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Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 1
Mersey Care NHS Foundation Trust
Evidence appendix
V7 Building
Kings Business Park
Prescot
Liverpool
L34 1PJ
Tel: 0151 473 0303
www.merseycare.nhs.uk
Date of inspection visit:
29 October to 20 December 2018
Date of publication:
5 April 2019
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.
Trust-wide leadership
Facts and data about this trust Mersey Care NHS Foundation Trust provides specialist inpatient and community mental health,
learning disability and substance misuse services to adults in Liverpool, Sefton and Kirkby. It also
provides community health services to adults and children in Liverpool and South Sefton. The
trust provides specialist high secure and learning disability and autism secure beds to a much
wider population encompassing North West England, parts of central England, and Wales.
The trust was established on 1 April 2001 and granted NHS Foundation Trust status in May 2016.
The trust currently employs almost 8000 staff. The trust provides local mental health, learning
disability and community health services to a population of around 1.2 million people, and
specialist high secure and learning disability services to a population of around 11 million people.
On 1 July 2016 the trust acquired Calderstones NHS Foundation Trust. On 1 June 2017 the trust
acquired the parts of Liverpool Community Health NHS Trust that were providing services in South
Sefton, and on 1 April 2018 the trust acquired the parts of the same trust that were providing
services in Liverpool.
The trust has an annual turnover of £370 million.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 2
At the time of our inspection the trust’s services were delivered through four divisions:
• Secure division comprising high secure services at Ashworth Hospital, medium secure
services at Scott Clinic, low secure services at Rathbone Hospital and mental health
services in HMP Liverpool.
• Specialist learning disability division comprising the low and medium secure wards, an
enhanced support ward and individualised packages of care at the trust’s Whalley site,
along with community, inpatient and respite services for people with a learning disability or
autism living in Liverpool, Sefton or Kirkby.
• Local division comprising the remaining mental health, learning disability and some social
care services provided to the adult population of Liverpool, Sefton or Kirkby.
• Community health division comprising community health services provided to the
population of Liverpool and South Sefton.
The trust’s services were commissioned by:
• NHS England and NHS Wales
• Liverpool, South Sefton, Southport and Formby, Knowsley, St Helens, Halton, West
Lancashire, East Lancashire, North Lancashire and Greater Manchester clinical
commissioning groups.
• Liverpool City Council, Sefton Metropolitan Council, Knowsley Metropolitan Council and
Halton Borough Council.
The trust is also part of the Health and Care Partnership for Cheshire and Merseyside (formerly
Cheshire and Merseyside Sustainability and Transformation Partnership).
The trust had 25 locations registered with the CQC (on 31 October 2018).
Registered location Code Local authority
Ambition Sefton (South) RW41R Sefton
Ambition Sefton North (Church Street) RW41T Sefton
Ashworth Hospital RW404 Sefton
Boothroyd Ward RW449 Sefton
Broadoak Unit RW433 Liverpool
Clock View Hospital RW41E Liverpool
Garston Walk in Centre RW4X1 Liverpool
HMP Liverpool RW4X6 Liverpool
Hesketh Centre RW403 Sefton
Heys Court RW435 Liverpool
Hope Centre RW446 Liverpool
Liverpool Walk in Centre RW4X5 Liverpool
Mersey Care NHS Trust Offices RW498 Knowsley
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 3
Registered location Code Local authority
Morley Road RW436 Sefton
Mossley Hill Hospital RW438 Liverpool
Old Swan Walk in Centre RW4X3 Liverpool
Rathbone Hospital RW401 Liverpool
Scott Clinic RW493 St Helens
Sid Watkins Building RW41K Liverpool
Smithdown Children's Walk in Centre RW4X2 Liverpool
Specialist Learning Disability Division RW41P Lancashire
Star Unit RW4W1 Liverpool
Ward 35 Intermediate Care Unit RW4W2 Liverpool
Wavertree Bungalow RW453 Liverpool
Windsor House RW454 Liverpool
The trust had 779 inpatient beds across 53 wards. The trust also had 2133 community physical
health clinics per month and 2195 community mental health clinics per month.
Total number of inpatient beds 779
Total number of inpatient wards 53
Total number of day case beds N/A
Total number of children's beds (MH setting) N/A
Total number of children's beds (CHS setting) N/A
Total number of community physical health clinics per month 2133
Total number of community mental health clinics per month 2042
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 4
Is this organisation well-led?
