rate Vacancy (%) rate Vacancy (%) rate North Fenland Cambridg Affective 4.7 7.4 64% 1.8 4.4 41% 11.2 21 53% eshire Disorder Hospital Pathway Fulbourn Cambridge Hospital North Affective 5.1 10.1 50% 1.8 8.0 23% 7.3 25.6 29% Disorder Pathway Fulbourn Huntingdon Hospital Affective -0.2 7.4 -3% 1.4 2.4 58% 2.6 15.9 16% Disorder Pathway Fulbourn Cambridge Hospital South - Affective 3.5 9.5 37% -1.7 4.5 2.5 19.7 13% 38% Disorder Pathway Fulbourn IST 11% -0.9 3.1 -29% 0.7 4.1 17% 1.1 9.9 Hospital

Fulbourn CAMEO - 5.8 15.7 37% -2.2 6.7 1.3 29.8 4% Hospital 33% Fulbourn Liaison and 2.5 11.4 22% 0 5 0% 1.5 16.4 9% Hospital Diversion Darwin n/a n/a n/a 0.5 6.3 8% 0.5 7.3 7% Nurseries Fulbourn Dual Hospital Diagnosis Street 0.0 0.0 n/a n/a n/a n/a -0.2 3.9 -5% Team (DDST) Fulbourn Adult ADHD -1.2 0.6 -200% n/a n/a n/a -0.4 1.6 -25% Hospital

20190830 RT1 Evidence appendix Page 172

CUH - LPS - - OPMH - IP n/a n/a n/a -3.5 1.5 233 -6.9 18.4 -38% % Fulbourn Peterborou Hospital gh Affective - -4.8 9.3 -52% -1.2 3.4 -8.2 18.1 -45% Disorder 35% Pathway Core service 13.5 74.5 18% -2.4 46.3 -5% 12.3 187.6 7% total Trust total 1,294. 164.0 13% 130.6 1,031.7 13% 334.2 3,984.1 8% 0 NB: All figures displayed are whole-time equivalents Between 1 January and 31 December 2018, 2,982 available hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. In the same period, agency staff covered 1,640 of available hours for qualified nurses and 154 of available hours were unable to be filled by either bank or agency staff. The main reason for bank and agency usage for the wards/teams was due to staff vacancies. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling.

Teams Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Cambridge North Affective 0 n/a 225 n/a 30 n/a Disorder Pathway Cambridge South Affective 0 n/a 863 n/a 15 n/a Disorder Pathway Liaison and Diversion 401 n/a 0 n/a 0 n/a Peterborough Affective Disorder 2,436 n/a 552 n/a 109 n/a Pathway HMP/ YOI Peterborough 138 n/a 0 n/a 0 n/a Darwin Nurseries 0 n/a 0 n/a 0 n/a Adult ADHD 8 n/a 0 n/a 0 n/a Core service total 2,982 n/a 1,640 n/a 154 n/a Trust Total 114,849 n/a 42,162 n/a 31,421 n/a

Between 1 January and 31 December 2018, 2,005 available hours were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reason for bank and agency usage for the wards/teams was acuity. In the same period, agency staff covered 0 of available hours for nursing assistants and 9 of available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that

20190830 RT1 Evidence appendix Page 173

they record this information based on the number of hours used and not the number of available hours that need filling. Teams Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Cambridge North Affective Disorder 0 n/a 0 n/a 0 n/a Pathway Cambridge South Affective Disorder 0 n/a 0 n/a 0 n/a Pathway Liaison and Diversion 2 n/a 0 n/a 0 n/a Peterborough Affective Disorder 0 n/a 0 n/a 0 n/a Pathway HMP/ YOI Peterborough 0 n/a 0 n/a 0 n/a Darwin Nurseries 2,005 n/a 0 n/a 9 n/a Adult ADHD 0 n/a 0 n/a 0 n/a Core service total 2,005 n/a 0 n/a 9 n/a Trust Total 202,495 n/a 31,831 n/a 25,769 n/a

This core service had 18.3 (10%) staff leavers between 1 January and 31 December 2018. This was lower than the 12% reported at the last inspection (from 1 October 2016 to 31 September 2017). Location Ward/Team Substantive staff Substantive staff Average % staff (at latest month) Leavers over the leavers over the last 12 months last 12 months North Cambs Fenland Affective 9.8 3.4 34% Hospital Disorder Pathway Fulbourn Hospital Liaison and 14.9 4 26% Diversion MH Services CUH - LPS - (CPFT) at OPMH - IP 23.6 3.5 15% Addenbrookes Fulbourn Hospital Peterborough Affective Disorder 24.3 3.4 13% Pathway Fulbourn Hospital IST 8.8 1 11% Fulbourn Hospital Cambridge North Affective Disorder 17.3 1.6 9% Pathway Fulbourn Hospital CAMEO 28.8 1 3% Fulbourn Hospital Cambridge South Affective Disorder 17.2 0.4 2% Pathway Fulbourn Hospital Dual Diagnosis Street Team 4.1 0.0 0% (DDST)

20190830 RT1 Evidence appendix Page 174

Location Ward/Team Substantive staff Substantive staff Average % staff (at latest month) Leavers over the leavers over the last 12 months last 12 months Fulbourn Hospital Huntingdon Affective Disorder 14.3 0.0 0% Pathway Fulbourn Hospital Darwin Nurseries 6.8 0 0% Fulbourn Hospital Adult ADHD 2 0 0% Core service total 171.9 18.3 10% Trust Total 3,575.2 446.3 13%

The sickness rate for this core service was 3.9% between 01 January and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 5.8%. This was lower than the sickness rate of 4.7% reported at the last inspection in September 2017. Location Ward/Team Total % staff sickness Ave % permanent staff sickness (at latest month) (over the past year) Fulbourn Hospital Peterborough Affective Disorder 12.7% 6.4% Pathway Fulbourn Hospital CAMEO 9.2% 6.2%

Fulbourn Hospital Darwin Nurseries 7.8% 5.2%

Fulbourn Hospital IST 3.0% 4.3%

Fulbourn Hospital Huntingdon Affective 4.2% 3.9% Disorder Pathway Fulbourn Hospital Cambridge North Affective Disorder 4.9% 3.3% Pathway North Cambs Fenland Affective 1.0% 2.7% Hospital Disorder Pathway Fulbourn Hospital Cambridge South Affective Disorder 7.1% 2.6% Pathway Fulbourn Hospital Liaison and Diversion 0.6% 2.5%

Fulbourn Hospital Adult ADHD 0.0% 1.8%

MH Services CUH - LPS - OPMH - (CPFT) at IP 2.4% 1.7% Addenbrookes Fulbourn Hospital Dual Diagnosis Street 0.0% 0.7% Team (DDST) Core service total 5.8% 3.9% Trust Total 5.3% 4.5%

20190830 RT1 Evidence appendix Page 175

Medical staff Between 1 January and 31 December 2018, of the (1,299) total working hours available, 0.4% were filled by bank staff to cover sickness, absence or vacancy for medical locums. In the same period, agency staff covered 0% of available hours and 0% of available hours were unable to be filled by either bank or agency staff. Ward/Team Total hours available Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Adult ADHD 1,299 6 0.4% 0 0% 0 0% Core service 1,299 6 0.4% 0 0% 0 0% total Trust Total 177,009 3,825 2% 18,562 11% 0 0%

Mandatory training The compliance for mandatory and statutory training courses at 31 December 2018 was 90%. Of the training courses listed 11 failed to achieve the trust target and of those, four failed to score above 75%. The trust set a target of 90% for completion of mandatory and statutory training. The trust has stated that the training data is reported as a final figure at year end (where applicable). The training compliance reported for this core service during this inspection was lower than the 91% reported in the previous year. Key:

Not met trust Met trust target Higher No change Lower Below CQC 75% target ✓  ➔  

Training Module Numb Numb YTD Trust Complian er of er of Complian Targ ce change eligibl staff ce (%) et when e staff traine Met compared d to previous year Deprivation of Liberty Safeguards 3 3 100% ✓ n/a Safeguarding Adults 206 206 100% ✓  Mental Capacity Act Level 1 49 49 100% ✓ n/a Infection Control (Level 1) 7 7 100% ✓ n/a Conflict Resolution 204 203 100% ✓ n/a Treating People with Respect 204 202 99% ✓  Working Safely 204 201 99% ✓  Safeguarding Children (Level 2) 40 39 98% ✓  Dementia 171 166 97% ✓  Good Governance 204 198 97% ✓  PREVENT (Level 1) 58 56 97% ✓ n/a

20190830 RT1 Evidence appendix Page 176

Training Module Numb Numb YTD Trust Complian er of er of Complian Targ ce change eligibl staff ce (%) et when e staff traine Met compared d to previous year PREVENT (Level 2) 148 142 96% ✓ n/a Safeguarding Children (Level 1) 15 14 93% ✓  Infection Control (Level 2) 199 184 92% ✓ n/a Fire Safety 204 183 90% ✓  Mental Capacity Act Level 2 123 110 89%   Safeguarding Children (Level 3) 151 131 87%   Basic Life Support (BLS) 199 170 85%   Mental Health Act Level 2 101 86 85%   Manual Handling (Level 1) 126 106 84%  n/a Carer Awareness 204 166 81%  n/a Safeguarding Children Level 3; Mandatory for 161 114 71%  n/a Role (3hrs) Mental Health Act Level 1 49 34 69%   Smoking Cessation 204 139 68%  n/a Manual Handling (Level 2) 20 13 65%  n/a Total 3,254 2,922 90% ✓ 

Assessing and managing risk to patients and staff Assessment of patient risk During the inspection we reviewed 43 care records and found that staff did a risk assessment for every patient at initial triage. Staff would then complete a more thorough risk assessment over three sessions with the patient. Staff at Peterborough, Cambridge and Huntingdon ensured that these records were kept updated every three months and after an incident. However, at Fenland we found that staff had not kept patient records updated, this included five out of eight risk assessments. Staff used a recognised risk assessment tool set out on the electronic records system to complete risk assessments.

Management of patient risk Duty staff monitored patients on the waiting list for a care co-ordinator and made contact each week depending on the risk level. If a patient was experiencing a sudden deterioration in mental health, staff prioritised their needs and would take their case to a multidisciplinary team meeting where staff would plan any urgent care needed. The provider had a lone working policy and each site had a process for staff to check in and out with the member of staff doing duty cover to ensure their safety. If there were concerns about a staff member’s safety, allocated staff would contact them or escalate concerns to the team manager.

20190830 RT1 Evidence appendix Page 177

Safeguarding A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made 298 safeguarding referrals between 1 January and 31 December 2018, of which 252 concerned adults and 46 children. The data reported during this inspection was not reported at core service level at the last inspection Number of referrals Core service Adults Children Total referrals MH - Community- based mental health 252 46 298 services for adults of working age.

The number of adult safeguarding referrals in month ranged from 42 in Jan 2018 to 11 in July 2018. The number of child safeguarding referrals ranged from seven in September 2017 to none in March 2017. Staff received training from the trust in safeguarding as part of their mandatory training and the compliance rate across all community teams for safeguarding adults was 98%. The teams had integrated social workers who were employed by the local authority and facilitated the process for making alerts. Each community team had staff who were trained as safeguarding investigators. The community teams had made 283 safeguarding referrals between 1 January and 31 December 2018. Staff we spoke with could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to identify adults and children at risk of significant harm and raised their concerns at daily handovers, weekly multidisciplinary team meetings or to their team manager if necessary. The team would plan together how to protect the patient and we saw evidence of this in team meeting minutes. The trust has submitted details of no serious case reviews commenced or published in the last 12 months (1 January and 31 December 2018) that relate to this service. Staff access to essential information

20190830 RT1 Evidence appendix Page 178

Staff stored and accessed information about patients using an electronic care records system. Some other records, such as prescription charts were paper based. Staff had access to all information needed to deliver patient care on this electronic system. Patient notes were written clearly but staff said they sometimes found it difficult to navigate the system. If a patient had been transferred from another area and their notes were not available on the system staff could request access through a specific team who had access to other records system such as GP notes. Doctors had access to the GP record systems which support them during the assessment process. Medicines management Staff followed good practice when storing, dispensing, transporting and administering medicines. We checked on site medicines storage procedures and found that staff were checking that medicines were fit for use and monitoring the environment they were stored in. All 30 prescription charts we reviewed were completed clearly, prescribers had followed prescribing guidance and staff were ensuring that patients received their medicines within an appropriate time. Staff reviewed the effects of medication on patients’ physical health regularly and in line with National Institute for Health and Care Excellence (NICE) guidance. Staff reviewed patients’ medicines at regular, appropriate intervals. Staff ensured that when patients were on high doses of antipsychotics, or those with medicines which required regular blood monitoring such as clozapine, they checked that it was safe to give their medicines. If patients were experiencing side effects, staff could raise this with the patient’s prescriber or at a multidisciplinary meeting. Staff had access to a range of materials in different languages and print types which could be used to help patients understand their medicines and how to manage potential side effects. Track record on safety Between 1 January and 31 December 2018 there were 19 serious incidents reported by this service. Of the total number of incidents reported, the most common type of incident was ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’ with 18. Sixteen of the unexpected deaths were instances of ‘Apparent/actual/suspected self-inflicted harm meeting SI’. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with 19 reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service reported no never events during this reporting period. The number of serious incidents reported during this inspection was higher than the 18 reported at the last inspection.

20190830 RT1 Evidence appendix Page 179

Number of incidents reported

Type of incident reported Apparent/actual/susp Disruptive/ Total (SIRI) ected self-inflicted aggressive/ violent harm meeting SI behaviour meeting SI criteria criteria Cambridge South Adult 7 0 7 Locality Team Fenland Adult Locality Team 3 0 3 Peterborough and Borders 3 0 3 Adult Locality Team Huntingdon Adult Locality 2 1 3 Team Cambridge North Adult 2 0 2 Locality Team CAMEO North 1 0 1 Total 18 1 19

Reporting incidents and learning from when things go wrong The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there has been no ‘prevention of future death’ reports sent to Cambridge and Peterborough NHS Foundation Trust. All staff knew what incidents to report, how to report them and reported them appropriately. They completed incident report forms through an online system which would send the report to their team manager. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. We saw incidents where team managers had reviewed an incident or complaint and had sent a letter of apology explaining next steps in the process and how to escalate concerns. Staff received feedback from investigation of incidents, both internal and external to the service. Staff could give examples of incidents which had happened in their team and with other community teams in the trust. Managers provided feedback through team meetings of which minutes were kept. Staff could identify lessons which had been learned as a result of these incidents. Staff received bulletins by email. We saw evidence in team meeting minutes that staff had changed their processes following an incident with a patient under the care of the community team who had not been engaging with the service. Staff had a protocol for patients who did not attend an appointment and would raise the concern with the team, the team would then plan together how best to support the patient. Staff were debriefed by a senior member of staff and a psychologist after a serious incident. Managers supported staff compassionately following an incident by offering emotional support, 20190830 RT1 Evidence appendix Page 180

through occupational health and psychology, and protected time for the staff member to engage with investigations.

Is the service effective?

Assessment of needs and planning of care During the inspection we reviewed 43 care records across all sites. 83 % of care plans were holistic, personalised and recovery orientated. 83% of patients had received a physical health check Duty staff completed a triage assessment of patients when they received a referral, speaking to urgent referrals within 24 hours and non-urgent referrals within three days. During the initial assessment sessions staff completed a comprehensive mental health assessment of the patient including their history, risks, physical health and any safeguarding concerns. Staff at Huntingdon, Peterborough, and Cambridge completed care plans that met the needs identified in the assessment. However, we found five patients who were cared for under the Fenlands team did not have a care plan. Staff ensured that patients’ physical health needs had been assessed when they triaged them. Where necessary staff referred patients to their weekly physical health clinic for regular monitoring. Best practice in treatment and care Staff provided a range of care and treatment interventions suitable for the patient group. Following a thorough assessment of the care needs staff would bring this information to weekly meetings with the multidisciplinary team where they would agree the different interventions which they could offer. Staff offered a range of treatments from medicines, opportunities to improve life skills through the re-enablement scheme, group therapies and recovery college. Staff ensured that patients had good access to physical healthcare by accessing information from their GP and offering weekly physical health monitoring clinics. Staff used the Health of the Nation Outcome Scale, a recognised rating scale, to rate severity. They reviewed these scored during and at the end of treatment and used them to measure their success. Staff engaged in clinical audit and benchmarking. Each team manager could access information about their team’s performance against key performance criteria for risk assessing and care planning for patients, this was benchmarked against other teams in the trust. Staff used information technology to support patients effectively. This service participated in two clinical audits as part of their clinical audit programme 1 January – 31 December 2018. Audit name Audit Core service Audit type Date Key actions scope completed following the audit Suicide Trust wide MH - Clinical 01/05/2018 “•Review and update Prevention Community- Clinical Risk training based mental to reflect the audit

20190830 RT1 Evidence appendix Page 181

Audit name Audit Core service Audit type Date Key actions scope completed following the audit Review - health services findings, to include 2015/16 for adults of discharge planning working age. among others. Clinical Risk training will incorporate training on RiO to improve compliance with record keeping standards • To complete the 2016/17 audit of possible/probable suicides • Undertake research to explore the influence that classroom-based training in the assessment and management of suicide risk has on a participant’s clinical practice • The Directorates will develop service- specific actions Adult & MH - Clinical 22/06/2018 • Clinical Risk training Specialist Community- will incorporate Mental Health based mental training on RiO to directorate, health services improve compliance for adults of with record keeping working age. standards

Skilled staff to deliver care The community teams included a range of specialists to support patient needs including doctors, nurses, clinical psychologists, social workers and peer support workers. However, we found in the Peterborough team and Huntingdon team there were vacancies in the psychology teams and social workers who were provided by the local authority. Staff were experienced, qualified, and had the right skills and knowledge to meet the needs of the patient group. New staff attended a trust induction covering a range of topics essential to complete their roles. Managers also provided a local induction which introduced staff members to the team’s procedures and included a period of shadowing with an experienced staff member. Managers at the Cambridge community teams gave staff a reduced caseload when they started and increased this over time.

20190830 RT1 Evidence appendix Page 182

Managers provided staff with supervision to discuss their case mix, to reflect on and learn from practice we reviewed staff supervision records for all staff on the community teams. We found that managers were keeping records of supervisions and the compliance rate was 58 %. Discussion records reviewed showed conversations about staff caseload and any incidents. However, staff members were required to record their supervisions on the trust’s academy system, this had not been completed in all cases and therefore the figures were incorrect. Managers ensured that staff met regularly as a team. Each community team met weekly for several different meetings including care planning, learning lessons, daily handovers. Each meeting had a clear structure and staff kept meeting minutes so that staff who were unable to attend could keep up to date. Managers used appraisals to identify learning needs of staff and objectives were manageable and linked to the trust’s strategy. Managers offered staff additional training through the e-learning system and staff could apply for specialist training according to their role. Managers had not had to deal with poor performance in the last 12 months. However, all managers explained that they would follow a performance management process and seek support from Human Resources should this arise in the future. The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 January and 31 December 2017), the overall appraisal rate for non-medical staff within this service was 80%. This year so far, the overall appraisal rates was 89% (as at 31 December 2018). The teams with the lowest appraisal rate at 31 December 2018 were Adult ADHD with an appraisal rate of 50%, IST with an appraisal rate of 80% and Peterborough Affective Disorder Pathway at 81%. The rate of appraisal compliance for non-medical staff reported during this inspection was lower than the 94% reported at the last inspection. Ward name Total Total % % number of number of appraisal appraisal permanen permanen s s t non- t non- (as at 31 (previous medical medical Decembe year 1 staff staff who r 2018 January – requiring have had 31 an an Decembe appraisal appraisal r 2018) Dual Diagnosis Street Team (DDST) 5 5 100% 50% Liaison and Diversion 14 14 100% 100% Cambridge North Affective Disorder 19 18 95% 82% Pathway Cambridge South Affective Disorder 19 18 95% 100% Pathway Huntingdon Affective Disorder Pathway 17 16 94% 57% Darwin Nurseries 10 9 90% 78% CAMEO 27 24 89% 89%

20190830 RT1 Evidence appendix Page 183

Ward name Total Total % % number of number of appraisal appraisal permanen permanen s s t non- t non- (as at 31 (previous medical medical Decembe year 1 staff staff who r 2018 January – requiring have had 31 an an Decembe appraisal appraisal r 2018) CUH - LPS - OPMH - IP 23 19 83% 73% Fenland Affective Disorder Pathway 11 9 82% 44% Peterborough Affective Disorder Pathway 27 22 81% 87% IST 10 8 80% 75% Adult ADHD 2 1 50% 100% Core service total 184 163 89% 80% Trust wide 3,503 2,807 80% 76%

One medical member of staff was eligible for appraisal and was appraised, making it an appraisal rate of 100%. The trust has not supplied a target for non-medical staff. Between 1 January and 31 December 2018, the average rate across all 13 teams in this service was 58%. The rate of clinical supervision reported during this inspection was lower than the 74% reported at the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision sessions delivered rate (%) required Liaison and Diversion 139 121 87% Dual Diagnosis Street Team (DDST) 45 35 78% IST 99 73 74% Darwin Nurseries 90 59 66% Cambridge South Affective Disorder 203 127 63% Pathway Cambridge North Affective Disorder 177 108 61% Pathway Peterborough Affective Disorder 248 151 61% Pathway

20190830 RT1 Evidence appendix Page 184

Team name Clinical Clinical Clinical supervision supervision supervision sessions delivered rate (%) required CAMEO 279 159 57% Personality Disorders Community 153 86 56% Service Adult ADHD 15 7 47% CUH - LPS - OPMH - IP 258 109 42% Huntingdon Affective Disorder 159 65 41% Pathway Fenland Affective Disorder Pathway 100 31 31% Core service total 1,965 1,131 58% Trust Total 31,881 15,835 50%

The trust has not supplied any clinical supervision data for medical staff in this core service. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Multidisciplinary and interagency team work Staff held regular and effective multidisciplinary meetings several times each week. Staff held specific meetings to discuss new patients, to monitor the waiting list and to respond to concerns about a patient’s health deteriorating. We attended three multidisciplinary team meetings and saw that they were detailed and effective. Staff shared information about patients at effective handover meetings within the team. Staff arranged cover for their caseloads. A duty member of staff could support patients who needed immediate care. The community teams had effective working relationships, including good handovers, with other relevant teams within the organisation for example ward teams. Staff could share and access case notes for each patient and keep in touch with them if they were admitted to a ward. If a patient’s health was deteriorating, staff worked alongside the crisis team to support them. At the Fenlands site staff were utilising a trust psychology service from outside of their team to support patients who were low risk but had been waiting a long time for treatment from their psychology team. The teams had effective working relationships with teams outside the organisation. Each community team had integrated social workers who were provided through the local authority. Staff worked alongside the patients’ general practitioner to provide care and ensured that information about care was shared. Adherence to the Mental Health Act and the Mental Health Act Code of Practice

20190830 RT1 Evidence appendix Page 185

As of 31 December 2018, 69% of the workforce in this service had received training in the Mental Health Act Level 1 and 85% in the Mental Health Act Level 2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed every three years. The training compliance reported during this inspection was lower than the 96% reported at the last inspection. Staff that we spoke with had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles. Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice through the trust Mental Health Act Office. Staff knew who their Mental Health Act administrators were and how to contact them. The provider had relevant policies and procedures that reflected the most recent guidance. These policies were available on the trust intranet. Staff had easy access to local Mental Health Act policies and procedures and to the Code of Practice. Patients had easy access to information about independent mental health advocacy. Staff explained to patients their rights under their Mental Health Act Community treatment orders in a way that they could understand, repeated it as required and recorded that they had done it. Managers kept records and accessed information on their dashboards about when patients were due to have their rights explained and highlighted this at team meetings. Staff kept these records up to date on the electronic system and any records which were overdue were raised with the staff member in supervision. Staff stored copies of patients’ community treatment orders correctly and the Mental Health Act team completed regular audits to ensure that staff had completed records correctly. Good practice in applying the Mental Capacity Act As of 31 December 2018, 100% of the workforce in this service had received training in the Mental Capacity Act Level 1 and 89% in the Mental Capacity Act Level 2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed three years. The training compliance reported during this inspection was higher than the 98% reported at the last inspection. Staff we spoke with had a good understanding of the Mental Capacity Act. The provider had a policy on the Mental Capacity Act which was available on the trust intranet. Staff knew where to get advice from within the provider regarding the Mental Capacity Act and could consult other team members who were knowledgeable. Staff took all practical steps to enable patients to make their own decisions. At Peterborough community team the manager gave an example of how they had supported a patient to consider whether they should be placed in a residential care setting and had supplied leaflets and arranged a visit to the location to help them decide. For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately on the electronic care records system. They did this on a decision-specific basis regarding significant decisions.