Leadership
The trust had the leadership capacity and capability to deliver high quality, sustainable care. Board
members had the skills, knowledge, experience and integrity needed to lead the trust. They
understood the challenges to quality and sustainability and could identify the actions needed to
address them.
The board comprised a chief executive, chair, executive director of finance (who was also deputy
chief executive), executive director of communications and corporate governance, executive
director of workforce, executive director of nursing and operations and medical director. The trust
also had a non-voting director of strategy. All executive directors had experience at board level
prior to joining the trust. The chief executive had been in post since 2012 and had previously been
chief executive at another NHS organisation. Non-executive directors had managed at very senior
level within private and/or public sector organisations. Two non-executive directors were clinicians
with executive experience in the NHS, four non-executive directors had strong backgrounds in
business and finance, and one non-executive director was a clinician with public health
experience.
NHS Improvement told us that the board was well-established and stable, with a broad range of
experience and skills appropriate to the delivery of high quality care. NHS Improvement also told
us that they had confidence in the director of finance and finance department. Commissioners told
us that the executive team were experienced and open to challenge.
During our well-led review we spoke with all of the board members and the trust secretary.
Executive and non-executive directors had an in-depth understanding of the running of the trust.
The trust’s chief executive and senior leadership team were also well-sighted on national and local
issues that impacted on service provision.
We reviewed all of the board members’ personnel files and undertook a detailed review of the
recruitment process for the most recently appointed executive and non-executive. There were
effective systems in place to ensure that board members were fit for the role on appointment and
throughout their employment. This included fit and proper person checks.
We attended two board meetings. We saw that discussion on issues was balanced and effective,
and that decisions were informed by consideration of quality, performance and strategy. Non-
executives provided constructive challenge and expertise.
The trust also had effective divisional and professional leadership in place. There was a chief
operating officer for each of the four divisions, and professional leads for nursing, psychology,
allied health professionals, social work, pharmacy and medics.
Leaders ensured that they were visible and approachable. Staff who spoke with us during focus
groups and during our inspections of core services knew who the chief executive and chair of the
trust were. One member of staff told us that the chief executive had visited their ward to see how
the staff were after a number of difficult incidents, and another said that the chief executive had
sent them a personal letter of thanks. Board members each engaged in a programme of visits to
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 5
services. Many staff told us that senior leaders had visited and worked in their services as part of
‘free up Fridays’. ‘Free up Fridays’ meant that leaders kept Fridays free of meetings so that they
could visit operational teams and work alongside staff. The trust had put this in place following the
results of NHS staff surveys.
The trust had implemented an additional programme of board member and chief operating officer
visits to community health services both before and after the acquisition to ensure that they were
listening to staff and acting on their concerns.
The chief executive published a weekly blog on the trust website. The blogs provided updates on
national, local and trust-level issues. Through his blog, the chief executive consistently gave
positive and motivational messages about staff commitment to ‘go the extra mile’, achievements in
line with trust strategy, and meaningful patient/carer involvement. All people, including staff,
patients, carers and members of the public were able to tell the chief executive what they thought
about the trust through the ‘tell Joe’ email address.
There was evidence of ‘collective leadership’. The King’s Fund define collective leadership as
‘everyone taking responsibility for the success of the organisation as a whole’. The trust had
distributed leadership power according to individuals’ expertise, capability and motivation. This
included patients taking on leadership roles in values-based recruitment and reducing restrictive
practice. We saw and heard about individuals with supportive, enabling and empowering
leadership styles from board level to core service level.
Commissioners told us that the chief executive and executive director of nursing and operations
were accessible and responsive.
There were clear priorities for sustainable, compassionate, inclusive and effective leadership. The
trust had a leadership development programme, which included succession planning.
The trust had undertaken a recent review of the capacity of the board, prompted by the acquisition
of Liverpool Community Health NHS Trust and by the departure (on secondment) of the previous
director of nursing. The role of director of operations was combined with the role of director of
nursing, and many of the previous responsibilities of the director of nursing were distributed
among the rest of the executive team.
The board had considered the implications in detail before combining the director of operations
and director of nursing roles. The chief executive and the director of nursing and operations
explained that the decision was made so that the director would have the authority to facilitate
rapid change in an area (community health) that employed 60% of the trust’s nurses. The chief
executive also explained that he was keen to provide challenge and development to the rest of his
leadership team, and that the spread of the portfolio played to people’s strengths. We saw
evidence of this in some of our interviews, for example the executive director of communications
and corporate governance was passionate and knowledgeable about the trust’s estate. However,
there was also evidence of directors still working to gain full oversight of some of their new
responsibilities.
At the time of inspection, the medical director was seconded to NHS England and NHS
Improvement for two and a half days a week. He also worked as a clinician for one day a week,
which left him one and a half days to fulfil his responsibilities as medical director, Caldicott
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 6
guardian, controlled drugs accountable officer, executive lead for Mental Health Act, executive
lead for quality improvement and innovation, executive lead for quality assurance and executive
lead for high secure services. There was no evidence that the medical director did not have
capacity to fulfil his role in the trust. The medical director was skilled, knowledgeable and had
reasonable oversight of all areas within his portfolio. He was well-supported by a team of
associate medical directors and by the director of patient safety. The potential risk of the medical
director being unable to fulfil his role in future was mitigated by the NHS Improvement secondment
coming to an end in March 2019, and by a planned restructure of medical posts within the trust.
The trust planned to commission a well-led and board skills review in 2019. The trust had also
appointed a new director of corporate transformation, directly reporting to the chief executive.
The trust’s leadership development pathway was open to all staff and included three values-based
core programmes: ‘strive’ for bands 5 and below, ‘thrive’ for bands 5 to 7, and ‘drive’ for 8a and
above. The Kirkup review into failings at Liverpool Community Health NHS Trust had identified a
lack of leadership skills at senior and management levels. Mersey Care NHS Foundation trust was
in the process of developing leadership skills for staff in community health teams through their
existing programme (‘thrive’, ‘strive’ and ‘drive’), training new ‘team coaches’ and including staff in
trust leadership forums.
The executive board had 0% Black and minority ethnic (BME) members and 50% women. The
non-executive board had 0% BME members and 43% women. The board recognised that it did
not reflect the demography of the population it served (around nine per cent of Liverpool’s
population is Black or minority ethnic). The board planned for governors to take a lead role in
involving local communities to make services more responsive to those with protected
characteristics.
BME % Women %
Executive 0 (0%) 3 (50%)
Non-executive 0 (0%) 4 (57%)
Total 0 (0%) 7 (64%)
Vision and strategy
There was a clear vision and set of values, with quality and sustainability as the top priorities. The
vision, values and strategy had been developed using a structured planning process in
collaboration with staff, people who use services and external partners.
The trust’s vision was ‘to strive for perfect care and a just culture’. Perfect care was defined as
‘setting our own stretching goals for improvements in care’, ‘getting the basics of care right every
time’ and ‘helping people try improvements, learn from their mistakes and apply what works more
rapidly’. A ‘just culture’ was about supporting and empowering staff to learn when things did not go
to plan, rather than feeling blamed. Staff knew and understood what the vision, values and
strategy were, and their role in achieving them.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 7
In 2018 the trust refreshed their values (continuous improvement, accountability, respect and
enthusiasm) as part of their people plan. The trust had prioritised the alignment of the trust and the
community health team’s values at a very early stage of the acquisition, as they had identified that
staff in Liverpool Community Health NHS Trust had not been working to values. To this end the
trust held a large-scale consultation and engagement event for all staff. The outcome was that a
fifth value was added, ‘support’. Trust values were integral to recruitment processes, staff
appraisals and staff awards. Many of the staff we spoke with during our inspection of services
were able to tell us what the values meant to them and their teams.
There was a robust, realistic strategy for achieving the priorities and delivering good quality
sustainable care. A ‘strategic wheel’ illustrated how the trust intended to achieve its vision through
empowered teams and empowered service users. The trust had four priorities, which were zero
suicides, no force first (reduction in restrictive practice), physical health and a just culture. The
trust had an overall operational plan 2018/2019 with an overall priority to deliver safe care while
developing integrated services. The trust had nine ‘top quality improvement priorities’ underpinned
by clear targets.