20190830 RT1 Evidence appendix Page 186

When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history. Staff gave examples of when they had considered these factors when supporting a patient to make decisions about care and could arrange pastoral care or access to a charity or external organisation who could aid them to understand a patient’s needs. The service had arrangements to monitor adherence to the Mental Capacity Act. Staff regularly audited the application of the Mental Capacity Act and any issues were fed back to the team manager.

Is the service caring?

Kindness, privacy, dignity, respect, compassion and support Staff that we spoke with were caring, discreet, respectful and responsive to patients. We observed staff providing practical and emotional support and advice to patients and working flexibly to meet their needs. Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care and treatment. Staff signposted patients to other services and made referrals to specialist services depending on patient need. One patient talked about being referred to family solicitors to get legal help and advice. Patients spoke highly of staff and said that they treated them well and always behaved appropriately towards them. Staff had detailed and holistic knowledge of their patients, including their personal circumstances, religious, cultural and social needs. Staff spoke confidently about raising concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients. They described managers as approachable and supportive. Staff followed policy to maintain patient confidentiality though a variety of methods. These included safe storage of records, seeking permission for CQC to speak to patients, maintaining up to date confidentiality and consent forms and discussing patients in confidential spaces. Involvement in care Involvement of patients Staff involved patients in their care, treatment and risk assessments and gave them access to their care plans. Staff actively sought feedback from patients on the quality of care provided. Staff made sure patients understood their care and treatment and found ways to communicate with patients who had communication difficulties. There was a hearing loop and information in braille at Wisbech. Staff involved patients in decisions about the service, when appropriate. The Recovery College encouraged former patients to participate in interview panels for the recruitment of new staff. Patients could give feedback on the service and their treatment and staff supported them to do this.

20190830 RT1 Evidence appendix Page 187

Staff supported patients to make advanced decisions on their care. Staff made sure patients could access advocacy services. Patients that we spoke with were aware of the advocacy service provider and posters were displayed at all sites.

Involvement of families and carers Staff supported, informed and involved families and carers including circumstances where carers had reached crisis point. Appointments were generally offered to carers at the base, but staff facilitated home visits when required. Staff conducted an annual review for families and if the patient had been discharged, staff referred the carer to Making Space who continued to support them. Staff actively helped families to give feedback on the service. Staff gave carers information on how to access a carers assessment. There was a dedicated carers worker who also completed carers assessments and made referrals to external agencies for carers support, access to work or education. Is the service responsive?

Access and waiting times The trust has identified the below services in the table as measured on ‘referral to initial assessment’ and ‘referral to treatment’. The trust has not set this service any referral to treatment targets. There is no data with which to compare this year’s data.

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) Fulbourn Adult The adult MH - Hospital ADHD ADHD service Community- is a specialist based mental clinical service health offering services for diagnostic adults of assessment working age. n/a 33 n/a 122 and short-term treatment for adults with possible ADHD and previously

20190830 RT1 Evidence appendix Page 188

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) diagnosed ADHD. It is a consultation and titration service only serving Cambridgeshir e and Peterborough Fulbourn Cambridg Community MH - Hospital e North rehabilitation Community- Affective service for based mental Disorder people with health Pathway serious and services for n/a 16 n/a 43 enduring adults of mental health working age. problems. 18- 65 yrs. Fulbourn Cambridg As above. MH - Hospital e North Community- Assessm based mental ent health n/a 14 n/a 33.5 Pathway services for adults of working age. Fulbourn Cambridg As above. MH - Hospital e North Community- Psychosis based mental Pathway health n/a 7 n/a 24.5 services for adults of working age. Fulbourn Cambridg As above MH - Hospital e South Community- Affective based mental Disorder health n/a 20 n/a 52 Pathway services for adults of working age.

20190830 RT1 Evidence appendix Page 189

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) Fulbourn Cambridg As above. MH - Hospital e South Community- Assessm based mental ent health n/a 12 n/a 29 Pathway services for adults of working age. Fulbourn Cambridg As above MH - Hospital e South Community- Others based mental Pathway health n/a 7 n/a 49 services for adults of working age. Fulbourn Cambridg As above MH - Hospital e South Community- Psychosis based mental Pathway health n/a 14 n/a 29 services for adults of working age. Fulbourn CAMEO First episode MH - Hospital psychosis Community- service. 18-35 based mental yrs. (links with health n/a 7 n/a 16 CAMH for 14- services for 17 yrs.). adults of working age. MH CUH - Psychological MH - Services LPS - medicine Community- (CPFT) at OPMH - services based mental Addenbro IP provide health okes assessment services for and treatment adults of n/a 1 n/a 1 for acute working age. hospital patients with co-morbid physical and

20190830 RT1 Evidence appendix Page 190

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) mental health needs (weekdays 09.00 – 17.00 unless otherwise specified). This includes, Addenbrooke’s Hospital – Emergency Department MH CUH – As above MH - Services LPS – Community- (CPFT) at Adults - based mental Addenbro ETDMHS health n/a 1 n/a 1 okes services for adults of working age. MH CUH - As above MH - Services LPS - Community- (CPFT) at Adults - based mental Addenbro OP health n/a 1 n/a 1 okes services for adults of working age. MH CUH – As above MH - Services LPS – Community- (CPFT) at Adults - based mental Addenbro PSYONC health n/a 1 n/a 1 okes services for adults of working age. MH CUH - As above MH - Services LPS - Community- (CPFT) at Adults based mental n/a 1 n/a 1 Addenbro - IP health okes services for

20190830 RT1 Evidence appendix Page 191

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) adults of working age. MH CUH - As above MH - Services LPS - Community- (CPFT) at CSMHS - based mental Addenbro OP health n/a 1 n/a 1 okes services for adults of working age. MH CUH - As above MH - Services LPS - Community- (CPFT) at Therapy based mental Addenbro health n/a 1 n/a 1 okes services for adults of working age. MH CUH - As above MH - Services LPS D + Community- (CPFT) at A - OP based mental Addenbro health n/a 1 n/a 1 okes services for adults of working age. Fulbourn Dual The team MH - Hospital Diagnosis assertively Community- Street outreach to based mental Team rough sleepers health (DDST) in services for Cambridgeshir adults of e who have working age. severe mental n/a 3 n/a 16 illness and substance misuse issues, and offer treatment and interventions based on the Recovery Star

20190830 RT1 Evidence appendix Page 192

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) model. They also signpost, support and offer guidance and advic North Fenland Community MH - Cambridg Affective rehabilitation Community- eshire Disorder service for based mental Hospital Pathway people with health serious and services for n/a 25 n/a 49 enduring adults of mental health working age. problems. 18- 65 yrs. North Fenland As above MH - Cambridg Assessm Community- eshire ent based mental Hospital Pathway health n/a 24.5 n/a 41 services for adults of working age. North Fenland As above MH - Cambridg Personalit Community- eshire y based mental Hospital Disorder health n/a 35 n/a 35 Pathway services for adults of working age. North Fenland As above MH - Cambridg Psychosis Community- eshire Pathway based mental Hospital health n/a 23 n/a 45 services for adults of working age. MH Huntingd Psychological MH - Services on - LPS - medicine Community- n/a 0 n/a 0 (CPFT) at services based mental provide health

20190830 RT1 Evidence appendix Page 193

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) Addenbro Adults - assessment services for okes IP and treatment adults of for acute working age. hospital patients with co-morbid physical and mental health needs (weekdays 09.00 – 17.00 unless otherwise specified). This includes, Addenbrooke’s Hospital – Emergency Department MH Huntingd As above MH - Services on - LPS - Community- (CPFT) at OPMH - based mental Addenbro IP health n/a 0 n/a 1 okes services for adults of working age. Fulbourn Huntingd Community MH - Hospital on rehabilitation Community- Affective service for based mental Disorder people with health Pathway serious and services for n/a 17 n/a 34 enduring adults of mental health working age. problems. 18- 65 yrs. Fulbourn Huntingd As above MH - Hospital on Community- Assessm based mental n/a 28 n/a 55 health services for

20190830 RT1 Evidence appendix Page 194

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) ent adults of Pathway working age. Fulbourn Huntingd As above MH - Hospital on Other Community- Pathway based mental health n/a 44.5 n/a 60 services for adults of working age. Fulbourn Huntingd As above. MH - Hospital on Community- Personalit based mental y health n/a 7 n/a 35 Disorder services for Pathway adults of working age. Fulbourn Huntingd As above MH - Hospital on Community- Psychosis based mental Pathway health n/a 14 n/a 28 services for adults of working age. Fulbourn IST Intensive MH - Hospital Support Team Community- will identify based mental those people health with LD who services for have been adults of placed out of working age. n/a 2 n/a 10 area and provide intensive support and treatment. 18 onwards.

20190830 RT1 Evidence appendix Page 195

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) Fulbourn Liaison Work with MH - Hospital and people who Community- Diversion enter the based mental criminal justice health system, providi services for ng assessment adults of n/a 13 n/a 23.5 for vulnerabiliti working age. es such as mental ill- health or learning disabilities. MH Peterboro Psychological MH - Services ugh - LPS medicine Community- (CPFT) at - Adults - services based mental Addenbro IP provide health okes assessment services for and treatment adults of for acute working age. hospital patients with co-morbid physical and mental health n/a 0 n/a 0 needs (weekdays 09.00 – 17.00 unless otherwise specified). This includes, Addenbrooke’s Hospital – Emergency Department MH Peterboro As above MH - Services ugh - LPS Community- (CPFT) at - OPMH - based mental n/a 1 n/a 1 Addenbro IP health okes services for

20190830 RT1 Evidence appendix Page 196

Name of Name of Please state CCQ core Days from Days from hospital Team service type. service referral to initial referral to site or assessment treatment location Target Actual Target Actual (median) (media n) adults of working age. Fulbourn Peterboro Community MH - Hospital ugh rehabilitation Community- Affective service for based mental Disorder people with health Pathway serious and services for n/a 19 n/a 43 enduring adults of mental health working age. problems. 18- 65 yrs. Fulbourn Peterboro As above MH - Hospital ugh Community- Assessm based mental ent health n/a 8 n/a 43 Pathway services for adults of working age. Fulbourn Peterboro As above MH - Hospital ugh Community- Personalit based mental y health n/a 33.5 n/a 75.5 Disorder services for Pathway adults of working age. Fulbourn Peterboro As above MH - Hospital ugh Community- Psychosis based mental Pathway health n/a 23 n/a 50 services for adults of working age. Ida Darwin Personalit Community MH - Hospital y based day Community- Disorders programme – based mental n/a 21.5 n/a 68 Communi Open Access health ty Service Support. 18-65 services for yrs.

20190830 RT1 Evidence appendix Page 197

This core service had a clear criterion for which patients would be offered a service. Staff saw urgent referrals quickly, including the same day if required and non-urgent referrals within the trust target time. The service provided a daily duty cover system and all new referrals were reviewed by the duty cover worker. Staff tried to engage with people who found it difficult, or were reluctant, to seek support from mental health services. This including offering home visits and requesting support from family and friends if appropriate. Staff tried to contact people who did not attend appointments and offer support. They did this by follow up phone calls, text messages and by letter. Patients had some flexibility and choice in the appointment times available. Staff took into account patients’ circumstances, work and caring responsibilities and carers availability. Staff worked hard to avoid cancelling appointments and when they had to they gave patients clear explanations and offered new appointments as soon as possible. Appointments ran on time and staff informed patients when they did not. The service used systems to help them monitor waiting lists/support patients. Staff supported patients when they were referred, transferred between services, or needed physical health care. The service followed national standards for transfer.

Facilities that promote comfort, dignity and privacy The design, layout, and furnishings of treatment rooms supported patients’ treatment, privacy and dignity. The service had a full range of rooms and equipment to support treatment and care. Interview rooms in the service had sound proofing to protect privacy and confidentiality. Waiting areas at all sites were clean and welcoming and cold water was available.

Patients’ engagement with the wider community Staff supported patients to access services in the community such as third sector support, benefits agencies, social services and access to education. We saw examples of staff providing references

20190830 RT1 Evidence appendix Page 198

for access to education. Staff also signposted patients to sports and gym facilities in the local community.

Meeting the needs of all people who use the service The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support. The service could support and make adjustments for people with disabilities, communication needs or other specific needs. There was disabled access and disabled toilets at all of the sites. Staff made sure patients could access information on treatment, local services, their rights and how to complain. The service provided information in a variety of accessible formats, so the patients could understand more easily. The service had information leaflets available in languages spoken by the patients and local community. Managers made sure staff and patients could access interpreters or signers easily when needed.

Listening to and learning from concerns and complaints This service received 17 complaints between 1 January to 31 December 2018. Two of these were upheld, five were partially upheld and six were not upheld. None were referred to the Ombudsman. Patients knew how to complain or raise concerns. We saw complaints posters and leaflets in the reception areas at the sites that we visited. Staff understood the policy on complaints and knew how to handle them. The service received a low number of complaints reflecting that patients were satisfied with their care. Managers investigated complaints and identified themes. Themes were discussed at team meetings. Staff protected patients who raised concerns or complaints from discrimination and harassment. Patients received feedback from managers after the investigation into their complaint. Staff received feedback from managers after investigations. This was discussed at team meetings

and supervision and managers sent emails highlighting lessons learned.

Ward name

Total Total

Other

Under Under

Referred to to Referred

Withdrawn

Not upheld Not

Complaints

Fully upheld Fully

Ombudsman

Investigation Partially upheld Partially Cambridge North Adult 6 0 1 3 0 2 0 0 Locality Team

20190830 RT1 Evidence appendix Page 199

Ward name

Total Total

Other

Under Under

Referred to to Referred

Withdrawn

Not upheld Not

Complaints

Fully upheld Fully

Ombudsman

Investigation Partially upheld Partially Cambridge South Adult 5 2 0 1 0 2 0 0 Locality Team CAMEO South 3 0 2 0 0 1 0 0 Liaison and Diversion (LADs) 1 0 0 1 0 0 0 0 Adult ADHD 1 0 0 1 0 0 0 0 Huntingdon Adult Locality 1 0 1 0 0 0 0 0 Team Total 17 2 5 6 0 5 0 0

This service received 437 compliments during the last 12 months from 1 January to 31 December 2018 which accounted for 7% of all compliments received by the trust as a whole. The high number of compliments reflected that patients were satisfied with their care.

Is the service well-led?

Leadership Leaders had the integrity, skills and abilities to run the service. They understood the issues, priorities and challenges the service faced and managed them effectively. Senior managers were visible in the service and supported staff to develop their skills and take on more senior roles. A support time and recovery worker had been supported to shape and develop the carers lead role and told us how they now attend the carers board meetings along with senior managers. Vision and strategy The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. They were aligned to local plans and the wider health economy. Managers made sure staff understood and knew how to apply them. Posters displaying the vision and values were displayed throughout the services. Staff that we spoke with were familiar with the vision and values and used them in their everyday work. They spoke with passion and commitment and were able to explain how they worked to deliver high quality care within the budgets and resources available to them. Culture

20190830 RT1 Evidence appendix Page 200

Staff felt respected, supported and valued. They told us that they felt positive and proud to work for the service and they spoke highly of managers. Staff that we spoke with told us that managers were approachable and that they were able to raise issues without fear of retribution. Staff knew where to easily locate the whistle blowing policy and knew how to use it. Teams were cohesive and worked well together. Staff described how the services continually worked to improve services for the benefit of patients and carers. We reviewed appraisal records and saw that they included conversations about career development and support to achieve this. They felt the service promoted equality and diversity and provided opportunities for career development. Adaptations such as stand desks were provided for staff and managers were supportive and understanding about the personal circumstances of staff teams. Sickness and absence rates were low. Governance

Leaders ensured there were structures, processes and systems of accountability for the performance of the service. The systems and procedures in place ensured that premises were clean, safe and well-staffed. Patients were assessed and treated well and referrals and waiting times were managed well. Incidents and complaints were reported and investigated, and lessons learned were effectively cascaded to the teams. Staff had implemented recommendations from reviews of deaths, incidents and complaints within the service. Staff participated in clinical audit and acted appropriately on the findings. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. Senior management meetings, governance meetings and team meetings had a standard agenda and were regularly and clearly recorded. Management of risk, issues and performance Managers had access to the risk register and staff could escalate concerns via the manager. The service had contingency plans for emergencies such as flu outbreaks and adverse weather conditions. Leaders managed performance using systems to identify, understand, monitor, and reduce or eliminate risks. They ensured risks were dealt with at the appropriate level. Clinical staff contributed to decision-making on service changes to help avoid financial pressures compromising the quality of care. Information management The service collected reliable information and analysed it to understand performance and to enable staff to make decisions and improvements. The information systems were integrated and secure. Staff had access to the equipment and information technology to carry out their roles effectively. They also had access to all of the patient information needed to provide an effective service.

20190830 RT1 Evidence appendix Page 201

Patient records were stored electronically, and any paper documentation was stored in a locked filing cabinet in a locked office. Managers had access to information to support them with their management role. This included service performance, staffing and patient care. Engagement Staff, patients and carers had access to up to date information about the work of the service through the intranet, bulletins, newsletters and leaflets. Patients and carers were actively encouraged to complete feedback questionnaires about the service they had received. We reviewed these and found that feedback was consistently very positive. Managers and staff had access to the feedback and used it to review and improve services. Patients and carers were involved in decision making about changes to the service. They had the opportunity to meet with senior leaders at board level to give feedback. The service engaged well with patients, staff, equality groups, the public and local organisations to plan and manage appropriate services. It collaborated with partner organisations to help improve services for patients. Learning, continuous improvement and innovation All staff were committed to continually improving services and had a good understanding of quality improvement methods. Leaders encouraged innovation and participation in research. NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. There were no services that had been awarded an accreditation.

20190830 RT1 Evidence appendix Page 202

Mental health crisis services and health-based places of safety

Facts and data about this service

Location site name Team name Number of clinics Patient group (male, female, mixed) Section 136 Not provided Not provided Fulbourn Hospital Suite CRHT Not provided Not provided Fulbourn Hospital Cambridge CRHT Not provided Not provided Cavell Centre Peterborough CRHTOP North Not provided Not provided Cavell Centre OP CRHTOP South Not provided Not provided Fulbourn Hospital OP First Response Not provided Not provided Fulbourn Hospital Service

Is the service safe?

Safe and clean environment All areas we visited were clean, well-furnished and well maintained. However, a cupboard containing blood pressure equipment in the Cambridge Crisis and Home Treatment team was dirty.