NHS Improvement told us that the trust developed robust financial plans for NHS Improvement in
line with national requirements. These plans were aligned to the trust’s overall strategy, with ‘our
resources’ one of the four aims within the operational plan.
The trust’s medicine optimisation strategy aimed to establish a working plan for the expanded
trust. The strategy was based on the four key principles from The Royal Pharmaceutical Society. It
provided a detailed action plan and timeframe necessary to achieve the necessary outcomes from
the strategy.
One of three deputy directors of nursing held responsibility for infection prevention and control.
There were systems in place to manage and monitor the implementation of the trust’s infection
prevention and control strategy.
The strategy was aligned to local plans in the wider health and social care economy. Services had
been planned to meet the needs of the relevant population. The trust’s original bid for community
health services emphasised a model of integrated care, ‘breaking down barriers between physical
and mental health and…addressing the holistic needs of the people using services’. The trust’s
vision was to address the wider factors impacting on poor health and shift towards prevention and
early intervention. We saw evidence of the trust starting to put this vision into action, for example
through the creation of ‘provider alliances’ in Liverpool and Sefton in November 2017 and
February 2018 respectively. Provider alliances were chaired by the trust and facilitated
collaboration between health, social care, voluntary sector and housing organisations who were
linked to or impacted by community services.
The trust was actively involved in the Health and Care Partnership for Cheshire and Merseyside
(formerly Cheshire and Merseyside Sustainability and Transformation Partnership). The trust’s
strategy was closely aligned to local plans in the health and social care economy, particularly in
terms of increased place-based delivery of services. The trust intended to merge its local and
community health divisions, developing integrated community care teams for populations of 30
000 – 50 000. Staff within these teams would be trained to deliver ‘biopsychosocial’ interventions,
with additional support available from specialist colleagues and ‘extended teams’ of voluntary
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 8
sector, community provider and hospital services. The trust had originally planned to roll out its
new community model in April 2019 but had amended its timescale to April 2020 following the
recommendations of an external post-acquisition review.
Culture
There was a culture of high-quality, sustainable care. The trust’s culture was centred on the needs
and experience of people who use services. The conversations that we observed at the trust
board meetings focused on the patient experience and the vision to strive for perfect care.
Staff felt supported, respected and valued. They also felt positive and proud to work in the
organisation. Many of the staff in the focus groups told us how passionate they were about
providing high-quality care to patients.
The trust had set up a system for colleagues, patients and/or carers to submit a ‘thank you’ to a
member of staff through the trust intranet. The thank you would also automatically go to the staff’s
manager and on their personnel record. A number of staff we spoke with during our focus groups
said that these ‘thank you’ messages meant a lot to them.
Staff at the trust’s Whalley site voiced some frustration and uncertainty about their future following
NHS England’s decision to close the hospital. Many of the staff from medium secure learning
disability wards spoke positively about the trust’s efforts to promote the new medium secure unit
(Rowan View) being built on the Maghull site. The trust had provided transport for groups of staff
to visit the site. Some staff told us they were now more likely to want to work there following the
closure of the learning disability services provided at Whalley. They said that the journey had not
been as difficult as they expected, and that they looked forward to providing services in the ‘state
of the art’ facilities. Staff from low secure learning disability wards were uncertain about their future
but still told us that communication from the trust had been good. They said that their uncertainty
was outside the trust’s control.