Staff working in the Crisis Resolution and Home Treatment teams in Peterborough and Cambridge did not usually see patients at their base but visited them at home. When staff saw patients at the hospital, they used a family room close to the hospital reception. Staff did not see patients alone and carried alarms with them to call for assistance if required.

Cambridgeshire & Peterborough NHS Foundation Trust had one Section 136 suite, in order to assess patients detained by the police under Section 136 of the Mental Health Act 1983. The room was large enough to accommodate six people, and to assess and restrain if necessary. It was well lit, had an observation window and contained good quality, heavyweight furniture. There were no ligature points within the suite and the provider had installed closed-circuit television inside and outside which was in good working order. Staff had access to a locked medical cabinet and to medical equipment, including emergency resuscitation equipment. There were good sleeping and washing facilities and two outward opening exits in each room. Hot drinks and snacks were available 24 hours a day. However, there was no clock and no intercom facility or external phone

20190830 RT1 Evidence appendix Page 203

line. Patients could make themselves heard to staff without an intercom if they spoke loudly; staff we spoke with told us that they generally allowed patients to take their mobile phone into the suite.

Staff had access to the clinic on Mulberry One ward. This was clean, well maintained and well organised.

Safe staffing Nursing staff The trust calculated the number of nursing staff required to provide safe staffing. On the Section 136 suite, the use of agency and bank staff was high because establishment levels had not yet been determined. However, the trust deployed workers who knew the unit well. Managers were reviewing establishment figures and intended to recruit a number of healthcare assistants to permanent positions which would reduce the need for agency staff at the unit. Registered staff were on duty 24 hours a day. The manager could call on additional staff when required and there were always enough staff to carry out observations and physical interventions when required. Managers told us that the suite had an establishment of six nurses with no vacancies. Staff sickness was extremely low at 0.5%.

The Crisis Resolution and Home Treatment (CRHT) teams in Cambridge and Peterborough operated 24 hours a day. The trust had calculated staffing levels based on team caseloads. These took account of shift systems and ensured that teams were always safely staffed, including the capacity to undertake joint visits to patients. There were six members of staff on duty per shift, of which four or five were registered. Both CRHT teams had some vacancies but managers we spoke with told us they did not use agency staff. Team members and bank staff picked up additional shifts. Staff we spoke with told us they were rarely short staffed. When necessary, managers made up numbers of registered staff on shift. Managers reviewed the team caseloads regularly. Workers did not hold individual caseloads but undertook work with patients according to need.

Patients had rapid access to a psychiatrist when needed. The service had consultant and specialty doctors within all the teams.

Staff received mandatory training. Data from the trust stated that overall staff had undertaken 90% of mandatory training, which was in line with the trust target. Four courses achieved less than 75% compliance. These were, safeguarding children level three (69%), smoking cessation (67%), moving and handling level one (58%) and medical emergency response course (57%).

This core service has reported a vacancy rate for all staff of 18% as of 31 December 2018. This was lower than the rate of 20% reported at the last inspection (between 1 October 2017 and 31 September 2018). This core service reported an overall vacancy rate of 35% for registered nurses at 31 December 2018. The vacancy rate for registered nurses was higher than the -1% reported at the last inspection. This core service reported an overall vacancy rate of 36% for healthcare assistants. The vacancy rate for healthcare assistants was higher than the 9% reported at the last inspection.

20190830 RT1 Evidence appendix Page 204

Registered nurses Health care Overall staff figures

assistants

Location Ward/Team

(%) (%) (%)

Vacancies Vacancies Vacancies

Vacancy rate rate Vacancy rate Vacancy rate Vacancy

Establishment Establishment Establishment Fulbourn Section 136 4.9 9.9 49% 1.3 2.3 57% 6.2 12.2 51% Hospital Suite Fulbourn CRHT 7.1 20.3 35% 2.0 5.0 40% 7.5 26.5 28% Hospital Cambridge Cavell CRHTOP 2.2 11.8 19% 0.2 4.6 4% 1.6 16.6 10% Centre North OP Fulbourn CRHTOP -1.0 11.4 -9% 0.0 4.7 0% 0 18.5 0% Hospital South OP First Fulbourn Response 19.3 39.6 49% 0 0 n/a 6.4 48.6 13% Hospital Service Core service 32.5 93.0 35% 3.5 16.6 36% 17.7 118.4 15% total Trust total 164.0 1,294 13% 126.6 1027.7 13% 334.2 3,984.1 8% NB: All figures displayed are whole-time equivalents

Between 1 January and 31 December 2018, 14,117 hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses.

In the same period, agency staff covered 864 of available hours for qualified nurses and 1,946 of available hours were unable to be filled by either bank or agency staff. The main reasons for bank and agency usage for the teams were vacancies.

Wards Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Section 136 Suite 3,170 n/a 780 n/a 149 n/a First Response Service 4,668 n/a 84 n/a 1,325 n/a CRHT Cambridge 5,453 n/a 0 n/a 426 n/a CRHTOP South OP 188 n/a 0 n/a 23 n/a CRHTOP North OP 639 n/a 0 n/a 24 n/a Core service total 14,117 n/a 864 n/a 1,946 n/a Trust Total 114,849 n/a 42,162 n/a 31,421 n/a

Between 1 January and 31 December 2018, 5,071 hours were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.

20190830 RT1 Evidence appendix Page 205

In the same period, agency staff covered 58 of available hours for nursing assistants and 403 of available hours were unable to be filled by either bank or agency staff.

The main reasons for bank and agency usage for the teams were vacancies.

The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. Wards Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % Section 136 Suite 3,205 n/a 58 n/a 251 n/a First Response Service 186 n/a 0 n/a 60 n/a CRHT Cambridge 913 n/a 0 n/a 47 n/a CRHTOP South OP 231 n/a 0 n/a 23 n/a CRHTOP North OP 538 n/a 0 n/a 23 n/a Core service total 5,071 n/a 58 n/a 403 n/a Trust Total 202,495 n/a 31,831 n/a 25,759 n/a

This core service had 6.6 (7%) staff leavers between 1 January and 31 December. This was lower than the 8% reported at the last inspection (from 1 October 2016 to 30 September 2017).

Location Ward/Team Substantive staff Substantive staff Average % staff (at latest month) Leavers over the last leavers over the last 12 12 months months Fulbourn Section 136 6 0 0% Hospital Suite Fulbourn CRHT 19 0 0% Hospital Cambridge Fulbourn CRHTOP 17.4 0 0% Hospital South OP Cavell CRHTOP 14.4 0 0% Centre North OP Fulbourn First Response 39.4 6.6 15% Hospital Service Core service total 96.2 6.6 7% Trust Total 3,575.2 446.3 13%

The sickness rate for this core service was 4.4% between 1 January and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 8%. This was higher than the sickness rate of 5% reported at the last inspection in September 2017.

Location Ward/Team Total % staff sickness Ave % permanent staff sickness (at latest month) (over the past year) CRHTOP North Cavell Centre 5.6% 2.3% OP

20190830 RT1 Evidence appendix Page 206

Location Ward/Team Total % staff sickness Ave % permanent staff sickness (at latest month) (over the past year)

Fulbourn Hospital CRHT Cambridge 7.0% 6.8%

First Response Fulbourn Hospital 11.9% 5.0% Service CRHTOP South Fulbourn Hospital 4.8% 3.1% OP

Fulbourn Hospital Section 136 Suite 0.5% 0.1%

Core service total 8.0% 4.4% Trust Total 5.3% 4.5%

Medical staff Between 1 January and 31 December 2018, of the (1,624) total working hours available, 0% were filled by bank staff to cover sickness, absence or vacancy for medical locums. In the same period, agency staff covered 85% of available hours and 0% of available hours were unable to be filled by either bank or agency staff.

Ward/Team Total hours Bank Usage Agency Usage NOT filled by available bank or agency Hrs % Hrs % Hrs % First Response 1,624 0 0% 1,324 85% 0 0% Service Core service total 1,624 0 0% 1,324 85% 0 0% Trust Total 176,009 3,585 2% 18,562 11% 0 0%

Mandatory training

The compliance for mandatory and statutory training courses at 31 December 2018 was 90%. Of the training courses listed 10 failed to achieve the trust target and, of those, four failed to score above 75%.

The trust set a target of 90% for completion of mandatory and statutory training. The trust has stated that the training data is reported as a final figure at year end (where applicable).

The training compliance reported for this core service during this inspection was lower than the 91% reported in the previous year.

Key:

Not met trust Met trust target Higher No change Lower Below CQC 75% target ✓  ➔  

20190830 RT1 Evidence appendix Page 207

Training Module Number of Number of YTD Trust Complianc eligible staff Complianc Target Met e change staff trained e (%) when compared to previous year PREVENT (Level 1) 67 67 100% ✓ n/a Infection Control (Level 1) 1 1 100% ✓ n/a Safeguarding Children (Level 1 1 100% ✓  1) Physical Interventions 5 5 100% ✓  Conflict Resolution 97 96 99% ✓  Safeguarding Adults 97 96 99% ✓  Dementia 96 95 99% ✓  Working Safely 97 95 98% ✓  Treating People with Respect 97 95 98% ✓  PREVENT (Level 2) 30 29 97% ✓ n/a Safeguarding Children (Level 58 56 97% ✓  3) Mental Health Act Level 1 43 41 95% ✓  Mental Capacity Act Level 1 43 41 95% ✓  Infection Control (Level 2) 96 91 95% ✓ n/a Good Governance 97 91 94% ✓  Fire Safety 97 89 92% ✓  Deprivation of Liberty 36 33 92% ✓ n/a Safeguards Basic Life Support (BLS) 75 66 88%   Mental Capacity Act Level 2 52 45 87%   Mental Health Act Level 2 52 45 87%  n/a Carer Awareness 97 82 85%  n/a Safeguarding Children (Level 38 32 84%  n/a 2) Manual Handling (Level 2) 6 5 83%  n/a Safeguarding Children Level 3; 58 40 69%   Mandatory for Role (3hrs) Smoking Cessation 97 65 67%  n/a Manual Handling (Level 1) 57 33 58%  n/a Medical Emergency Response 21 12 57%  n/a Course (MERC) Core Service Total 1,611 1,447 90% ✓ 

Assessing and managing risk to patients and staff Staff in the crisis teams and First response team triaged patients and completed initial risk assessments and updated them regularly in the light of incidents or new information. First Response staff used detailed triage assessments to risk assess patients and the DICES assessment tool to assess patient risk when referring to other services. We looked at 16 patient records. Staff recorded risk assessments in all records. Fifteen were detailed, thorough and

20190830 RT1 Evidence appendix Page 208

included historical and current risks. However, staff did not routinely complete crisis plans or advance decisions. Staff in crisis and First Response teams were aware of sudden deterioration in patients’ health and were able to respond quickly and refer to other services, including inpatient services when needed. Staff visited patients at home unless they assessed the risks as too high or the patient wished to be seen at the hospital. Staff did not usually visit patients alone. Where they did, they followed clear lone worker policies, including using a buddy system, arrangements to call in after visits and codewords to trigger a response and summon assistance when necessary. Section 136 suite staff did not undertake standalone risk assessments for patients. The police completed an initial risk formulation, in conjunction with First Response staff based at the police station. Staff recorded risks in progress notes but did not complete formal risk assessments while patients were under section 136 care. We reviewed two patient records. These did not contain risk assessments although some risk information was included in progress notes. The manager of the unit confirmed this was current practice. This does not meet the 2011 guidance from the Royal College of Psychiatrists in relation to standards for the use of section 136 of the Mental Health Act.

Section 136 suite staff maintained close observations of patients and responded to changing patient presentation and need quickly.

Safeguarding

A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made 54 safeguarding referrals between 1 January and 31 December 2018, of which 23 concerned adults and 31 children.

The data reported during this inspection was not reported at core service level at the last inspection, so cannot be compared.

Number of referrals Core service Adults Children Total referrals MH - Mental health crisis services and health-based 23 31 54 places of safety

The number of adult safeguarding referrals in a month ranged from none to five. The number of child safeguarding referrals ranged from none to 12

Staff received trained in safeguarding. Data from the trust stated that 99% of staff had received training in safeguarding adults, 84% had received level two safeguarding children training and

20190830 RT1 Evidence appendix Page 209

97% had received training in level three safeguarding children. Trust data also stated that only 69% of staff had received training in level three safeguarding children.

Staff knew how to identify adults at risk of significant harm. They were aware of how to make safeguarding referrals and seek advice from the trust or the local authority. Staff worked closely with other agencies, such as the local authority and police.

The trust submitted details of eight serious case reviews commenced or published in the last 12 months (1 January to 31 December 2018). However, none of these relate to this service.

Staff access to essential information

Staff generally had good access to essential information through the trust’s electronic system. Staff in psychiatric liaison teams had access to systems used by the trust and by the acute trust where they were located. Three staff in the First Response team sat in a police station and had access to police systems as well as trust systems.

However, the First Response team stated that sometimes the system would stop working in the middle of the night and staff would have to use paper records and upload them onto the system the following day. Staff in the section 136 suite did not have access to the acute trust’s systems and were not able to search for patients not known to the trust. Staff we spoke with reported that the system was very slow.

Medicines management

Staff in the two crisis teams and the First Response team managed medicines well. We looked at 15 prescription charts which were all in order. Teams kept small amounts of medication on site. Doctors and non-medical prescribers prescribed medicines in an appropriate manner. The teams also used patient group directives to issue small amounts of medications to patients without a prescription to prevent a hospital admission. The trust had a list of staff authorised to issue medication in this way. Staff did not use this routinely or in place of prescribing. Staff had completed authorisation for this procedure correctly.

In the Cambridge crisis team, staff did not keep medical equipment appropriately. Staff stored equipment in two filing cabinets rather than a dedicated cupboard. Staff had not calibrated the blood glucose monitor since November 2018. There was a cupboard containing blood-pressure equipment which was dirty and chaotic. There were two full and closed sharps bins; both were undated, and one was located in a tool box used to store blood taking equipment.

Track record on safety

Between 1 January and 31 December 2018 there were 22 serious incidents reported by this service. Of the total number of incidents reported, the most common type of incident was ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’ with 21. Fifteen of the unexpected deaths were instances of ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’.

20190830 RT1 Evidence appendix Page 210

We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with 22 reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service reported no never events during this reporting period. The number of serious incidents reported during this inspection was higher than the 13 reported at the last inspection. Nine of the serious incidents were reported by the First Response Service, including six unexpected deaths. Eight of these serious incidents was where the contact was solely with FRS and one where there was FRS involvement.

Type of incident reported (SIRI) Apparent/actual/suspec Slips/trips/fal Tota ted self-inflicted harm ls meeting SI l meeting SI criteria criteria First Response Service 9 0 9 Crisis Resolution and Home Treatment Team 4 1 5 South Liaison Psychiatry Service - Addenbrookes 4 0 4 Liaison Psychiatry Service - Huntingdon 1 0 1 Liaison Psychiatry Service - Peterborough 1 0 1 Peterborough and Huntingdon Crisis Team 1 0 1 Crisis Resolution and Home Treatment Team 1 0 1 North Total 21 1 22

Reporting incidents and learning from when things go wrong

The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there has been no prevention of future death reports sent to Cambridgeshire and Peterborough NHS Foundation Trust. All staff had access to the electronic incident reporting system and reported incidents appropriately. Managers shared lessons learned through trust briefings and monthly governance meetings where they discussed incidents, including serious incidents and safeguarding concerns and identified areas for learning and improvement. We saw evidence that staff made changes after feedback which was beneficial to the service. However, we also saw that the same issues arose several months in succession meaning that learning was not always effective.

The First Response team recorded calls and could assist staff to learn from difficult situations and adverse incidents.

Staff received debriefs after serious incidents. Managers told us they gave an urgent debrief on the day and a further debrief a week later with an external facilitator. Staff confirmed they received debriefs after incidents.

20190830 RT1 Evidence appendix Page 211

Is the service effective?

Assessment of needs and planning of care Staff assessed the mental health needs of all patients. Assessments were thorough, detailed and well evidenced, containing historical and current information. Eighteen of the 19 patient records we looked at contained clear and comprehensive assessment information. Staff addressed physical health issues as part of the assessment. The teams did not routinely complete physical health assessments but liaised closely with GPs. They were aware of, and recorded, patients’ physical health problems. Staff working for the mental health crisis teams worked with patients and families and carers to develop individual care plans and updated them when needed. Care plans completed by the Cambridge crisis team involved parents and carers, reflected patients’ assessed needs, were personalised, holistic and recovery-oriented. Care plans completed by the Peterborough crisis team were brief, were not holistic or personalised and showed little evidence of patient or carer involvement. Staff supplemented care plans by additional, hand written plans which formed part of the welcome pack. Staff updated care plans regularly as necessary. Patients across all the teams received copies of their care plans. Best practice in treatment and care This service participated in one clinical audit as part of their clinical audit programme 1 January – 31 December 2018.

Audit Audit Core Audit Date Key actions following the audit name scope service type completed First Adult & MH - Clinical 29/06/2018 "78% of staff recorded relevant Response Specialist Mental information in the 'physical health' Triage Audit First health section of the triage form Response crisis 78% of face to face assessments Service services occurred within the timeframe of and the referral category health- based 97% of staff recorded service places of users' housing information in the safety 'social circumstances' section of the triage form 97% of staff recorded the service users' current mental health symptoms in the 'presentation' section of the triage form 91% of staff recorded the events leading up to contact in the 'presentation' section of the triage form

20190830 RT1 Evidence appendix Page 212

Audit Audit Core Audit Date Key actions following the audit name scope service type completed 72% of staff recorded the summary of referral / 'crisis at a glance' in the 'presentation' section of the triage form

The First Response team made initial assessments and made plans with patients for short-term interventions, such as referral to the Sanctuary, a project run jointly with MIND, where patients could go, by appointment, for support and advice. The team also referred onto to other agencies, such as the Citizens Advice Bureau, and to the crisis teams if further interventions were required. Staff working for the mental health crisis teams provided a range of care and treatment interventions that were informed by best practice guidance and suitable for the patient group. They ensured that patients had good access to physical healthcare. Staff supported patients with employment, benefits and housing issues where appropriate. Crisis teams took responsibility for antipsychotic medication whilst patients were under their care. Teams offered a wide range of psychological therapies, including brief interventions such as cognitive behavioural therapy, dialectical behaviour therapy, life skills, mindfulness and anxiety management groups. The team also offered more specialist interventions, including eye movement desensitisation and reprocessing (EMDR), systematic family therapy and children’s accelerated trauma technique (CATT). The First Response team had a data analyst to monitor trends and look for ways to improve the service. Staff working for the mental health crisis teams used the health of the nation outcome scale to assess and record severity and outcomes. Staff working for the crisis teams and in the health- based places of safety participated in clinical audit, benchmarking and quality improvement initiatives.

Skilled staff to deliver care The trust’s target rate for appraisal compliance is 95%. At the end of last year (April 2017 and 31 March 2018), the overall appraisal rate for non-medical staff within this service was 59%. This year so far, the overall appraisal rates was 83% (as at 31 January 2019). The wards with the lowest appraisal rate at 31 January 2019 were First Response Service with an appraisal rate of 76% and Section 136 Suite with an appraisal rate of 83%. The rate of appraisal compliance for non-medical staff reported during this inspection was higher than the 59% reported at the last inspection. Ward name Total number Total number % appraisals % appraisals of permanent of permanent (as at 31 (previous year non-medical non-medical January 2019) 1 April 2017-31 staff requiring staff who have March 2018) an appraisal had an appraisal CRHT Cambridge 18 16 89% 75% CRHTOP South OP 18 16 89% 88%

20190830 RT1 Evidence appendix Page 213

Ward name Total number Total number % appraisals % appraisals of permanent of permanent (as at 31 (previous year non-medical non-medical January 2019) 1 April 2017-31 staff requiring staff who have March 2018) an appraisal had an appraisal CRHTOP North OP 17 15 88% 71% Section 136 Suite 6 5 83% 43% First Response Service 41 31 76% 25% Core service total 100 83 83% 59% Trust wide 3,503 2,807 80% 76%

The trust has not supplied any details of appraisals for medical staff relating to this core service. The trust has not supplied a target for non-medical staff. Between 1 April 2018 and 31 December 2018, the average rate across all eight teams in this service was 41%. The rate of clinical supervision reported during this inspection was lower than the 80% reported at the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide.

Team name Clinical supervision Clinical supervision Clinical supervision sessions required delivered rate (%) CRHT Cambridge 180 91 51% Section 136 Suite 46 22 48% First Response 394 175 44% Service CRHTOP South OP 161 59 37% CRHTOP North OP 131 29 22% Core service total 912 376 41% Trust Total 31,881 15,835 50%

The trust has not supplied any clinical supervision data for medical staff in this core service. The mental health crisis teams included or had access to the full range of specialists required to meet the needs of patients under their care. Managers made sure that staff had a range of skills needed to provide high quality care. Managers supported staff with appraisals, supervision and opportunities to update and further develop their skills. Ten staff across all teams in the service said they received regular supervision and felt well supported by their managers. Managers told us they supervised staff regularly but

20190830 RT1 Evidence appendix Page 214

said staff did not always input this onto the electronic system. We saw examples where supervision had taken place but not recorded. However, staff in the Peterborough crisis team said nurses found it difficult to access specialist training. Staff had access to regular team meetings and governance meetings to discuss patients and work issues. Managers provided an induction programme for new staff. This consisted of a week’s induction with the trust and two weeks in the team, completing mandatory training and shadowing staff, including staff in other teams, such as the First Response team. The team included, or had access to, the full range of specialists required to meet the needs of patients. These included nurses, doctors, psychologists, support workers, occupational therapists and peer support workers. Staff were qualified, experienced and had the right skills and knowledge to meet the needs of patients. These included specialist skills such as systematic family therapy and eye movement desensitisation and reprocessing. Multi-disciplinary and interagency team work Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. The teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation. Staff held regular multi-disciplinary meetings. Crisis teams held handover meetings three times a day. We attended one handover meeting. This gave a clear and detailed account of patients on the caseload with clear planning for discharges and next steps. The service also had weekly virtual ward round meetings and daily conference calls. The teams within the crisis service worked very closely with each other. This included the First Response team, the integrated mental health team based in the police station, crisis teams and psychiatric liaison teams. Teams also worked effectively with other services, such as GPs, community mental health teams, police, acute trusts and the local authority. Adherence to the Mental Health Act and the Mental Health Act Code of Practice As of 31 December 2018, 95% of the workforce in this service had received training in the Mental Health Act Level 1 and 87% in the Mental Health Act Level 2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed three years. The training compliance reported during this inspection was higher than the 93% reported at the last inspection for Mental Health Act Level 1 and the 58% reported for the Mental Health Act Level 2. Staff understood their roles and responsibilities under the Mental Health Act 1983, and the Mental Health Act Code of Practice. Staff had good access to advice and support about the Mental Health Act and knew how to contact Mental Health Act administrators. The trust had policies and procedures which reflected the most recent guidance and staff knew where to find these. Staff were knowledgeable about the Mental Health Act. Approved Mental Health Professionals worked within the crisis and First Response teams and provided updates and support to other members of the team. The crisis teams were not working with any patients under a community treatment order but were knowledgeable about this.

20190830 RT1 Evidence appendix Page 215

Staff working on the Section 136 suite had a good understanding of section 136 processes and informed patients of their rights under the Act as part of the admissions process.

Good practice in applying the Mental Capacity Act As of 31 December 2018, 95% of the workforce in this service had received training in the Mental Capacity Act L1 and 87% in the Mental Capacity Act L2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed every three years. The training compliance reported during this inspection was higher than the 94% reported at the last inspection for MCA L1 and higher than the 68% for MCA L2. Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and conducted mental capacity assessments where appropriate. Staff across all the teams in this service had a good understanding of the Mental Capacity Act. Psychiatric liaison teams assessed capacity on admission to the service. The First Response team assessed patients’ capacity to consent as part of the triage assessment. Crisis teams assessed patients’ capacity where appropriate. Consultant psychiatrists in the teams provided advice to staff in the acute trust when needed. However, three of the five patient records we looked at in the Cambridge crisis team did not record capacity well. The teams placed emphasis on assisting patients to make decisions for themselves wherever possible. Staff carried out formal mental capacity assessments rarely and in relation to specific decisions. The provider had a policy on the Mental Capacity Act and provided advice to staff when needed. Staff knew how to access the policy and who to go to for advice.

Is the service caring?

Kindness, privacy, dignity, respect, compassion and support Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Staff attitudes and behaviours when interacting with patients showed that they were discreet, respectful and responsive, providing patients with help, emotional support and advice at the time they needed it. We observed staff in the First Response team, both on telephone calls and during face to face assessments. They took time with patients and explained the support they could offer clearly and helped to ease patients’ anxieties at a very distressing time. Patients said that staff were kind and supported them well to understand and manage their symptoms and explore different treatment options. Staff in crisis teams worked flexibly with patients to provide them with the support they needed. The First Response team did not have exclusion criteria and supported a number of frequent callers, including people no longer in crisis. The team spoke regularly to some patients to keep them well rather than signpost them elsewhere. Staff arranged services for patients, for example at the Sanctuary or with psychologists to look at specific therapies and helped them to access services when needed. Staff at the First Response

20190830 RT1 Evidence appendix Page 216

team helped patients access foodbanks, on occasions, and teams assisted with employment and benefit issues where appropriate. Staff understood the needs of patients and treated them as individuals when looking at interventions. Staff kept information about patients confidential and said they could raise issues about discriminatory attitudes towards patients without fear of the consequences. Involvement in care Involvement of patients Staff in the mental health crisis teams involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. They ensured that patients had easy access to advocates when needed. Staff gave leaflets to patients about the service, including a safety plan and information for carers. Staff in the First Response team involved patients appropriately in the assessment process, planning their care and exploring a range of treatment options. Staff in the Peterborough crisis team produced brief care plans which had little evidence of patient involvement. However, staff supplemented these with handwritten plans which formed part of the welcome pack. Staff told patients what their care plans were and gave them copies of assessments and planned interventions. Staff communication with patients was good and patients understood their treatment plan. However, one patient calling in the First Response Team stated that the call handler did not speak good English, and another said they found the person they spoke to difficult to understand. Staff encouraged and enabled patients to give feedback about the service through patient experience surveys. In the First Response survey from 1 May 2018 to 1 May 2019, 78% of 74 patients said they were happy with the service. Involvement of families and carers Staff informed and involved families and carers appropriately. Staff included information for carers in the welcome pack they gave to new patients entering the service. However, a patient who called the First Response Team said that the staff member would not allow his wife to speak to them and another said staff did not ask them about their caring responsibilities, which would have been helpful.

Is the service responsive?

20190830 RT1 Evidence appendix Page 217

Name Days from Days from of referral to initial referral to CCQ hospita Name of Please state assessment treatment core l site or Team service type. Actual service Actual locatio Target Target (media (median) n n) Provides: • urgent assessment to those at risk of being admitted to MH - hospital, • home Mental treatment as health alternative to crisis Fulbour CRHT admission in the services n n/a 1 n/a 2 Cambridge form of intensive and Hospital support and care health- during a crisis, based and • early places of discharge as a safety step down from inpatient treatment. 18-65 Provides: • urgent assessment to those at risk of being admitted to MH - hospital, • home Mental treatment as health alternative to crisis CRHT Cavell admission in the services Peterboroug n/a 1 n/a 2 Centre form of intensive and h support and care health- during a crisis, based and • early places of discharge as a safety step down from inpatient treatment. 18-65

Intermediate care MH - for older people Mental with acute mental health Cavell CRHTOP health needs crisis n/a 1 n/a 4 Centre North OP provided by staff services who outreach to and patient’s homes health- 65+ yrs based

20190830 RT1 Evidence appendix Page 218

Name Days from Days from of referral to initial referral to CCQ hospita Name of Please state assessment treatment core l site or Team service type. Actual service Actual locatio Target Target (media (median) n n) places of safety MH - Intermediate care Mental for older people health with acute mental crisis Fulbour CRHTOP health needs services n n/a 2 n/a 4 South OP provided by staff and Hospital who outreach to health- patient’s homes based 65+ yrs places of safety

The mental health crisis service was available 24-hours a day. It was generally easy to access – including through a dedicated crisis telephone line. The referral criteria for the mental health crisis teams did not exclude patients who would have benefitted from care. Staff assessed and treated patients promptly. Staff followed up patients who missed appointments. Some patients ringing the First Response team said they found dialling 111 and selecting option two could be unreliable and staff took too long to answer. The service could be difficult to access for some patients living near Wisbech, due to the way 111 calls operated in that area. Some mobile calls could also be affected. Patients were not able to select option two; instead they had to wait for the initial message to finish and speak to the nurse to request the First Response team. The team had also set up other systems to ensure that patients in need were able to get through. In April 2019, 20% of calls (577 calls in total), received via 111, option two, were abandoned by callers. Of the remaining calls, staff answered 72% within one minute and the average length of time taken to answer the call was two minutes and 50 seconds. However, staff did not answer one patient’s call for 56 minutes. The team carried out 100% of telephone assessments within four hours and 67% of face to face assessments, where required, within four hours. The team saw 82% of patients assessed as requiring an assessment within 24 hours and 91% of patients assessed as requiring an assessment within 72 hours. Staff reported breaches under the electronic incident reporting system and identified reasons, such as patients requesting visits at certain times or not being at home when visited. It was not clear how the service addressed breaches with no identified reason. The First Response team did not have an exclusion criteria and supported patients and carers who rang. The team signposted to other services where appropriate, such as the crisis teams, the Sanctuary or Citizens Advice Bureau. Crisis teams responded quickly to new referrals and did not have a waiting list. Skilled staff saw urgent referrals quickly, including during the night when needed.

20190830 RT1 Evidence appendix Page 219

Staff offered flexible appointments to patients and rearranged visits when patients were unavailable or did not attend appointments. Staff supported patients to attend appointments where appropriate, including to inpatient wards when patients required an admission. The health-based places of safety were available when needed and there was an effective local arrangement for young people who were detained under Section 136 of the Mental Health Act. The trust did not consistently assess patients referred to the Section 136 suite within the three hours recommended by the Royal College of Psychiatrists. Between 1 April 2018 and 31 March 2019, the trust provided data for 370 cases of which 42% received an assessment within three hours. The trust had one Section 136 suite in Cambridge. When this was in use, patients were taken to a place of safety in the emergency department of the local acute trust. Between 1 April 2018 and 31 March 2019, this occurred on 55 occasions, 19 times at Peterborough City Hospital, 33 times at Addenbrookes and three times at Hinchingbrooke. The facilities promote comfort, dignity and privacy Staff in crisis teams did not meet patients at their office. Where they needed to interview patients outside of a home environment, they used family rooms in the hospital, close to their base. These room had appropriate furniture and adequate soundproofing. In the Section 136 suite, patients had access to quiet areas, could meet with relatives and could make phone calls from their mobile phones. They had access to outside space and staff enabled them to receive snacks and hot drinks 24 hours a day. Patients’ engagement with the wider community Staff worked with patients to access work and education where appropriate. They supported patients to maintain relationships with their families and those important to them. Meeting the needs of all people who use the service The services met the needs of all patients who used the service. Staff ensured patients with mobility issues could access the service. However, staff had not received specific training in relation to supporting people with a protected characteristic or in relation to lesbian, gay, bisexual or transgender issues. The First Response team did not provide access to deaf patients in relation to the support line. Staff ensured information about treatment options was available for all patients using the service. Staff had easy access to interpreters when needed and could get leaflets printed in languages other than English. Complaints This service received 22 complaints between 1 January to 31 December 2018. Three of these were upheld, four were partially upheld and nine were not upheld. None were referred to the Ombudsman.

20190830 RT1 Evidence appendix Page 220

Ward name

Total Total

Other

Under Under

Referred to to Referred

Withdrawn

Not upheld Not

Complaints

Fully upheld Fully

Ombudsman

Investigation Partially upheld Partially

First Response Service 7 2 2 2 0 0 1 0 CRHT Peterborough and Hunts (Adult) 4 1 0 1 0 1 1 0 Addenbrookes Hospital - Liaison Psychiatry Team 4 0 0 3 0 1 0 0 CRHT Cambridge 3 0 1 1 0 0 1 0

Peterborough City Hospital - Liaison Psychiatry 2 0 1 0 0 1 0 0 Hinchingbrooke Hospital - Liaison Psychiatry 1 0 0 1 0 0 0 0 Fulbourn Hospital - 136 Suite 1 0 0 1 0 0 0 0 Total 22 3 4 9 0 3 3 0

The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. Patients knew how to make complaints about the service and received feedback from managers. Staff knew how to handle and escalate complaints appropriately. Managers gave feedback to staff about complaints and acted on the findings. This service received 227 compliments during the last 12 months from 1 January to 31 December which accounted for 3.4% of all compliments received by the trust as a whole.

Is the service well-led?

Leadership

Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff. Leaders had a clear understanding of the services they managed and explained the role and function of the teams and how to provide high quality care for patients. Leaders knew how the team fitted into the overall organisation, for example in reducing pressure on other parts of the service, such as acute wards. They were visible, and staff could contact them when needed. Senior managers visited the crisis teams and staff in the First Response team said the modern matron visited on occasions. Vision and strategy

Staff knew and understood the provider’s vision and values and how they could apply them in the work of their team. The organisation used PRIDE (professionalism, respect, innovation, dignity and empowerment) to describe the values of the team. Staff knew and understood this and

20190830 RT1 Evidence appendix Page 221

applied it to the work of the team. They were able to describe how they delivered high quality care and how they fitted into the organisation as a whole.

Staff had opportunities to contribute to discussions about corporate and team values and future plans for the service through team meetings. Culture

Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution. Staff we spoke with felt positive about working for the trust and felt well supported by their colleagues and managers and proud to be part of the team. This feeling was particularly strong in the First Response team. Staff felt able to raise any concerns without fear of the consequences.

Managers dealt with performance issues through supervision. Staff told us managers discussed professional and career development in supervision and appraisals. Sickness rates over the previous 12 months were 4.4%, slightly lower than the trust average of 4.5%. Staff had access to support when needed through the trust’s occupational health service.

The provider recognised and celebrated success of individuals and teams through their PRIDE awards.

Governance

Our findings from the other key questions demonstrated that governance processes operated effectively at team level and that performance and risk were managed well. The provider had systems in place to ensure teams had enough staff and could draw on staff from within the team and wider organisation to cover for vacancies and sickness. Managers ensured staff were well trained, appraised and supervised. Staff treated patients well and promptly. They reported incidents and managers looked at these and acted on them. Managers ensured staff learned from incidents and complaints through supervision, team meetings and clinical governance meetings. Crisis team managers ensured that they had access to beds when needed and made them available if staff assessed a patient no longer required an admission. Managers consistently applied this. The First Response team analysed data from the incoming calls received by the team and looked at issues and trends, such as the numbers of abandoned calls and frequent callers. Psychologists audited triage assessments and gave feedback to managers and the staff team. In crisis teams, clinical staff undertook audits and fed back to teams through team and clinical governance meetings. Staff worked extremely effectively with other teams within the service, other services in the trust and with acute trusts and outside agencies such as the local authority and the police.

Management of risk, issues and performance

Staff had access to the risk register and could escalate concerns through the team manager. Staff recorded risks in relation to patient care, staffing, information technology and lone working arrangements. 20190830 RT1 Evidence appendix Page 222

Teams had contingency plans in the event of an emergency.

Information management

Teams had access to the information they needed to provide safe and effective care and used that information to good effect. The service used systems to collect data that were not over- burdensome for frontline staff and assisted them to treat patients effectively. Staff had access to information technology systems needed to complete their work. However, staff we spoke with told us that computer systems were often slow, sometimes froze, did not always pull through previous assessments and did not pull through previous physical health assessments. First Response staff told us that if the computer system went wrong during the night, they had to complete paper records and upload them when staff had repaired the system the following morning. Managers had systems to assist them to monitor the performance of the team and to ensure staff had completed risk assessments and care plans for patients. They were able to monitor staff mandatory training, appraisal and supervision. However, staff did not always input their supervision figures onto the system, meaning that managers did not have an up to date record of compliance. Staff made notifications to external bodies, such as the local authority and Care Quality Commission appropriately. Engagement

There were effective, multi-agency arrangements to agree and monitor the governance of the mental health crisis service and the health-based places of safety. Managers of the service worked actively with partner agencies (including the police, ambulance service, primary care and local acute medical services) to ensure that people in the area received help when they experienced a mental health crisis, regardless of the setting. Staff, patients and carers had access to up-to-date information about the service. Patients and carers could give feedback while in the service and staff formally asked for patient feedback at the end of their treatment. The First Response team’s patient experience survey showed that 76% of respondents would recommend the service to friends and family. Learning, continuous improvement and innovation

NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.

The table below shows which services within this service have been awarded an accreditation together with the relevant dates of accreditation.

Accreditation scheme Core service Service accredited Comments Psychiatric Liaison MH - Community-based Huntingdon LPS Cambridge LPS Accreditation Network mental health services for commenced process (reviewed Dec 2018) (PLAN) adults of working age. January 2019

20190830 RT1 Evidence appendix Page 223

Accreditation scheme Core service Service accredited Comments Psychiatric Liaison MH - Community-based Peterborough LPS Accreditation Network mental health services for Accredited Dec 2018. (PLAN) adults of working age.

Staff collected analysed data about outcomes and performance and fed back information to teams. Staff did not engage actively in local and national quality improvement activities.

20190830 RT1 Evidence appendix Page 224

Specialist community mental health services for children and young people

Facts and data about this service

Location site name Team name Number of clinics Patient group (male, female, mixed) Fulbourn Hospital CAMHS LD Central Not provided Not provided

Fulbourn Hospital CAMHS LD Not provided Not provided Peterborough Fulbourn Hospital CAMHS Central Choice Not provided Not provided

Fulbourn Hospital CAMHS Central Neuro Not provided Not provided ADHD Fulbourn Hospital CAMHS Central Neuro Not provided Not provided ASD Fulbourn Hospital CAMHS Central On Call Not provided Not provided

Fulbourn Hospital CAMHS Central Not provided Not provided Partnership Ida Darwin Hospital CAMHS IST (Intensive Not provided Not provided Support Team) Fulbourn Hospital CAMHS LD South Not provided Not provided

Fulbourn Hospital CAMHS North Choice Not provided Not provided

Fulbourn Hospital CAMHS North On Call Not provided Not provided

Fulbourn Hospital CAMHS North Not provided Not provided Partnership Fulbourn Hospital CAMHS Single Point of Not provided Not provided Access Fulbourn Hospital CAMHS South Choice Not provided Not provided

Fulbourn Hospital CAMHS South Neuro Not provided Not provided ADHD Fulbourn Hospital CAMHS South Neuro Not provided Not provided ASD Fulbourn Hospital CAMHS South On Call Not provided Not provided

Fulbourn Hospital CAMHS South Not provided Not provided Partnership Fulbourn Hospital CASUS Not provided Not provided

Ida Darwin LD & SS CCPNR Not provided Not provided

Fulbourn Hospital FCAMHS Not provided Not provided

20190830 RT1 Evidence appendix Page 225

Is the service safe?

Safe and clean environment We visited community child and adolescent services at Winchester Place, Peterborough; Newtown Centre, Huntingdon; and Brookside Family Clinic, Cambridge. Staff completed and regularly updated thorough risk assessments of all areas and removed or reduced any risks they identified. All interview rooms had alarms and staff available to respond. All clinic rooms had the necessary equipment for patients to have thorough physical examinations. All areas were clean, well maintained, well-furnished and fit for purpose. Staff made sure cleaning records were up to date and the premises were clean (delete as applicable). Staff always followed infection control guidelines, including handwashing. Staff made sure equipment was well maintained, clean and in working order. The services we visited did not hold or dispense medication but where clinic rooms were used to monitor physical observations of service users the equipment was clean and calibrated on a regular basis. Safe staffing Nursing staff This core service has reported a vacancy rate for all staff of 15% as of 31 December 2018. This was higher than the rate of 14% reported at the last inspection (between 1 October 2016 and 31 September 2017). This core service reported an overall vacancy rate of 41% for registered nurses at 31 December 2018. The vacancy rate for registered nurses was higher than the 20% reported at the last inspection. This core service reported an overall vacancy rate of -16% for nursing assistants. The vacancy rate for nursing assistants was higher than the -14% reported at the last inspection.

Registered nurses Health care assistants Overall staff figures

Location Ward/Team

Vacancies Establishment (%) rate Vacancy Vacancies Establishment (%) rate Vacancy Vacancies Establishment (%) rate Vacancy Fulbourn FCAMHS n/a n/a n/a n/a n/a n/a 6.7 9.3 72% Hospital

20190830 RT1 Evidence appendix Page 226

Ida CAMHS IST 5.2 10 52% 0.9 6.8 13% 6.1 17.8 34% Darwin (Intensive Hospital Support Team) Fulbourn CAMHS LD 2.6 11 24% 1.2 5.8 21% 4.8 23.4 21% Hospital Central Fulbourn CAMHS LD 1.0 4.4 23% -0.8 2.8 -29% 1.5 11.2 13% Hospital Peterborough Fulbourn CAMHS 6.2 10.2 61% -2 0 n/a 1.2 14.2 8% Hospital North Choice Fulbourn CAMHS Hospital Single Point -1.7 0 n/a n/a n/a n/a 0.1 4.8 2% of Access Fulbourn CAMHS 0 1 0% -0.6 0 n/a -0.7 13.9 -5% Hospital Central Choice Ida CCPNR Darwin LD 0 0 n/a -0.2 0.4 -50% -0.3 4 -8% & SS Fulbourn CAMHS 5.5 9.1 60% -1 0 -n/a -1.7 12.3 - Hospital South Choice 14% Core service total 18.8 45.7 41% -2.5 15.8 -16% 17.7 110.9 16% Trust total 164.0 1,294.0 13% 130.6 1,031.7 13% 334.2 3,984.1 8% NB: All figures displayed are whole-time equivalents Between 1 January and 31 December 2018, 357 available hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. In the same period, agency staff covered 179 of available hours for qualified nurses and 319 of available hours were unable to be filled by either bank or agency staff. The main reasons for bank and agency usage for the wards/teams were vacancies. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. Wards Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % CAMHS South Choice 6 n/a 172 n/a 221 n/a

CAMHS LD Central 228 n/a 8 n/a 0 n/a CAMHS Central Choice 124 n/a 0 n/a 8 n/a CAMHS North Choice 0 n/a 0 n/a 90 n/a Core service total 357 n/a 179 n/a 319 n/a Trust Total 114,849 n/a 42,162 n/a 31,421 n/a

Between 1 January and 31 December 2018, there were no hours of bank and agency used for nursing assistants.

20190830 RT1 Evidence appendix Page 227

Wards Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % CAMHS South Choice 0 n/a 0 n/a 0 n/a CAMHS LD Central 0 n/a 0 n/a 0 n/a CAMHS Central Choice 0 n/a 0 n/a 0 n/a CAMHS North Choice 0 n/a 0 n/a 0 n/a Core service total 0 n/a 0 n/a 0 n/a Trust Total 202,495 n/a 31,831 n/a 25,769 n/a

At the time of inspection staffing levels had increased and therefore use of bank and agency staff reduced. Managers limited their use of bank and agency staff and requested staff familiar with the service. Managers made sure all bank and agency staff had a full induction and understood the service before starting their shift. This core service had 8.7 (10%) staff leavers between 1 January and 31 December 2018. This was lower than the 12% reported at the last inspection (from 1 October 2016 to 31 September 2017).

Location Ward/Team Substantive staff Substantive staff Average % staff (at latest month) Leavers over the leavers over the last 12 months last 12 months Fulbourn Hospital CAMHS LD 9.7 2 23% Peterborough Fulbourn Hospital CAMHS North 12.2 2.8 19% Choice Fulbourn Hospital CAMHS South 13.8 1.4 9% Choice Fulbourn Hospital CAMHS LD 19.6 1 7% Central Fulbourn Hospital CAMHS Central 14.6 1 7% Choice Ida Darwin CAMHS IST 11.8 0.5 5% Hospital (Intensive Support Team) Fulbourn Hospital CAMHS Single 4.7 0 0% Point of Access Fulbourn Hospital FCAMHS 2.6 0 0% Ida Darwin LD & CCPNR 4.3 0 0% SS Core service total 93.3 8.7 10% Trust Total 3,575.2 446.3 13%

The sickness rate for this core service was 5.6% between 1 January and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 3.2%. This was the same as the sickness rate of 2.9% reported at the last inspection in September 2017.

20190830 RT1 Evidence appendix Page 228

Location Ward/Team Total % staff sickness Ave % permanent staff sickness (at latest month) (over the past year) Fulbourn Hospital CAMHS LD 5.1% 7.6% Central Fulbourn Hospital CAMHS Central 0.0% 7.4% Choice Fulbourn Hospital CAMHS LD 1.3% 7.1% Peterborough Fulbourn Hospital CAMHS North 6.0% 5.8% Choice Ida Darwin CAMHS IST 4.0% 5.0% Hospital (Intensive Support Team) Fulbourn Hospital CAMHS South 0.9% 4.0% Choice Fulbourn Hospital CAMHS Single 9.4% 1.5% Point of Access Ida Darwin LD & CCPNR 2.0% 0.6% SS Fulbourn Hospital FCAMHS 0.0% 0.0%

Core service total 3.2% 5.6% Trust Total 5.3% 4.5%

The number and grade of staff matched the provider’s staffing plan. However, the numbers of staff required to meet the demand on the service had not been reviewed by the commissioners and so we could not be assured that current staffing levels were sufficient to meet the increasing number of referrals into the service. Medical staff There was no data provided for medical locum usage within this core service between 1 January 2017 and 31 December 2018. Teams had a psychiatrist available via telephone at weekends for staff on duty cover to contact when required. Mandatory training The compliance for mandatory and statutory training courses at 31 December 2018 was 88%. Of the training courses listed 11 failed to achieve the trust target and of those, seven failed to score above 75%. The trust set a target of 90% for completion of mandatory and statutory training. The trust has stated that the training data is reported as a final figure at year end (where applicable). The training compliance reported for this core service during this inspection was lower than the 90% reported in the previous year. Key:

20190830 RT1 Evidence appendix Page 229

Not met trust Met trust target Higher No change Lower Below CQC 75% target ✓  ➔  

Complian Numb ce change Numb Trust er of YTD when er of Targ Training Module staff Complian compared eligibl et traine ce (%) to e staff Met d previous year Working Safely 99 99 100% ✓  Conflict Resolution 99 99 100% ✓  Manual Handling (Level 2) 2 2 100% ✓ n/a Safeguarding Children (Level 1) 4 4 100% ✓  Safeguarding Adults 99 98 99% ✓  Treating People with Respect 99 98 99% ✓  PREVENT (Level 1) 51 50 98% ✓ n/a PREVENT (Level 2) 48 47 98% ✓ n/a Good Governance 99 95 96% ✓  Fire Safety 99 92 93% ✓  Basic Life Support (BLS) 94 87 93% ✓  Infection Control (Level 2) 95 85 89%  n/a Safeguarding Children (Level 3) 95 82 86%  n/a Carer Awareness 99 75 76%  n/a Infection Control (Level 1) 4 3 75%  n/a Smoking Cessation 99 69 70%  n/a Safeguarding Children Level 3; Mandatory for n/a 95 66 69%  Role (3hrs) Manual Handling (Level 1) 58 30 52%  n/a Dementia 2 0 0%  n/a Mental Capacity Act Level 2 1 0 0%  n/a Medical Emergency Response Course (MERC) 1 0 0%  n/a Mental Health Act Level 2 1 0 0%  n/a Total 1,343 1,181 88%  

Managers monitored mandatory training and alerted staff when they needed to update their training. The training courses that fell below 75% were as a result of training sessions being cancelled. Assessing and managing risk to patients and staff Assessment of patient risk Staff undertook a thorough assessment of risk at the first contact with service users following referral including a safety plan to address identified risks. Staff used a recognised risk assessment tool. We reviewed 23 care records and found that 22 of these had a thorough risk assessment completed and that these were updated at each appointment.

20190830 RT1 Evidence appendix Page 230

Staff could recognise when to develop and use crisis plans and advanced decisions according to patient need. Management of patient risk Referrals were screened, and risk level assessed so that referrals could be classified as urgent, moderate or routine. Staff continually monitored patients on waiting lists for changes in their level of risk and responded when risk increased. Where referrals were classed as routine, staff contacted service users, carers and referrers by letter whilst they were waiting for assessment and asked them to contact the service if anything had changed that increased the service users risk level or in the event of crisis. Staff responded promptly to any sudden deterioration in a patient’s health. Safeguarding A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made 116 safeguarding referrals between 1 January and 31 December 2018, none of which concerned adults and 116 children. The data reported during this inspection was not reported at core service level at the last inspection Number of referrals Core service Adults Children Total referrals MH - Specialist community mental health services for 0 116 116 children and young people

The number of child safeguarding referrals ranged from none in July 2018 to 16 in August 2018. Staff received training on how to recognise and report abuse, appropriate for their role.

Staff kept up to date with their safeguarding training. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. Staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The trust has submitted details of no serious case reviews commenced or published in the last 12 months (1 January and 31 December 2018) that relate to this service.

20190830 RT1 Evidence appendix Page 231

Staff access to essential information Patient notes were comprehensive, and all staff could access them easily on the trust electronic system. When patients transferred to a new team, there were no delays in staff accessing their records. Medicines management None of the locations we visited stored or dispensed medications. Track record on safety Between 1 January and 31 December 2018 there was one serious incident reported by this service. This was ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’ and was also categorised as an unexpected death. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with one reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service reported no never events during this reporting period. The number of serious incidents reported during this inspection was the same as the one reported at the last inspection. Type of incident reported (SIRI) Apparent/actual/suspected self- Total inflicted harm meeting SI criteria’ CAMH South Core Team 1 1 Total 1 1

All staff knew what incidents to report and how to report them. Staff reported all incidents that they should report. Staff reported serious incidents clearly and in line with trust policy. Reporting incidents and learning from when things go wrong The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths. In the last two years, there has been no ‘prevention of future death’ reports sent to Cambridgeshire and Peterborough NHS Foundation Trust. Is the service effective?

Assessment of needs and planning of care Staff completed a comprehensive core assessment for each service user that included mental and physical health, education, social and family situations. We reviewed 23 patient records and found that 100% had a comprehensive assessment completed.

20190830 RT1 Evidence appendix Page 232

We found that 100% of 23 records reviewed had a personalised, recovery focussed care plan drawn up with the service user following their assessment. The central core team conducted a monthly audit of care plans using the Quality Improvement Evaluation Tool. Best practice in treatment and care Staff provided a range of care and treatment interventions suitable for the patient group. The interventions were those recommended by and were delivered in line with National Institute for Health and Care Excellence guidance. These included cognitive behavioural therapy, family therapy, cognitive analytical therapy and trauma therapy.

Staff made sure patients had support for their physical health needs, either from their GP or community services. Staff supported patients to live healthier lives by supporting them to take part in programmes or giving advice. Staff used recognised rating scales to assess and record the severity of patient conditions and care and treatment outcomes. Staff used technology to support patients. Staff took part in clinical audits, benchmarking and quality improvement initiatives. Managers used results from audits to make improvements.

This service participated in three clinical audits as part of their clinical audit programme 1 January – 31 December 2018.

Audit name Audit scope Core Audit type Date Key actions service complete following the d audit Various • Ensure exam couches have received planned maintenance at Trust wide: CAMEO and Adult & Specialist Adult Locality Mental Health (Union House), directorate, Clozapine Clinic Children, Young (Tennyson People and Road), CASUS Medical Devices – 31/10/201 Families Clinical (The Bridge) and Community 8 Directorate, CFS/ME (Botolph Older People's Bridge) and Adult • Ensure Community availability of Directorate - All sphygmanometer community teams at District Nurses (Nye Bevan House) and Neighbourhood Team (NCH)

20190830 RT1 Evidence appendix Page 233

Audit name Audit scope Core Audit type Date Key actions service complete following the d audit • Ensure sphygmanometer s have received planned maintenance at CRHTT (Beechcroft), CAMH Core (Newtown Centre), Neighbourhood Team and Tissue Viability (Histon Police Station), CASUS (The Bridge), Neighbourhood Team (Wyboston Lakes), Neighbourhood Team (City Care Centre), First Response (Redshank House), Continence and Tissue Viability (City Clinic), Neighbourhood Team (Botolph Bridge) Hospital at Home (Commerce Road), Memory Clinic (Newtown Centre), Neighbourhood Team (Redshank House), Memory Clinic (The Pines) • Ensure availability of thermometer at District Nurses (Nye Bevan House) and Neighbourhood Team (Wyboston

20190830 RT1 Evidence appendix Page 234

Audit name Audit scope Core Audit type Date Key actions service complete following the d audit Lakes) • Ensure scales have received planned maintenance at District Nurses (Nye Bevan House), Physiotherapy (Signet Court), IST (Ida Darwin), Clozapine Clinic (Tennyson Road), Neighbourhood Team (Wyboston Lakes), Minor Injuries (PoW), CRHTT (Cavell Centre), CFS/ME (Botolph Bridge), Heart Failure (Commerce Road), Clare Lodge Health Team (Clare Lodge), Podiatry (Oaktree Centre) • Ensure availability of Glucometer at Clozapine Clinic (Tennyson Road) and Neighbourhood Team (Kings Hall) • Ensure availability of Suction Unit at Neighbourhood Team (Sawston Medical Practice) • Ensure dopplers have received planned maintenance at Tissue Viability (Histon Police

20190830 RT1 Evidence appendix Page 235

Audit name Audit scope Core Audit type Date Key actions service complete following the d audit Station), Neighbourhood Team (NCH), Neighbourhood Teams (Botolph Bridge) and Tissue Viability (City Clinic) • Ensure bladder scanners have received planned maintenance at Neighbourhood Team (Histon Police Station) and Neighbourhood Team (NCH) • Ensure availability of coagulation analysers at Neighbourhood Team (Signet Court) and Neighbourhood Team (Kings Hall) • Ensure coagulation analysers receive planned maintenance at Neighbourhood Team (Wyboston Lakes) • Send quarterly reminder email to all community teams to call in any missed items Various Each unit has an individual report with specific Medicines All Community Clinical/medicine 01/03/201 action plans. The Management - Services s 8 pharmacy team Community will review the audit standards ahead of next

20190830 RT1 Evidence appendix Page 236

Audit name Audit scope Core Audit type Date Key actions service complete following the d audit round. Pharmacy team will contact non engaging teams with advice on how to audit locally. The pharmacy team will expedite the injectable medicines template and disseminate to all areas where needed. The pharmacy team will contact all teams with FP10 prescription pads to ensure the correct addresses are recorded. CQUIN 5 Adult & Specialist MH - Clinical 01/06/201 • As a joint Transitions out of Mental Health Specialist 8 transitions group, Children and directorate, communit to consider how Young People’s Children, Young y mental we could Mental Health People and health encourage Services Families services increased (CYPMHS) Directorate for engagement of 2017/18 children young people and with the young participation of people the pre and post transition survey • To recruit to the outstanding peer support worker posts • To embed the new transition booklet into practice with the child and adolescent mental health teams • To further embed the transition

20190830 RT1 Evidence appendix Page 237

Audit name Audit scope Core Audit type Date Key actions service complete following the d audit pathway, including the ratification of the transition SOP between child and adult mental health services within CPFT CQUIN 5 Adult & Specialist MH - Clinical 26/10/201 Establish a Transitions out of Mental Health Specialist 8 reliable and Children and directorate, communit accurate ongoing Young People’s Children, Young y mental list of all young Mental Health People and health persons Services Families services transitioned (CYPMHS) Directorate for between CYPF & 2017/19 children ASMH. Ensure and CYPF/ASMH young transitions people oversight group meets on a regular basis. A service Adult & Specialist MH - Service 04/07/201 • To continue evaluation: Mental Health Specialist evaluation 8 dialogue with Cambridge Centre Directorate - communit commissioners to for Paediatric Cambridge Centre y mental try and secure Neuropsychologic for Paediatric health long-term funding al Rehabilitation Neuropsychologic services commitments. al Rehabilitation for children • To continue and current young discussions people. around standardising clinical records.

• To conduct an analysis of the validity and suitability of the current assessment and outcome measures, and to begin using the Family Needs Questionnaire Paediatric Version.

20190830 RT1 Evidence appendix Page 238

Audit name Audit scope Core Audit type Date Key actions service complete following the d audit • To continue the service evaluation cycle

Skilled staff to deliver care The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 January and 31 December 2017), the overall appraisal rate for non-medical staff within this service was 88%. This year so far, the overall appraisal rates was 86% (as at 31 December 2018). The wards with the lowest appraisal rate at 31 December 2018 were CAMHS South Choice with an appraisal rate of 69%, ward with an appraisal rate of 71% and CAMHS IST (Intensive Support Team) at 75% The rate of appraisal compliance for non-medical staff reported during this inspection was lower than the 97% reported at the last inspection. Ward name Total Total % % number of number of appraisals appraisals permanent permanent (as at 31 (previous non- non- December year 01 medical medical 2018) January – staff staff who 31 requiring have had December an an 2017 appraisal appraisal CCPNR 7 7 100% 100% FCAMHS 2 2 100% 100% CAMHS North Choice 9 9 100% 91% CAMHS Central Choice 16 16 100% 100% CAMHS Single Point of Access 5 5 100% 100% CAMHS LD Peterborough 9 8 89% 100% CAMHS IST (Intensive Support Team) 12 9 75% 89% CAMHS LD Central 17 12 71% 93% CAMHS South Choice 13 9 69% 57% Core service total 90 77 86% 88% Trust wide 3,503 2,807 80% 76%

One medical member of staff was appraised in this core service, constituting an appraisal rate of 100% this year. The trust has not set a clinical supervision target for non-medical staff. Between 1 January and 31 December 2018, the average rate across all nine teams in this service was 69%.

20190830 RT1 Evidence appendix Page 239

The rate of clinical supervision reported during this inspection was lower than the 89% reported at the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision sessions delivered rate (%) required CAMHS North Choice 130 100 77% CAMHS LD Central 152 116 76% CCPNR 63 47 75% CAMHS Central Choice 145 102 70% CAMHS South Choice 153 104 68% CAMHS IST (Intensive Support 103 65 63% Team) CAMHS LD Peterborough 80 44 55% CAMHS Single Point of Access 45 22 49% FCAMHS 3 1 33% Core service total 874 601 69% Trust Total 31,881 15,835 50%

The trust has not set a clinical supervision target for medical staff. Between 1 January and 31 December 2018, out of three sessions required for medical staff, none were completed. There is no comparable data from the last inspection. Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. At the time of the inspection, staff received both clinical and management supervision within trust policy. Management supervision figures had been low prior to this, however staff told us that they received regular clinical supervision both in group and one to one sessions and felt supported. Managers made sure staff received any specialist training for their role. Managers recognised poor performance, could identify the reasons and dealt with these. Multidisciplinary and interagency team work Teams held daily handover meetings where teams discussed and allocated new referrals. The team managers and service managers for the core teams attended a monthly directorate meeting where they could share good practice and discuss risk issues affecting the service and monthly governance meetings to discuss risks, staffing, incidents and performance. Teams held weekly multi-disciplinary meetings where managers fed back any learning, updates and outcomes from the governance and directorate meetings.

20190830 RT1 Evidence appendix Page 240

Teams worked closely with other teams within the trust, including adult mental health teams, crisis and first response team. The three core teams each had a dedicated transitions practitioner post whose role was to work with other teams to ensure that there were effective transitions between services when patients needed to be referred on. Adherence to the Mental Health Act and the Mental Health Act Code of Practice As of 31 December 2018, 0% of the workforce in this service had received training in the Mental Health Act Level 2. It should be noted that only one staff member was eligible for this training. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed every three years. The training compliance reported during this inspection was the same as the 0% reported at the last inspection. Good practice in applying the Mental Capacity Act As of 31 December 2018, 0% of the workforce (from one eligible person) in this service had received training in the Mental Capacity Act Level 2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed three years. The training compliance reported during this inspection was the same as the 0% reported at the last inspection. We reviewed 23 patient care records and found that in all cases staff had completed an assessment of capacity. Staff we spoke with had a good understanding of capacity and consent and we saw that this was an integral part of their everyday practice. There was a clear policy on the Mental Capacity Act, which staff could describe and knew how to access. Staff knew where to get accurate advice on Mental Capacity Act. Staff gave patients all possible support to make specific decisions for themselves before deciding a patient did not have the capacity to do so. Staff assessed and recorded capacity to consent clearly each time a patient needed to make an important decision. When staff assessed patients as not having capacity, they made decisions in the best interest of patients and considered the patient’s wishes, feelings, culture and history. The service monitored how well it followed the Mental Capacity Act and made changes to practice when necessary. Staff audited how they applied the Mental Capacity Act and identified and acted when they needed to make changes to improve. Staff understood how to support children under 16 wishing to make their own decisions and applied the Gillick competency principles when necessary. Staff knew how to apply the Mental Capacity Act to patients aged 16 and 18 and where to get information and support on this. Is the service caring?

20190830 RT1 Evidence appendix Page 241

Kindness, privacy, dignity, respect, compassion and support We observed five episodes of care and saw that staff treated patients and their families with compassion, dignity and respect. Staff gave patients help, emotional support and advice when they needed it. Staff supported patients to understand and manage their own care treatment or condition. Staff directed patients to other services and supported them to access those services if they needed help. Patients said staff treated them well and behaved kindly. Staff understood and respected the individual needs of each patient. Staff felt that they could raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes towards patients and staff. Staff followed policy to keep patient information confidential. Involvement in care Involvement of patients Staff involved patients and gave them access to their care plans. Staff made sure patients understood their care and treatment (and found ways to communicate with patients who had communication difficulties). Staff involved patients in decisions about the service, when appropriate. Patients could give feedback on the service and their treatment and staff supported them to do this. Staff supported patients to make decisions on their care. Staff made sure patients could access advocacy services. Involvement of families and carers Staff supported, informed and involved families or carers. Staff helped families to give feedback on the service. Staff supported patient and their families to understand their care and treatment options and advised them of their options. The service employed family therapists to work with patients and their carers, and families told us how this had a positive impact. Is the service responsive?

Access and waiting times Access and waiting times Prior to the inspection, the trust has identified the below services in the table as measured on ‘referral to initial assessment’ and ‘referral to treatment’. The service met the referral to assessment target in all the targets listed. The trust did not set any referral to treatment targets for this service. There is no data with which to compare this year’s data.

20190830 RT1 Evidence appendix Page 242

Name of Name of Please CCQ core Days from Days from hospital Team state service referral to initial referral to site or service assessment treatment location type. Target Actual Target Actual (median) (media n) Fulbourn CAMHS Community MH - Specialist Hospital Central psychiatric community Choice services for mental health children and services for 126 32.5 n/a 64.5 young children and people up to young people. 17 yrs. Fulbourn CAMHS As above MH - Specialist Hospital Central community Neuro mental health 126 87.5 n/a 117 ADHD services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital Central community Neuro mental health 126 41 n/a 92 ASD services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital Central community On Call mental health 126 0 n/a 0 services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital Central community Partnersh mental health 126 28 n/a 62.5 ip services for children and young people Ida Darwin CAMHS Time limited MH - Specialist Hospital IST intensive community (Intensive community mental health Support support as services for 126 4 n/a 9 Team) an children and alternative young people to hospital

20190830 RT1 Evidence appendix Page 243

Name of Name of Please CCQ core Days from Days from hospital Team state service referral to initial referral to site or service assessment treatment location type. Target Actual Target Actual (median) (media n) admission. 12-18 yrs. Fulbourn CAMHS The Child MH - Specialist Hospital LD and community Central Adolescent mental health Mental services for Health children and (CAMHS) young people Learning Disability Team works 126 120 n/a 146 with children and young people up to the age of 18 who have a learning disability and their families. Fulbourn CAMHS ADHD and MH - Specialist Hospital LD South ASD community services up mental health to 17 yrs. services for (under children and review). The young people Child and Adolescent Mental Health 126 35.5 n/a 81 (CAMHS) Learning Disability Team works with children and young people up to the age of 18 who have a learning

20190830 RT1 Evidence appendix Page 244

Name of Name of Please CCQ core Days from Days from hospital Team state service referral to initial referral to site or service assessment treatment location type. Target Actual Target Actual (median) (media n) disability and their families. Fulbourn CAMHS Community MH - Specialist Hospital North psychiatric community Choice services for mental health children and services for 126 20.5 n/a 52 young children and people up to young people 17 yrs. Fulbourn CAMHS As above MH - Specialist Hospital North On community Call mental health 126 0 n/a 2 services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital North community Partnersh mental health 126 15 n/a 55 ip services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital South community Choice mental health 126 29 n/a 57.5 services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital South community Neuro mental health 126 116 n/a 138 ADHD services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital South community 126 68 n/a 108.5 Neuro mental health ASD services for

20190830 RT1 Evidence appendix Page 245

Name of Name of Please CCQ core Days from Days from hospital Team state service referral to initial referral to site or service assessment treatment location type. Target Actual Target Actual (median) (media n) children and young people Fulbourn CAMHS As above MH - Specialist Hospital South On community Call mental health 126 0 n/a 1 services for children and young people Fulbourn CAMHS As above MH - Specialist Hospital South community Partnersh mental health 126 5.5 n/a 28 ip services for children and young people Fulbourn CASUS CASUS MH - Specialist Hospital work with community young mental health people and services for their children and families, young people who have drug and 18 n/a 79 alcohol n/a concerns, issues or problems and live in Cambridges hire. Ida Darwin CCPNR This is a MH - Specialist LD & SS multi- community disciplinary mental health team services for offering children and n/a 68 n/a 68 specialist young people holistic assessment and neurorehabil

20190830 RT1 Evidence appendix Page 246

Name of Name of Please CCQ core Days from Days from hospital Team state service referral to initial referral to site or service assessment treatment location type. Target Actual Target Actual (median) (media n) itation for children with non- progressive, acquired brain injury (if they are experiencing educational needs) and provides support for parents and families. Service

The service had introduced a single point of access since the last inspection so that all referrals were received and processed effectively. Referrals were triaged by the single point of access service and allocated as urgent, moderate or routine referrals dependent on risk level. At the time of inspection 92% of referrals were assessed within the eighteen-week target with 47% assessed within six weeks of referral. However, 24% patients were waiting over 18 weeks from referral to treatment. The service could respond to urgent referrals within the same day if received with enough time to complete the assessment, however as the service was not commissioned to provide out of hours care any urgent referral received after mid-afternoon was not assessed until the following day. This meant that young people in crisis were sometimes admitted to a paediatric ward in general hospital overnight until the assessment could take place. Staff tried to engage with people who found it difficult, or were reluctant, to seek support from mental health services. Staff tried to contact people who did not attend appointments and offer support. Staff worked hard to avoid cancelling appointments and when they had to they gave patients clear explanations and offered new appointments as soon as possible. Appointments ran on time and staff informed patients when they did not. The service used systems to help them monitor waiting lists/support patients. Staff supported patients when they were referred, transferred between services, or needed physical health care. The service followed national standards for transfer.

20190830 RT1 Evidence appendix Page 247

Facilities that promote comfort, dignity and privacy The service had a full range of rooms and equipment to support treatment and care. Interview rooms in the service had sound proofing to protect privacy and confidentiality. Patients’ engagement with the wider community Staff worked closely with the local authority, social workers and schools to ensure that patients had access to education and training. Staff worked with families and carers where appropriate to maintain family and social relationships. Meeting the needs of all people who use the service All locations we visited had access to premises for people with reduced mobility including wheelchair access. Services had information available on treatments, local services and patient rights. Listening to and learning from concerns and complaints This service received 16 complaints between 1 January to 31 December 2018. Three of these were upheld, seven were partially upheld and three were not upheld. None were referred to the

Ombudsman.

Ward name

Referred to

Total Total Complaints Fullyupheld Partiallyupheld upheld Not Other Under Investigation Withdrawn Ombudsman CAMH Cambs Neuro Team (Huntingdon 4 2 0 0 0 2 0 0 and Cambridge)0 CAMH Central 3 0 0 3 0 0 0 0 Core Team CAMH North Core Team 3 1 0 2 0 0 0 0 (Peterborough) CAMH North Neuro Team 3 0 1 2 0 0 0 0 (Peterborough) CAMH South 2 0 2 0 0 0 0 0 Core Team CAMH SPA 1 0 0 0 0 0 1 0 Team Total 16 3 3 7 0 2 1 0

20190830 RT1 Evidence appendix Page 248

Patients knew how to complain or raise concerns. Staff understood the policy on complaints and knew how to handle them. The service received a low number of complaints reflecting that patients were satisfied with their care The trust had a central complaints team who collated all formal complaints and responded to the complainant. All complaints and serious incidents were allocated for investigation to team and service managers who had received appropriate training. However, managers reported that completing these investigations were time consuming and impacted on their ability to complete their day to day work. This service received 277 compliments during the last 12 months from 1 January to 31 December 2018 which accounted for 4% of all compliments received by the trust as a whole.

Is the service well-led?

Leadership Leaders had the integrity, skills and abilities to run the service. They understood the issues, priorities and challenges the service faced and managed them. They were visible in the service and supported staff to develop their skills and take on more senior roles. Vision and strategy The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. They were aligned to local plans and the wider health economy. Managers made sure staff understood and knew how to apply them. Culture Staff felt respected, supported and valued. They felt the service promoted equality and diversity and provided opportunities for career development. They could raise concerns without fear. Governance

Leaders ensured there were structures, processes and systems of accountability for the performance of the service. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. Management of risk, issues and performance Leaders managed performance using systems to identify, understand, monitor, and reduce or eliminate risks. They ensured risks were dealt with at the appropriate level. Clinical staff contributed to decision-making on service changes to help avoid financial pressures compromising the quality of care. Managers had identified the risks to patient caused by demand for the service being higher than current provision which led to longer than expected waiting times for treatment. Managers had recorded this on the trust risk register and had set up a project and performance group to look at how to address this and an action plan was in place. Information management

20190830 RT1 Evidence appendix Page 249

The service collected reliable information and analysed it to understand performance and to enable staff to make decisions and improvements. The information systems were integrated and secure. Managers worked closely with other local healthcare services and organisations (schools, public health, local authority, voluntary and independent sector) to ensure that there was an integrated local system that met the needs of children and young people living in the area. There were local protocols for joint working between agencies involved in the care of children and young people. Engagement The service engaged well with patients, staff, equality groups, the public and local organisations to plan and manage appropriate services. It collaborated with partner organisations to help improve services for patients. Services had an electronic tablet in the waiting areas that patients and families could use to complete a feedback questionnaire. Learning, continuous improvement and innovation NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. The table below shows which services within this service have been awarded an accreditation together with the relevant dates of accreditation. Accreditation scheme Core service Service accredited Comments Quality Network for MH - Specialist community North CAMHS peer Community CAMHS mental health services for - review was cancelled (QNCC) children and young people twice by QNCC

20190830 RT1 Evidence appendix Page 250

Specialist eating disorders service

Facts and data about this service

Number of beds or Patient group (male, Location site name Ward / Team name number of clinics female, mixed) CAMHS Eating Fulbourn Hospital - - Disorders (Trustwide) MH Services (CPFT) at Community Eating - - Addenbrookes Disorders Cambridge MH Services (CPFT) at Community Eating - - Addenbrookes Disorders Norfolk Ida Darwin Hospital Phoenix Centre 14 beds Mixed MH Services (CPFT) at S3 14 beds Mixed Addenbrookes

Safe and clean environment At S3 ward and Phoenix Centre staff supported regular observations to monitor patient interaction, risk and respond to patient needs. There were blind spots within some areas of the wards however, staff mitigated the risks with mirrors, patient observations and a staff member were always present in communal areas. Both community eating disorder services did not have environmental risk assessments, although Cambridge community eating disorder service had identified risks in the patient toilet areas and included these in the service risk register. We raised these issues with managers during the inspection. Curved mirrors to aid observation of patients in the reception area had arrived but the maintenance team had not installed them. The Norfolk team was updating the environmental risk assessment to include awareness of ligature points at the time we visited. Safety of the ward layout Over the 12month period from 1 January 2018 to 31 December 2018 there were no same sex accommodation breaches within this service. The wards complied with guidance on eliminating mix-sex accommodation. At the time of our visit on S3 ward one patient was male. Staff demonstrated a separate bedroom corridor area with a separate bathroom without compromising patients’ privacy and dignity. The service had female/male signs which could be placed on patients’ doors to inform staff of the sex of the occupant.

20190830 RT1 Evidence appendix Page 251

At S3 ward and Phoenix Centre staff had access to alarms and patients had easy access to nurse call systems. There were ligature risks on two wards within this service. No wards had not had a ligature risk assessment in the last 12 months. Both the Phoenix Centre and S3 ward had detailed environmental ligature assessments to ensure a safe care environment. (A ligature anchor point is a point in the environment to which patients may fix a ligature with the intention of harming themselves). Ligature assessments included pictures of areas of risk, colour coded to indicate the level of risk. Mitigation included the use of individual risk assessments, keeping high risk areas locked unless a patient was accompanied by staff, and with regular observations. S3 ward had a ligature risk assessment but had not included the garden area. The garden back gate was unlocked, which maybe a risk to patients who are at risk of absconding. We raised this with managers during the inspection. Following the inspection, the garden area was risk assessed and the back gate secured.

Both community eating disorder services’ environmental risk assessments did not include awareness of ligature points at the time of the inspection but there were being updated.

Briefly describe risk - High level of Summary of actions taken Ward / unit one sentence preferred risk? Yes/ No name Phoenix Low Service User Risk No Detailed audit report available on Centre request. S3 Low Service User Risk No Most recently audited 22/01/19 Detailed audit report available on request.

Maintenance, cleanliness and infection control All wards were clean and tidy, staff cleaned ward areas regularly and kept cleaning records up to date. The eating disorder services were cleaned by the trusts cleaning provider. The Cambridge community eating disorder service had no cleaning records. However, we found cleanliness issues in the Phoenix Centre clinic room where floors were dirty. The Norfolk eating disorder team’s premises were clean and well maintained.

Staff adhered to infection control principles including handwashing, disposable gloves and aprons, with accessible gels and displayed handwashing signs around all services. However, there were no disposable gloves and aprons in the Cambridge community eating disorder service.

At Cambridge community eating disorder service, we saw an emergency incident when staff attended to a patient there was a body fluid spillage. Staff were unable to access disposable gloves or aprons as these were not available in the clinic. The trust failed to provide basic infection control equipment to protect patients and staff.

During the inspection at the Phoenix Centre staff sought guidance from the trust’s infection control nurse as three patients were unwell, and barrier nursing protocols were put in place. Barrier nursing is when isolation nursing is carried out by placing the patient in a single room or side room and precautions are implemented to prevent the spread of germs.

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018), all the locations scored higher than similar trusts for cleanliness and for condition, appearance and maintenance.

20190830 RT1 Evidence appendix Page 252

Condition Site name Core service(s) Cleanliness appearance and maintenance MH - Acute wards for adults of working age and psychiatric intensive care units MH - Eating Disorders Fulbourn MH - Forensic inpatient 100.0% 99.3% Hospital MH - Other Specialist Services MH - Wards for older people with mental health problems Other - PMS service Ida Darwin MH - Child and adolescent mental health wards 100.0% 99.1% Hospital MH - Other Specialist Services MH - Eating Disorders Addenbrooke 100.0% 99.0% s Hospital MH - Eating Disorders

Trust overall 99.6% 98.7% England average (Mental 98.4% 95.4% health and learning disabilities)

Clinic room and equipment The clinic rooms at S3 ward was fully equipped with accessible resuscitation equipment, emergency drugs, and ECG. An electrocardiogram (ECG) is a test which measures the electrical activity of your heart to show whether or not it is working normally. The clinic room was clean and well maintained. The service shared resuscitation equipment and emergency drugs with Cambridge community eating disorder service across the corridor. The clinic room at the Phoenix Centre was messy and grubby. There were sticky substances on worktops. Cleaning records showed one-week cleaning not recorded in April. It was hard to find items. An oxygen mask was missing, patients’ Lucozade was out of date. There was no record of items that needed regular calibration for example the oximeter pulse and electrocardiogram. Following the inspection, the trust provided evidence of current equipment checks for the both items in May 2019. At the Cambridge community eating disorder service the clinic room, was basic, clean and tidy, with no medicines held. The clinic room floor was badly scratched. Managers told us the clinic room floor would be replaced as part of the refurbishment plan. Staff were not able to access disposable gloves or aprons.

Safe staffing Nursing staff This core service has reported a vacancy rate for all staff of 22% as of 31 December 2018.

20190830 RT1 Evidence appendix Page 253

This core service reported an overall vacancy rate of 8% for registered nurses at 31 December 2018. This core service reported an overall vacancy rate of 34% for nursing assistants. There were sufficient staffing levels to meet the needs of patients. The service had introduced an e-rostering staffing tool, which was widely used across the trust, to plan staffing requirements for each shift. The service had introduced a system of flexible working. This meant bank staff could flexibly work across S3 Ward and the Phoenix Centre. Both wards used bank staff or offered shifts to substantive, permanent staff, before requesting agency staff. Both wards could seek resources and staffing from the duty nursing officer. Managers were supported by a modern matron. The service was also engaging with local universities to attract newly qualified nurses. At S3 ward there were two nurse, two health care assistants and one psychologist vacancies. Managers had recruited staff, some of which had starting dates early June 2019. Three nurses were on sick leave, two on long term sick. Shifts were being offered to substantive, permanent staff, with agency requested as a last resort. At the Phoenix Centre they had previously experienced staffing issues and closed the ward between May and October 2018. The team had dispersed to work across the trust and had continued to meet regularly in preparation for the re-opening. In the summer of 2018 the service recruited 14 new staff, this included the nurses, health care assistants, ward manager (secondment) and clinical nurse specialist. There was one nurse maternity leave and two health care assistants’ vacancies. The ward manager had submitted a request for funding for a staffing uplift from commissioner for an additional nurse at night. At the Cambridge community eating disorder service the service was led by the modern matron. There was no team leader post at this service. There were no permanent staffing vacancies. Two psychologists were on maternity leave and the manager had just short listed for both posts one- year fixed contracts. The service offered shifts to substantive, permanent staff and did not use agency staff. The manager was working on a business plan to request funding from commissioners for additional staff to enhance medical monitoring of patients. This would include two health care assistants and two clinical nurse specialists. At the Norfolk community eating disorder service the service was led by a team leader. The modern matron supported the team leader and was based one day a week at the Norfolk service. The modern matron had been in post since November 2018. There had been gaps in staffing in previous months, but most were now filled. There remained vacancies for one speciality doctor and two psychologist vacancies due to maternity leave and a part time band 7 nurse. An agency doctor had been appointed on a fixed term contract from April to November 2019. Two psychologist posts had just been shortlisted. The manager anticipated the full team would be in place by August/September 2019.

Health care Registered nurses Overall staff figures assistants

20190830 RT1 Evidence appendix Page 254

Location Ward/Team

(%) (%) (%)

Vacancies Vacancies Vacancies

Vacancy rate rate Vacancy rate Vacancy rate Vacancy

Establishment Establishment Establishment CAMHS Fulbourn Eating Hospital 0.5 2.8 18% - - - 2.6 5.7 46% Disorders (Trustwide) MH Services (CPFT) at S3 2.0 13.4 15% 7.1 9.6 74% 10.6 28.1 38% Addenbrookes Ida Darwin Phoenix 0.3 11.3 3% 2.4 15.1 16% 5.0 33.1 15% Hospital Centre

MH Services Community (CPFT) at Eating - - - 1.0 2.0 50% 1.4 11.8 12% Addenbrookes Disorders Norfolk

MH Services Community (CPFT) at Eating -0.7 0.0 - -1.2 0.6 -200% -0.5 6.5 -8% Addenbrookes Disorders Cambridge Core service total 2.1 27.5 8% 9.3 27.3 34% 19.1 85.2 22% Trust total 164.0 1294 13% 130.6 1031.7 13% 334.2 3984.1 8% NB: All figures displayed are whole-time equivalents

Between 1 January 2018 and 31 December 2018 6785 hours were filled by bank staff to cover sickness, absence or vacancy for qualified nurses. The main reason for bank and agency usage was vacancies. In the same period, agency staff covered 1602 available hours for qualified nurses and 1348 of available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling.

NOT filled by bank or Bank Usage Agency Usage agency Wards Hrs % Hrs % Hrs %

S3 4701 - 1166 - 825 -

Phoenix Centre 2084 - 437 - 524 -

20190830 RT1 Evidence appendix Page 255

Core service total 6785 - 1602 - 1348 -

Trust Total 114849 - 42162 - 31421 -

Between 1 January 2018 and 31 December 2018, 12264 were filled by bank staff to cover sickness, absence or vacancy for nursing assistants. The main reason for bank and agency usage was vacancies. In the same period, agency staff covered 1189 available hours and 2210 available hours were unable to be filled by either bank or agency staff. The trust has supplied the bank and agency usage in addition to the total establishment hours available, so percentages of hours filled/not filled cannot be calculated. The trust has stated that they record this information based on the number of hours used and not the number of available hours that need filling. There was low use of bank and agency staff. On S3 ward staff between January to March 2019 for shifts filled with bank and agency staff were 482 and unfilled were 72 shifts. At the Phoenix Centre shifts filled with bank and agency staff were 162 were and unfilled were 23 shifts. Managers made sure all bank and agency staff had a full induction and understood the service before starting their shift.

NOT filled by bank or Bank Usage Agency Usage Wards agency Hrs % Hrs % Hrs % S3 9523 - 1044 - 1314 - Phoenix Centre 2741 - 145 - 897 - Core service total 12264 - 1189 - 2210 - Trust Total 202495 - 31831 - 25759 -

Managers local records showed the staff turnover for S3 and Phoenix Centre in the last quarter January to March 2019 were nil. This core service had 13.2 (22%) staff leavers between 1 January 2018 and 31 December 2018.

Substantive staff Average % staff Substantive staff Location Ward/Team Leavers over the leavers over the (at latest month) last 12 months last 12 months MH Services Community Eating (CPFT) at 10.7 4 36% Disorders Norfolk Addenbrookes Ida Darwin Phoenix Centre 26.6 5.4 25% Hospital MH Services (CPFT) at S3 16.5 3.8 22% Addenbrookes

20190830 RT1 Evidence appendix Page 256

MH Services Community Eating (CPFT) at Disorders 7.1 0 0% Addenbrookes Cambridge CAMHS Eating Fulbourn Disorders 3.1 0 0% Hospital (Trustwide) Core service total 64 13.2 22% Trust Total 3575.2 446.3 13%

The sickness rate for this core service was 3.8% between 1 January 2018 and 31 December 2018. The most recent month’s data (December 2018) showed a sickness rate of 1.3%. Managers supported staff who needed time off for ill health. At the Phoenix Centre in January 2019 sickness levels were at 5% and in 2% in March 2019. At S3 ward January 2019 sickness levels were at 8% and 6% in March 2019. At the Cambridge community eating disorder service the sickness rate was 5% in March 2019 and dropped to nil in April 2019. At the Norfolk community eating disorder service the modern matron told us three staff had long periods of sickness including the team leader, but staff had returned to work.

Total % staff sickness Ave % permanent staff Location Ward/Team sickness (over the past (at latest month) year) MH Services (CPFT) at S3 1.3% 7.3% Addenbrookes CAMHS Eating Fulbourn Hospital 1.0% 3.5% Disorders (Trustwide) Ida Darwin Phoenix Centre 1.0% 3.2% Hospital MH Services Community Eating (CPFT) at 1.5% 0.9% Disorders Norfolk Addenbrookes MH Services Community Eating (CPFT) at 2.3% 0.9% Disorders Cambridge Addenbrookes Core service total 1.3% 3.8% Trust Total 5.3% 4.5%

The below table covers staff fill rates for registered nurses and care staff during September, October and November 2018. S3 ward had below 90% of planned care staff for all day shifts which were reported. The Phoenix Centre had above 125% of planned nursing staff and care staff for multiple shift across

20190830 RT1 Evidence appendix Page 257

Key:

> 125% < 90%

Day Night Day Night Day Night Care Care Care Care Care Care Nurses Nurses Nurses Nurses Nurses Nurses staff staff staff staff staff staff (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) September 2018 October 2018 November 2018 S3 110 81 95 97 102 75 94 94 107 79 97 100 Phoenix - - - - 148 81 96 135 138 88 93 140 Centre

Medical staff Between 1 January 2018 and 31 December 2018, of the (6009) total working hours available, 2% were filled by bank staff to cover sickness, absence or vacancy for medical locums. The main reasons for bank and agency usage for the wards/teams was vacancies. In the same period, agency staff covered 6% of available hours and 0% of available hours were unable to be filled by either bank or agency staff. The service had enough nursing and medical staff who knew the patients and received basic training to keep people safe from avoidable harm. Both wards had a full-time consultant and a trainee doctor. The wards had access to Addenbrookes Hospital doctors 9am to 5pm Monday to Friday. Outside of these hours staff would contact the acute hospital’s on-call doctors out of hours and at weekends. Staff told us it was rare that a doctor would be required out of hours, but that on- call doctors had always been responsive and timely whenever they had been called to see a patient. Patients at both community eating disorder services were monitored by their GP’s and given out of hours contacts for evenings and weekends.

Ward/Team Total hours available Bank Usage Agency Usage NOT filled by bank or agency Hrs % Hrs % Hrs % S3 3086 92 3% 0 0% 0 0% Phoenix Centre 2923 0 0% 384 13% 0 0% Core service 6009 92 2% 384 6% 0 0% total Trust Total 176009 3835 2% 18562 11% 0 0%

Mandatory training Staff had completed and were up to date with their mandatory training. Managers showed us records held locally.

Where the mandatory training programme was not specifically targeted at staff working with eating disorder services managers arranged for additional and bespoke training for their staff as

20190830 RT1 Evidence appendix Page 258

needed. This would be at team meetings, governance meetings, inhouse training days and eating disorder conferences. The manager at Phoenix Centre had asked the trusts learning and development team to provide nasogastric feeding training for staff. A nasogastric feeding tube (NGT) is a long polyurethane or silicone tube that is passed through the nasal passages via the oesophagus into the stomach; used with patients in an eating disorder service. Staff at the Phoenix Centre told us about extensive training over weeks with external trainers to prepare the team to reopen the service in May 2018. The modern matron at Cambridge community eating disorder service was arranging- First episode rapid early intervention for eating disorders (FREED) training for staff. A suicide and self- harm event were planned for staff in June. The compliance for mandatory and statutory training courses at 31 December 2018 was 88%. Of the training courses listed 11 failed to achieve the trust target and of those, five failed to score above 75%. The trust set a target of 90% for completion of mandatory and statutory training. The training compliance reported for this core service during this inspection was slightly higher than the 86% reported in the previous year. Key: Not met trust Met trust target Higher No change Lower Below CQC 75% target ✓  ➔  

Complian ce Numb Numb Trust change er of YTD er of Targ when Training Module staff Complian eligibl et compare traine ce (%) e staff Met d to d previous year

Safeguarding Children (Level 2) 13 13 100% ✓ ➔

Conflict Resolution 63 63 100% ✓ 

PREVENT (Level 1) 18 18 100% ✓ n/a Mental Health Act Level 1 13 13 100% ✓ 

Mental Capacity Act Level 1 2 2 100% ✓ ➔

Infection Control (Level 1) 5 5 100% ✓ n/a Safeguarding Children (Level 1) 5 5 100% ✓ ➔

Working Safely 63 62 98% ✓ 

Safeguarding Adults 63 62 98% ✓ 

Good Governance 63 61 97% ✓ 

Treating People with Respect 63 61 97% ✓ 

Dementia 30 29 97% ✓ 

20190830 RT1 Evidence appendix Page 259

Deprivation of Liberty Safeguards 15 14 93% ✓ n/a PREVENT (Level 2) 45 41 91% ✓ n/a Basic Life Support (BLS) 22 20 91% ✓ 

Physical Interventions 22 20 91% ✓ 

Carer Awareness 63 56 89%  n/a Fire Safety 63 56 89%  

Infection Control (Level 2) 58 51 88%  n/a Safeguarding Children (Level 3) 45 39 87%  

Medical Emergency Response Course (MERC) 36 29 81%  n/a Smoking Cessation 63 47 75%  n/a Mental Capacity Act Level 2 45 33 73%   Safeguarding Children Level 3; Mandatory for 45 33 73%  n/a Role (3hrs)

Manual Handling (Level 1) 3 2 67%  n/a Manual Handling (Level 2) 37 24 65%  n/a Mental Health Act Level 2 24 14 58%   Total 987 873 88%  

Assessing and managing risk to patients and staff Assessment of patient risk We reviewed 18 risk assessments. Risk assessments were comprehensive and showed that staff completed a risk assessment for each patient on admission, and in consultation with family and carers. Staff used recognised risk assessment tools management of really sick patients with anorexia nervosa (MARSIPAN) and health of the nation outcome scales (HoNOS). Teams sought the views of the multidisciplinary team, healthcare providers, such as general practitioners and CAMHS. Risk assessments demonstrated a strong focus on regular physical health monitoring, weight, blood tests. Risk assessments were updated regularly and when changes to risk occurred. The risk factors involved in the assessment of risk in people with eating disorders included: Medical risk, psychological risk, psychosocial risk, insight/capacity and motivation. High risk patients were placed on a high-risk register- severe and enduring eating disorder (SEEDS) and discussed as a priority once a week. Management of patient risk Overall staff knew about any risks to each patient and acted to prevent or reduce risks. Staff identified and responded to any changes in risk to, or posed by, patients promptly. Regular meetings for patients ensured all staff knew of any current patients risks.

20190830 RT1 Evidence appendix Page 260

Wards had curved mirrors to aid observation. A staff member was always based in the communal areas for general observation. On both wards’ patients were not allowed to enter each other’s bedroom, in order to keep them and others safe. This was a way of monitoring the patient and removing or reducing risks as far as possible. Staff followed trust policies and procedures when they needed to search patients or patients’ bedrooms to keep them safe from harm. At Phoenix Centre staff told us they tried to build up trust with patients. However, on Phoenix ward we found two incidents where staff had not documented risks accurately. One patient had a historical risk of hiding weights on her body. This was not recorded in the risk assessment but in found in information provided upon admission. There was mitigation to ensure when female patients were weighed attention was given to female clothing. Following on discussions with managers and the team, this was not deemed a current risk. Records showed on the 5 May 2019 a patient had a “blade” discovered in the back of their mobile phone case by a fellow patient. This was immediately handed in and discussed with the patient, however staff had not recorded this on datix, despite the situation being well described in the progress notes, and in team meeting minutes. The manager immediately followed this up with staff and asked them to complete a datix retrospectively. Datix is incident report system used by the trust to record any adverse incident which has the potential to produce unexpected or unwanted effects, or any incident which has a consequence or a learning point. Managers said this was a genuine error and agreed that staff should have recorded this as an incident, both as a contraband item and as a near miss should the “blade” have been found by another patient who did intend to harm themselves. Staff told us searches of patients /bedrooms were not routinely carried out. Use of restrictive interventions Staff received training in de-escalation techniques and proactive preventive interventions, which included how to safely restrain a patient with low body mass index. Staff told us they would only use safe holding techniques with patients. Patients and staff told us a lot of restraint was used at the Phoenix Centre and occasional restraint used at S3 ward.

This service had 238 incidences of restraint (six different service users) and no incidences of seclusion between 1 January 2018 and 31 December 2018.

The below table focuses on the last 12 months’ worth of data, 1 December 2018 and 31 December 2018.

Staff at the Phoenix Centre told us about one patient had challenged the service when they were first admitted on the ward in early 2018 and restrained (safe holding techniques). The same patient was more settled. There is a de-escalation room at the Phoenix Centre, staff told us the area is not used regularly. The room was set up for patients taking school and college national exams.

Of restraints, Of restraints, Patients incidences of Ward name Seclusions Restraints incidents of prone restrained rapid restraint tranquilisation Phoenix 0 238 6 0 (0%) 0 (0%) Centre

20190830 RT1 Evidence appendix Page 261

Core service 0 238 6 0 (0%) 0 (0%) total

Restraint were low level for this service. On the Phoenix ward staff had introduced a safety pod for use during restraint, and staff had received appropriate training. The pod could also be used when refeeding was required which was considered the least restrictive option and innovative. Research undertaken by the team suggested that the pod helped to reduce fear and anxiety and reduce injury for both staff and patients. The team were continuing to monitor the use of the pod.

There were no incidences of prone restraint, which was the same as the previous 12-month period. There were no incidences of rapid tranquilisation, which was the same as the previous 12-month period. There were no incidences of mechanical restraint, which was the same as the previous 12-month period. The number of restraint incidences reported during this inspection (238) was higher than the 82 reported during the previous 12-month period. There were no incidences of seclusion, which was the same as the previous 12-month period. There were no incidences of long-term segregation, which was the same as the previous 12-month period. Safeguarding A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional. Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place. This core service made seven safeguarding referrals between 1 January 2018 and 31 December 2018 all of which concerned adults. All staff received training in safeguarding that was right for their role. Staff had a strong understanding of how to protect patients from abuse and the service worked well with other agencies to do so. Named staff included a named nurse and named doctor. Staff were aware of the nominated individuals and how to report concerns.

There were systems in place to ensure safeguarding concerns were identified and reported. Staff at the Phoenix Centre told us safeguarding concerns would be recorded on the trust’s electronic system. Staff understood the safeguarding referral process and how to make a referral. Section 85 notifications were clearly documented on patients care records at the Phoenix Centre where patients were under 16. Section 85 of the Children Act 1989 places a duty on local authorities to check on the safety and welfare of children living in residential education or hospital provision for any continuous period exceeding and/or likely to exceed 12 weeks.

20190830 RT1 Evidence appendix Page 262

There was an alert field in Phoenix Centre (under 18’s service) care notes to flag to staff if there were safeguarding concerns relating to a child or young person.

There were arrangements for group safeguarding supervision and staff we spoke with told us they could access this monthly with the safeguarding team lead.

Number of referrals Core service Adults Children Total referrals MH - Eating Disorders 7 0 7

The number of adult safeguarding referrals in month ranged between zero and two a month. There were no serious case reviews commenced or published in the last 12 months (1 January and 31 December 2018) that relate to this service. Staff access to essential information Patient notes were comprehensive, up to date and in an electronic format. However, paper files were also available as a safeguard, if systems went down. When patients transferred to a new team, staff ensured that all key information was available to the receiving team. Medicines management We visited four clinic rooms and observed medicines management on two wards and reviewed 22 medication charts. Staff followed best practice when storing, dispensing and recording. There were effective systems in place for safe management and administration of medication. Staff had easy access to clinical information and it was easy for them to maintain quality clinical records. A pharmacist was based on S3 ward and Phoenix Centre across the week. Pharmacists audited the ward clinic rooms and medication. Staff followed national guidance and best practice in all aspects of medicines management. Doctors would speak with patients individually about medicines before prescribing. Records showed staff regularly reviewed the effects of medicines on each patient’s physical health. Track record on safety Between 1 January 2018 and 31 December 2018 there was two serious incidents were reported by this service. One incident related to ‘Sub-optimal care of the deteriorating patient’ while the other incident related to a ‘Confidential information leak/information governance breach’. Staff knew what incidents to report and how to report them. Staff reported all the incidents they should have. Staff understood duty of candour. They were open, transparent and gave patients a full explanation when things went wrong. Managers investigated incidents, gave feedback to staff and shared feedback from incidents both internally and externally to the service. We saw serious incidents were recorded in team meetings as a standard agenda item. Lessons learned were not being shared consistently across the eating services. Staff at S3 ward were not familiar with incidents, developments and news on other’s wards.

20190830 RT1 Evidence appendix Page 263

Managers and staff made changes to practice because of incidents and feedback. Managers told us about a conference in November 2018 where learning from a patient death took place with all stakeholders and trust staff present. Staff met regularly to discuss feedback and look at improvements to patient care. Managers debriefed and supported staff after any serious incident. During our visit at Cambridge Community eating disorder service there was an emergency incident with a patient. After the incident all the staff involved were invited to the debrief to discuss feedback and receive support. Patients on both wards told us they were also supported and debriefed following an incident. We reviewed the serious incidents reported by the trust to the Strategic Executive Information System (STEIS) over the same reporting period. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS with two reported. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This service reported no never events during this reporting period. Type of incident reported (SIRI) Norfolk Eating The Phoenix Centre Disorder Community Service Confidential information leak/information governance 1 0 breach Sub-optimal care of the deteriorating patient 0 1 Total 1 1

Reporting incidents and learning from when things go wrong There was one death of a patient known to the service in December 2012. Most of the NHS organisations that dealt with the young person’s care and treatment and discharge had failed in some way. In 2018 the PHSO upheld a complaint regarding the treatment and risk management offered by the eating disorder services in respect of the care of the young person. The service had considered learning and improvement.

Some staff were familiar with the Parliamentary and Health Service Ombudsman – Ignoring the alarms- How NHS eating disorder services are failing patients. This paper included the young person death and recommendations.

There have been three other deaths of patients known to services. The coroner had enquired as to whether there are any similarities surrounding the deaths and subsequently scheduled the inquests to take place simultaneously.

Is the service effective?

20190830 RT1 Evidence appendix Page 264

Assessment of needs and planning of care We reviewed 25 care records and six treatment plans across the four services. We found that staff completed a mental health assessment on admission and supported patients with accessing appropriate interventions. Staff completed a comprehensive physical health assessment prior to admission and reviewed this again upon admission. Care records showed ongoing physical health monitoring including regular weighing of patients, blood checks, and monitoring effects of re- feeding syndrome. In the 11 care records we looked at on ward S3 and the Phoenix Centre, patients had a range of care plans for different needs. Most patients had around 20 care plans, including a wellbeing plan. Care plans were personalised, and recovery orientated. Care plans included goals and aspirations. One patient at the Phoenix Centre had a care plan for their hopes and dreams. Where patients had met specific goals in their care plans, these had been reviewed and the goal was noted on the care plan as having been met. Staff recorded patient views in care plans. Staff updated care plans with the patient and families weekly and staff provided a copy of care plans weekly. Patients had meal plans which devised by dietician, occupational therapist and multidisciplinary team. Meals plans were graded, and calories were increased over time to support patients reaching their weight goals. Meal plans included patients’ preferred choices of main meals and snacks. There was robust attention given to physical and psychological aspects of treatment, with attention given to the dual presentation and complexity of the illness. Patients’ care programme approach (CPA) review meetings (every 4-6 weeks) took place with members of the Phoenix Centre team, the young person, their family and referrers from the young person’s local child and adolescent mental health service (CAMHS). Electrocardiograms (ECG) were completed on the wards. This is a simple test that can be used to check the heart's rhythm and electrical activity. We looked at 14 treatment plans at Cambridge and Norfolk community eating disorder services. We found that staff completed a mental health assessment upon assessment; and supported patients with accessing appropriate intervention for example family therapy 1-1 therapy. Staff completed a comprehensive physical health assessment. Care records showed physical health monitoring including regular weighing of patients and blood checks, completed by the patients GP. Patients would self-weigh and report in their weights to the eating disorder service. Treatment plans were personalised, and recovery orientated and included goals and aspirations. Patients had a crisis management plan. Staff recorded patient views in the treatment plans. Staff sent patient treatment plans to the patients in a letter format. Staff sent GPs recommendations of medical monitoring required with details of the patient’s risks, weight and blood monitoring. The service worked closely with patients GP’s and had access to the same electronic systems used by the GPs. This meant that the service had easy access to patient information (with their consent) Patients whose physical health may become severely compromised could be admitted to the S3 inpatient ward or offered day attendance at the ward. Best practice in treatment and care

20190830 RT1 Evidence appendix Page 265

Across the service the staff team planned and delivered care and treatment interventions based on best practice and evidence-based guidance. The staff team followed guidance based on the management of patients with anorexia nervosa (MARSIPAN) guidelines. These provided guidance on the clinical management and care of patients with anorexia nervosa. The tool is approved by the Royal College of Psychiatrists and the Royal College of Physicians and staff used this to carry out safe re-feeding, risk management and monitoring. Services provided a range of NICE guidelines evidence based psychological interventions such as: • Individual eating disorder focused Cognitive Behavioural Therapy (CBT ED) • Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) • Motivational Enhancement Therapy • Cognitive Analytical Therapy (CAT) • Specialist Supportive Clinical Management (SSCM) Therapies were delivered by experienced psychologists and included: intensive family therapy, cognitive analytical therapy, cognitive remediation, behaviour therapy, body imaging, and motivational enhancement therapy. We saw at the Phoenix Centre patients followed a work book- “Am I ready to change?”. This included modules the patient followed the workbook until discharge. The workbook charted the patient’s journey, with goals setting, strengths, vulnerabilities, motivation for change, maintenance factors and guidance. The workbook was devised by the eating disorder staff and patients and is yet to be signed off by the trust. The service is looking for this to be produced as an app. The dietitian carried out comprehensive nutritional and hydration assessments for all patients upon admission to ensure that re-feeding was carried out safely including nasogastric feeding. Staff adhered to guidance from the National Patient Safety Agency (NPSA) relating to the safe insertion and nasogastric feeding. The presence of dieticians and physiotherapy professionals within teams, enhanced the staff understanding and safe management of - dieting or restrictive practices, problems arising from severe and enduring illness, compensatory behaviours- over- exercising/vomiting, re-feeding syndrome. For patients with an eating disorder and diabetes, the service followed NICE guidelines to: • Agree who has responsibility for monitoring physical health • Follow recommendations for blood glucose tests • Invite relevant professionals to CPA meetings

The trust promoted a smoke free environment. Staff offered nicotine replacement products to patients who smoked and supported patients to stop smoking. This supported patients in living healthier lives. This service participated in no local or national audits in the last 12 months (1 January and 31 December 2018). Pharmacists audited the ward clinic rooms and medication. Nurses audited patients care records monthly on S3 ward and the Phoenix Centre. 20190830 RT1 Evidence appendix Page 266

Skilled staff to deliver care Patients had access to a range of mental health professionals including doctors, specialist nurses, nurses, psychologists, family therapist, eating disorder therapist, occupational therapists, physiotherapist, dieticians and pharmacists. Teams were supported by a modern matron.

There were regular team meetings across services including governance meetings, referral meetings, high risk patients’ meetings and doctor’s morning meetings.

Staff received regular in-house supervision this provided opportunities to share their experiences of working in the services, recognising challenges, expressing feelings about their work and reflection on their personal style of working. Staff received weekly/fortnightly clinical group supervisions run by nurses and the psychologist. A clinical nurse specialist had responsibilities for facilitating staff supervision at the Phoenix Centre. The trust confirmed clinical supervision for medical staff was not recorded centrally and as such this data was not collected. Staff told us they did not always remember to record the supervision meeting and outcome. The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 April 2017 to 31 March 2018), the overall appraisal rate for non-medical staff within this service was 61%. This year so far, the overall appraisal rates was 43% (as at 1 January 2019). The wards with the lowest appraisal rate at 1 January 2019 were S3 Ward with an appraisal rate of 27% and the Phoenix Centre with a rate of 31%. Ward name Total Total % appraisals % appraisals number of number of (as at 1 (previous permanent permanent January year 1 April non-medical non-medical 2019) 2017 – 31 staff staff who March 2018) requiring an have had an appraisal appraisal CAMHS Eating Disorders (Trustwide) 3 3 100% 50% Community Eating Disorders Cambridge 7 6 86% 0% Community Eating Disorders Norfolk 6 4 67% 40% Phoenix Centre 29 9 31% 64% S3 15 4 27% 77% Core service total 60 26 43% 61% Trust wide 3503 2807 80% 76%

The trust’s target rate for appraisal compliance is 95%. At the end of last year (1 April 2017 to 1 March 2018), the overall appraisal rate for medical staff within this service was 25%. This year so far, the overall appraisal rates this was 100% (as at 31 January 2019). Managers’ local records confirmed staff had received annual appraisals. The manager at ward S3 ward had completed all appraisals except for five new staff starters. The ward matron at Cambridge Community eating disorder service told us annual appraisals had been completed but was unable to access the electronic records for appraisals for both community services staff at the time of inspection. All relevant staff at the Norfolk team had received an appraisal at the time of the visit.

20190830 RT1 Evidence appendix Page 267

Ward name Total Total % % appraisals number of number of appraisals (previous year 1 permanent permanent (as at 31 April 2017 – 31 medical staff medical staff January March 2018) requiring an who have 2019) appraisal had an appraisal Community Eating Disorders Norfolk 2 2 100% 50% S3 2 2 100% 0% Core service total 4 4 100% 25% Trust wide 112 73 65% 42%

The trust has not supplied a target for non-medical staff. Between 1 April 2018 and 31 December 2018, the average rate across all five teams in this service was 48%. Staff told us they did not always remember to record the supervision meeting and outcome. The trust was unable to provide details of staff supervision for non-medical staff. However, staff we confirmed they received regular supervision. The trust reported a very poor level of staff supervision recording in March 2019 due to the system being closed for the financial year before a large number of staff recorded their supervision. The trust made changes from April 2019 to the recording of supervision allowing supervisors to record the supervision, as well as supervisees.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, so it’s important to understand the data they provide. Team name Clinical Clinical Clinical supervision supervision supervision rate sessions required delivered (%) CAMHS Eating Disorders (Trustwide) 30 28 93%

Community Eating Disorders Cambridge 66 52 79%

Community Eating Disorders Norfolk 82 44 54%

Phoenix Centre 183 78 43%

S3 141 41 29%

Core service total 502 243 48%

Trust Total 31881 15835 50%

The trust has not supplied any clinical supervision data for medical staff in this core service. Medical staff had clinical supervision every first and third Thursday of each month, fortnightly case-based discussions, peer supervision and access to systemic family therapy course. Each doctor and trainee doctor holds a personal development plan group which monitors their education, peer supervision’s and continuing professional development. They are expected to take part in group supervisions.

20190830 RT1 Evidence appendix Page 268

Multidisciplinary and interagency team work Staff held regular and effective multidisciplinary (MDT) meetings on the wards, including ward rounds and handover meetings. Patients attended multidisciplinary meetings, along with their carers, and were involved in making decisions about their care and treatment where appropriate. There was a highly skilled multidisciplinary expertise in the field of treating eating disorders, providing proactive evidence-based treatment across services. At the Phoenix Centre, there were a small group of senior clinicians who were developing the culture within the service and supporting the workforce development of numerous new to service nursing staff. This resulted a gap of knowledge base and experience, that should lessen with time and additional training. We observed a morning handover meeting on S3 ward. Staff reviewed and discussed information about each patient this included: mental health status, risks, blood results or any concerns, physical health monitoring, feeding progress, weights, observation levels, medication that needed reviewing, and physical pain. Staff also discussed patient’s engagement with their peers, in groups and with staff. Staff maintained effective relationships with other services and organisations such as social services and GP services to ensure patients received on-going care and treatment when they were discharged from the hospital. For example, GPs were responsible for the medical monitoring of patient’s post-discharge. Staff had access to the GP electronic records system and staff said this ensured effective communication between services.

Staff across services worked closely with the diabetic service. At the Phoenix Centre the diabetic consultant and nurse attended one patient’s care programme approach meeting. Patients and carers on wards said they were always included in care programme approach meetings. Care programme approach meetings were held every four to six weeks, but managers said they were planning to hold them every four weeks instead.

The inpatient services had established effective working relationships, particularly when young adults turned 19 years, and transitioned to adult and community services.

Staff at the Norfolk community team confirmed that had developed good relationships with the local mental health trust and acute trusts to ensure effective treatment for patients.

Adherence to the Mental Health Act and the Mental Health Act Code of Practice Staff had a robust understanding of the Mental Health Act (MHA) and the MHA Code of Practice in relation to their practice. Staff were aware of how to access advice relating to the MHA. We found that all necessary paperwork relating treatment forms were attached to medicine records as required and were completed accurately. For example, forms (T2) certificates were completed where necessary and attached to patients’ medicine charts in accordance with the code of practice on both wards.

Patients detained under the MHA on S3 and the Phoenix Centre had appropriate documentation in place, in accordance with the requirements of the MHA and MHA Code of Practice. For example, section 17 leave forms had been completed and recorded the conditions of leave. Section 17 forms had been signed by the patients.

20190830 RT1 Evidence appendix Page 269

We saw documentation in care records where patients were given full explanations for interventions and weighing up the risks and benefits.

Patients were given information about their rights under the Mental Health Act regularly and this was recorded. Patients could access advocacy services from Independent Mental Health Advocates (IMHAs) for support and advice. Contact information for IMHA was displayed on noticeboards and information leaflets were also available on the wards. As of 31 December 2018, 100% of the eligible workforce (13) in this service had received training in the Mental Health Act Level 1, however, 58% (14 of 24) had received training in the Mental Health Act Level 2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed three years. The training compliance reported during this inspection was higher than the 89% reported for the previous year for Level 1 and lower than the 68% reported for the previous year for Level 2. We saw local records that confirmed staff across services were up to date with Mental Health Act training at 100% compliance. Good practice in applying the Mental Capacity Act The Phoenix Centre admitted young people aged 13–18 years old. The Mental Capacity Act 2005 (MCA) does not apply to young people aged 16 and under. For children under the age of 16, staff applied the Gillick competency test. This recognised that some children might have a sufficient level of maturity to make some decisions themselves. Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and confirmed that capacity was assumed unless proven otherwise. We saw Section 85 Notifications clearly documented for under 16’s. Section 85 Notifications are required when a child is likely to be resident within an institution for 12 weeks or more and also when a child is discharged after a 3- month period. The trust had policies and procedures in place in relation to the Mental Capacity Act and the Deprivation of Liberty Safeguards. Staff could access these on the intranet. Staff could contact the Mental Capacity Act and Deprivation of Liberty Safeguards leads within the trust when they required additional support and guidance. We saw detailed records relating to the assessment and understanding of capacity across the service where decision specific assessments had been made and the best interests of the individual considered. Staff obtained consent from patients before providing care. They understood their legal obligations on how to support people who could not consent to their own care and treatment. Patients’ capacity to consent was reviewed at weekly ward rounds and documented. Patients records had detailed assessments regarding people’s capacity to make informed decisions about their care and treatment. When patients lacked capacity, staff made decisions in their best interests, which recognised the importance of the person’s wishes, feelings, culture and history. Where appropriate staff involved the patient’s family members to obtain further information. As of 31 December 2018, 100% of the eligible workforce (two) in this service had received training in the Mental Capacity Act Level 1, however, 73% (33 of 45) had received training in the Mental

20190830 RT1 Evidence appendix Page 270

Capacity Act Level 2. The trust stated that this training is mandatory for all services for inpatient and all community staff and renewed three years. The training compliance reported during this inspection was the same as the 100% reported for the previous year for Level 1 and higher than the 46% reported for the previous year for Level 2. The trust told us that no Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority for this service between 1 January 2018 to 31 December 2018. Is the service caring?

Kindness, privacy, dignity, respect, compassion and support We observed positive and caring interactions between staff and patients on the wards. Feedback from patients about staff was positive in the way that staff treated people. Patients felt staff cared about their well-being and health. We spoke with four carers, one person told us- staff were amazing and very caring and that staff always had the patient at the heart of their care. Carers stated they would not have coped without the army of help received.

Staff supported patients to understand and manage their care and treatment. Managers told us an ex-patient who had recovered from their condition came to speak with patients and provide motivation and answered questions.

Staff ensured that respect was given patients’ personal preferences, such as bed time and clothing. Staff on wards were compassionate and responsive. We saw in staff handovers staff cared about the patients. Staff had a good rapport with patients.

We saw at the Phoenix Centre staff used the new Maudsley approach with animal analogies. Each patient had an animal picture on their badge in their rooms in a light-hearted manner to explain what type of animal they were in terms of care.

The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at the locations scored similar to or slightly higher than similar organisations. Privacy, Site name Core service(s) provided dignity and wellbeing MH - Acute wards for adults of working age and psychiatric intensive care units MH - Eating Disorders Fulbourn Hospital MH - Forensic inpatient 93.7% MH - Other Specialist Services MH - Wards for older people with mental health problems Other - PMS service MH - Child and adolescent mental health wards Ida Darwin Hospital MH - Other Specialist Services 91.1% MH - Eating Disorders Addenbrookes Hospital MH - Eating Disorders 95.1% Trust overall 91.6% England average (mental health and 91.0% learning disabilities)

20190830 RT1 Evidence appendix Page 271

Involvement in care Involvement of patients Staff involved patients in care planning and gave them weekly copies of their care plans. Staff made sure patients understood their care and treatment. The psychologist on S3 ward ran weekly sessions with patients to check how patents were felt about their care and treatment: “How are people feeling.” Staff involved patients in decisions about the service at ward rounds, and community meetings every morning on both wards. The service was looking to employ a head of patient participation involvement (HOPPI) to work across the trusts children’s inpatients wards. Interviews were due early June. The head of patient participation involvement would enable patients to give feedback on the service received. Staff supported patients to maintain and develop their relationships with those close to them, and their social networks in the community.

Staff at the Phoenix Centre planned to involve patients in decisions about the service, participating in staff interviews for health care assistants’ and head of patient participation in June.

Staff ensured that patients could access advocacy. The advocate visited weekly and provided the S3 ward manager with a summary report each week.

Involvement of families and carers Staff contacted family members about joining multidisciplinary meetings, ward rounds, or care programme approach meetings. At S3 ward and the Phoenix Centre we saw records of detailed discussions around the level of involvement of family members at ward rounds, and care programme approach meetings. Staff had completed a carers assessment for one patient’s partner. Staff involved family and carers in the service.

At the Phoenix Centre family dining took place twice a week where patients families and carers were involved.

At the Cambridge community eating disorder service there were monthly carers group meetings, collaborative evening classes with topics suggested by patients and carers for example coping at Christmas, exercise and body image. Friends and ex-patients were able to attend. The service had a carers support pathway and we saw evidence of staff offering carer’s assessments to family members. At the Norfolk team carers were involved through family days: a carers group was also in development. Support for families/carers included impact of eating disorder on the family, with family-based Interventions, psycho-education and support groups attended by ex-parents/patients. Podcasts were available that provided guidance and information to both carers and patients awaiting and receiving a service.

20190830 RT1 Evidence appendix Page 272

Is the service responsive?

Access and discharge The trust provided a transitional worker that assisted young people discharge to adult and community services. Patient workbooks included planning for discharge with achievable targets to work towards. The multidisciplinary team assisted patients prepare for discharge and arranged for patients to see different professionals towards the end of their stay with a service. The community service psychiatrist attended all discharge meetings and had knowledge and access to patient details prior to discharge so the community team was aware and equipped with information even before a referral was made. When patients went on leave there was always a bed available when they returned. Staff did not move or discharge patients at night or very early in the morning. The psychiatric intensive care unit always had a bed available if a patient needed more intensive care. This was sufficiently close for the person to maintain contact with family and friends. The trust provided information regarding average bed occupancies for the two wards in this service between 1 January 2018 to 31 December 2018. Neither of the wards within this service reported average bed occupancies ranging above the recommendation of 85% over this period. However, the Phoenix Centre did have bed occupancy rates of between 97% and 99% between January and March 2018. Ward name Average bed occupancy range (1 January 2018 – 31 December 2018) S3 74% Phoenix Centre 66%

The trust provided information for average length of stay for the period 1 January 2018 to 31 December 2018. Ward name Average length of stay range (1 January 2018 – 31 December 2018) S3 143 Phoenix Centre 184

Staff data for Cambridge community eating disorder service showed an average wait from assessment to treatment was 16 weeks, the longest wait was 32 weeks. Where a patient was a priority they would be seen within seven weeks. The longest wait was 13 weeks. In the last six months patients would wait 25 working days for a routine appointment and 15 working days for an urgent appointment. Very urgent patients would be seen within two weeks. There were 39 patients on the waiting list. Four clinicians’ appointments were available each day at the service. The Norfolk community team had temporarily adjusted the criteria for admission to the service at the end of 2018. This meant that the service would only assess patients with a severe eating disorder with a BMI of less than 15. This had related to significant staff shortages that have since been resolved through active recruitment. The service had reduced a backlog of referrals and was looking to open admissions to additional patients when all new staff are in post. At the time of the inspection, there were 76 patients in treatment. All patients urgently referred had been assessed 20190830 RT1 Evidence appendix Page 273

but eight patients were waiting assessment following routine referral: four of these were above the 28-day target for being assessed. Thirteen patients were awaiting treatment following assessment. Eight patients were above the 18 week target. Waits ranged between two and 74 weeks, the average was 25 weeks. This had reduced from 48 patients awaiting treatment in October 2018. The trust has identified the below services in the table as measured on ‘referral to initial assessment’ and ‘referral to treatment’. The service met the referral to assessment target for the team where a target was provided. Targets were not provided for referral to treatment times. Days from referral to Days from referral Name of initial assessment to treatment Name of Please state hospital site or Team service type Actual Actual location Target Target (median) (median)

Provides services for CAMHS young people and Fulbourn Eating adolescents with 28 13 - 22 Hospital Disorders eating disorders up (Trustwide) to and including 18 yrs. Community based Community MH Services service for outpatient Eating (CPFT) at psychology-based - 21 - 68 Disorders Addenbrookes treatments. 17-65 Cambridge yrs. Community based Community MH Services service for outpatient Eating (CPFT) at psychology-based - 43 - 58.5 Disorders Addenbrookes treatments. 18-65 Norfolk yrs.

This service reported that two out area placements had been received from another provider between 1 January 2018 to 31 December 2018. As of 21 January 2019, both of these placements were ongoing. This service reported no readmissions within 28 days between 1 January 2018 to 31 December 2018. Managers and staff ensured they did not discharge patients before they were ready. We saw clear discharge plans in care records and patients were aware and involved in these plans. Staff ensured that patients and carers had copies of all discharge paperwork including any aftercare plans. Staff supported patients and their families when transferring between services. Particular focus was when a young person transitioned to the adult service. The transition worker worked across the adult and community services to ensure effective transition of patient care. No information was provided regarding delayed discharges for this service between 1 January 2018 and 31 December 2018.

20190830 RT1 Evidence appendix Page 274

Facilities that promote comfort, dignity and privacy Services had a range of rooms and equipment to support treatment and care. Managers at S3 ward and Cambridge community eating disorder service told us they had recently ordered new furniture and flooring for the service. There were quiet areas on the wards where patients could meet visitors. On S3 wards quiet areas were limited. Patients could make and receive phone calls in private. Most patients used their personal mobile phones. Patients on both wards had their own bedroom, which they could personalise. Bedrooms did not have ensuite facilities, however there were sufficient disabled toilets and bathroom facilities on wards. There were activity and therapy rooms including sensory rooms, large dining areas, adapted baths and shower facilities. On S3 ward the spacious dining room was also used as the activity room. There was a male lounge off the ward, near the ward main entrance. Patients had areas to secure their possessions. S3 ward was on a first floor and this could be accessed via a lift or stairs. The ward had a dedicated ground floor garden where wild rabbits sometimes visited. This included chairs, benches, mature trees shrubs, plants and a merlin statue. The garden gate was unlocked and maybe a risk to patients who are at risk of absconding. Garden furniture was dirty and not maintained, the bin was overflowing and there were large items of debris. These issues were raised with managers during the inspection. Action was immediately taken to clean up the garden risk assess the area and secure the gate.

Phoenix Centre patients had access to a large fenced garden area with shade, shrubs, and flowers and plants, planted by patients and staff. Garden furniture was identified for removal on the ward risk register, and alternative garden furniture obtained.

Food was provided on both wards by a catering provider. Patients had access to a range of food and drink choices including healthy snacks. Staff provided specialist food consistencies and supplements to meet assessed need. Mealtimes were structured and planned by the dietician occupational therapist. Patients on both wards were offered meal cookery activities.

Both wards had timetables displayed on the ward detailing patient activities, including activities in the evening and at weekends. Activities included walks with staff, arts and crafts groups, pampering days and board games.

Blanket restrictions were used only when justified. For example, patients on both wards were not allowed to enter each other’s bedroom, in order to keep themselves and others safe. This was a way of monitoring the patient and removing or reducing risks as far as possible. We saw in the ward information packs about ward expectations (ward rules).

Patients at the Phoenix Centre had access to a school on site. We saw most young people preparing for school/college exams.

The 2018 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at Fulbourn Hospital scored lower than similar trusts. Both Ida Darwin Hospital and Addenbrookes Hospital scored slightly higher.

Site name Core service(s) provided Ward food

MH - Acute wards for adults of working age and psychiatric intensive care units Fulbourn Hospital MH - Eating Disorders 83.2% MH - Forensic inpatient MH - Other Specialist Services

20190830 RT1 Evidence appendix Page 275

MH - Wards for older people with mental health problems Other - PMS service MH - Child and adolescent mental health wards Ida Darwin Hospital 95.1% MH - Other Specialist Services MH - Eating Disorders Addenbrookes Hospital MH - Eating Disorders 96.3% Trust overall 89.4% England average (mental health and learning 92.2% disabilities)

Patients’ engagement with the wider community One patient on S3 ward told us they had been out to the cinema with a group of patients and staff and really enjoyed the occasion. There were regular days out in the summer time and staff offered patients trips to the theatre and doctors gave patients regular leave. At the Phoenix Centre there was a weekly pilates and yoga class, led by a trained instructor. The occupational therapy team also offered patients meals out, where patients had the option to eat a meal out with the therapist as opposed to eating within the hospital. Staff gave families the opportunity to take patients to the hospital concourse or on days out. Meeting the needs of all people who use the service The service could support and make adjustments for people with disabilities, communication needs or other specific needs.

Information leaflets for patients in different language were not routinely available. Managers made sure staff and patients could get hold of interpreters or signers when needed. On wards staff gave patients and their families and carers information packs that gave key information, including information on treatment, psychological interventions, their rights, recommended reading including useful websites, and how to complain. Patients had meal plans devised with input from the dietician, occupational therapist and multidisciplinary team. At the Phoenix Centre special dietary requirements were met, one patient was provided a vegetarian diet and soya milk products as they were lactose intolerant. Patients had access to spiritual, religious, and cultural support. Three chaplains were appointed for mental health services and could be contacted by mobile phone or email. There were a range of ‘easy read’ leaflets available, including information on: care planning, complaints, Section 17 leave, the Mental Capacity Act, and the Deprivation of Liberty Safeguards.

For the most recent Patient-Led Assessments of the Care Environment (PLACE) (2018) Fulbourn Hospital and Addenbrookes Hospital scored higher than similar trusts for the environment being dementia friendly and for the environment supporting those with disabilities. Ida Darwin Hospital scored lower than similar trusts for both domains.

Dementia Site name Core service(s) provided Disability friendly

20190830 RT1 Evidence appendix Page 276

MH - Acute wards for adults of working age and psychiatric intensive care units Fulbourn MH - Eating Disorders 96.3% 96.2% Hospital MH - Forensic inpatient MH - Other Specialist Services MH - Wards for older people with mental health problems Other - PMS service Ida Darwin MH - Child and adolescent mental health wards 70.0% 83.9% Hospital MH - Other Specialist Services MH - Eating Disorders Addenbrook 100.0% 98.5% es Hospital MH - Eating Disorders Trust 92.9% 95.0% overall England average (Mental 88.3% 87.7% health and learning disabilities)

Listening to and learning from concerns and complaints Staff told us the service were committed to patient complaints being listened to and responded to appropriately. Patients knew how to complain or raise concerns. Managers told us staff received feedback on the outcome of investigations of complaints and acted on the findings. We saw complaints feedback in team meeting and governance meeting minutes. This service received three complaints between 1 January 2018 to 31 December 2018. One of these was upheld, one was partially upheld, and one was withdrawn. None were referred to the Ombudsman.

Ward

name

Total Total

Other

Under Under

Withdrawn

Not upheld Not

Referred to Referred

Complaints

Fully upheld Fully

Ombudsman

Investigation Partially upheld Partially S3 2 1 0 0 0 0 1 0 Phoenix 1 0 1 0 0 0 0 0 Centre

We looked at complaints’ information at the Norfolk community team there had been three complaints to the service since December 2018. Complaints reviewed had detailed investigations and had been responded to appropriately. The three complaints related to delays in treatment or a lack of service.

20190830 RT1 Evidence appendix Page 277

This service received 109 compliments during the last 12 months from 1 January 2018 to 31 December 2018 which accounted for 2% of all compliments received by the trust as a whole.

Is the service well-led?

Leadership Leaders at local levels had the right skills, knowledge and experience to lead their teams. They had a clear understanding of the services they managed and knew how their teams worked to provide high quality care. Staff reported they respected their local leaders and supported them. Patients and staff knew who the ward managers/team leaders/ matrons were, they were visible at the service and staff reported they were approachable. Vision and strategy Staff knew and understood the trust’s vision and values and strategic goals. At the Phoenix Centre a clinical nurse post had been created to co-work with the ward manager. The team were preparing for a move to a new build in around 2023 and actively planning for this. Staff were offered the opportunity to give feedback and input into service development. Staff did this through regular team meetings and contributing to discussions about the new build.

The modern matron at Cambridge community eating disorder service was preparing a business case with the trust for funding for- first episode rapid early intervention for eating disorders (FREED). The programme had been shown to reduce waiting times for treatment and the duration of untreated eating disorders in young people (aged 16 to 25) who have had an eating disorder for less than three years. Culture Managers promoted a positive culture. Staff felt respected and supported by their team, and local and senior managers. Staff felt proud to work for their team and the trust staff felt they could raise concerns without fear. At the Phoenix Centre not all staff felt valued or positive about their work in the team. Nursing leadership was still at the early stages of development. Staff understood the whistleblowing policy and knew about the Freedom to Speak Up Guardian. Managers supported staff who needed it to perform their jobs. We saw effective team working on all wards and good staff morale. Managers dealt with any difficulties when they happened. Staff were open and transparent and explained to patients when something went wrong. Managers supported staff during their appraisals and discussed career progression and development.

The trust promoted equality and diversity. The trusts equality, diversity and inclusion (ED&I) campaign is called Embrace. Staff had access to a range of equality and diversity training to ensure that there was sufficient expertise. The trust supported their staff with access to occupational health services. Staff made us aware of examples where the trust had recognised staff success and innovation in this core service. At Cambridge community eating disorder service, the staff team had been put forward for a Patients Experience Award and shortlisted to one of five teams.

20190830 RT1 Evidence appendix Page 278

Governance Across services there was a good understanding of best practice guidance NICE/MARSIPAN. Services provided support to patients’ families and carers and considered the impact of eating disorders on the family, family-based interventions, psycho –educational and support groups attended by carers, friends and ex-patients. Managers and staff received mandatory training and yearly appraisals. Shifts were covered by sufficient numbers of staff at the right grade and experience. Staff took part in local clinical audits and acted on the results. Staff learned from incidents, complaints and patient feedback. Staff at the Phoenix Centre and S3 wards were not all familiar with developments across the service. Staff had a robust understanding of safeguarding under the Care Act 2014, the Mental Health Act 1983 and the Mental Capacity Act 2005 procedures. Staff implemented recommended changes following reviews of the service.

Management of risk, issues and performance The provider understood risk but had not identified safety concerns around standards of cleanliness in the clinic room at the Phoenix Centre and failure to provide disposable gloves and aprons at Cambridge community eating disorder service. The service was sharing an electrocardiogram across three sites. Managers at the community eating disorder services had were yet to develop environmental risk assessments that addressed potential ligature points. Effective multidisciplinary meetings across the service helped to reduce patient risks and keep patients and staff safe. Staff notified and shared information with external organisations. Staff were open and transparent and explained to patients when something went wrong. We saw staff had good rapport with patients and good staff morale.

Staff were offered the opportunity to give feedback and input into service development. Staff did this through regular team meetings. The trust provided information governance systems to measure key performance indicators and to gauge the performance of teams. Managers had information that supported them.

Information management The systems to collect ward and directorate data did not create extra work for frontline staff. The system in place for recording staff supervision were not robust and did not provide assurance that staff were receiving regular supervision. Information governance systems included policy on confidentiality of patient records. Managers had access to information that supported them. All information was accessible, usually accurate and identified areas for improvement. There was an information sharing agreement with local GPs too, where the service could have access to the GPs electronic system and access patient information easily, with their consent. Staff notified and shared information with external organisations when necessary, seeking patient consent when required to do so.

Engagement

20190830 RT1 Evidence appendix Page 279

Staff, patients and their carers could access up to date information about the services they used, and the trust, through the service information, and the trust web site. Patients and carers could give feedback about their care and in ways that reflected their individual needs. Managers used the feedback from patients and carers to make improvements to the service. Managers and staff involved patients, families and carers in decisions about changes to the service at ward/service level. Directorate leaders engaged with external stakeholders.

Learning, continuous improvement and innovation NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited. Both inpatient wards were working towards re-assessment for accreditation schemes Quality Network for Eating Disorders (QED).

20190830 RT1 Evidence appendix Page 280