In the 2017 NHS Staff Survey the trust had better results than other similar trusts in six key areas:
Key finding Trust score Similar trusts average
KEY FINDING 20. Percentage of staff experiencing discrimination at work
in the last 12 months
11% 14%
KEY FINDING 16. Percentage of staff working extra hours 69% 72%
KEY FINDING 24. Percentage of staff / colleagues reporting most recent
experience of violence
97% 93%
KEY FINDING 27. Percentage of staff / colleagues reporting most recent
experience of harassment, bullying or abuse
70% 61%
KEY FINDING 31. Staff confidence and security in reporting unsafe
clinical practice
3.79 3.71
KEY FINDING 2. Staff satisfaction with the quality of work and care they
are able to deliver
3.88 3.83
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 9
In the 2017 NHS Staff Survey the trust had worse results than other similar trusts in 12 key areas: Key finding Trust score Similar trusts average
KEY FINDING 18. Percentage of staff attending work in the last 3 months
despite feeling unwell because they felt pressure from their manager,
colleagues or themselves
55% 53%
KEY FINDING 15. Percentage of staff satisfied with the opportunities for
flexible working patterns
56% 60%
KEY FINDING 22. Percentage of staff experiencing physical violence from
patients, relatives or the public in last 12 months
27% 22%
KEY FINDING 23. Percentage of staff experiencing physical violence from
staff in last 12 months
3% 3%
KEY FINDING 7. Percentage of staff able to contribute towards
improvement at work
70% 73%
KEY FINDING 12. Quality of appraisals 3.05 3.22
KEY FINDING 13. Quality of non-mandatory training, learning or
development
4.01 4.06
KEY FINDING 30. Fairness and effectiveness of procedures for reporting
errors, near misses and incidents
3.70 3.75
KEY FINDING 4. Staff motivation at work 3.87 3.91
KEY FINDING 8. Staff satisfaction with level of responsibility and
involvement
3.85 3.88
KEY FINDING 9. Effective team working 3.76 3.84
KEY FINDING 10. Support from immediate managers 3.85 3.95
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 87% and 92% for patients who would recommend the trust as a place to
receive care between March 2018 and August 2018. July 2018 saw the highest percentage of
patients who would recommend the trust as a place to receive care with 92%.
The trust was better than the England average in terms of the percentage of patients who would
not recommend the trust as a place to receive care in four of the six months and scored the same
in the remaining two months.
Trust wide responses England averages
Total eligible Total responses
% that would
recommend
% that would not
recommend
England average
recommend
England
average not
recommend
Aug 2018 12,362 408 87% 3% 90% 3%
Jul 2018 12,542 449 92% 2% 89% 4%
Jun 2018 13,282 438 87% 4% 89% 4%
May 2018 14,207 488 91% 2% 89% 4%
Apr 2018 13,997 411 90% 3% 89% 4%
Mar 2018 14,402 388 87% 3% 89% 4%
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 10
The Staff Friends and Family Test asks staff members whether they would recommend the trust
as a place to receive care and as a place to work.
The percentage of staff that would recommend the trust as a place to work in Q1 18/19 stayed
about the same when compared to the same time last year.
The percentage of staff that would recommend the trust as a place to receive care in Q1 18/19
increased when compared to the same time last year.
There is no reliable data to enable comparison with other individual trusts or all trusts in England.
The table below gives an overview of trust staffing levels. It provides data on substantive staff
numbers, vacancies and sickness, and use of bank and agency staff. This data was provided to us
by the trust in August 2018 and covers the period 1 August 2017 to 31 July 2018.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff July 2018 6283 N/A
Total number of substantive staff leavers August 2017 – July 2018 640.94 N/A
Average WTE* leavers over 12 months (%) August 2017 – July 2018 13% N/A
Vacancies and sickness
Total vacancies overall (excluding seconded staff) July 2018 634.64 N/A
Total vacancies overall (%) July 2018 -9% 5%
Total permanent staff sickness overall (%) July 2018 8% N/A
August 2017 – July 2018 7% N/A
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) July 2018 2218.5 N/A
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 11
Substantive staff figures Trust target
Establishment levels nursing assistants (WTE*) July 2018 1652.3 N/A
Number of vacancies, qualified nurses (WTE*) July 2018 180.1 N/A
Number of vacancies nursing assistants (WTE*) July 2018 190.0 N/A
Qualified nurse vacancy rate July 2018 8% 5%
Nursing assistant vacancy rate July 2018 12% 5%
Bank and agency use
Hours bank staff filled to cover sickness, absence or vacancies
(qualified nurses) August 2017 – July 2018 114766 N/A
Hours filled by agency staff to cover sickness, absence or
vacancies (Qualified Nurses) August 2017 – July 2018 63806 N/A
Hours NOT filled by bank or agency staff where there is
sickness, absence or vacancies (Qualified Nurses) August 2017 – July 2018 32534 N/A
Hours filled by bank staff to cover sickness, absence or
vacancies (Nursing Assistants) August 2017 – July 2018 230748 N/A
Hours filled by agency staff to cover sickness, absence or
vacancies (Nursing Assistants) August 2017 – July 2018 94847 N/A
Hours NOT filled by bank staff where there is sickness,
absence or vacancies (Nursing Assistants) August 2017 – July 2018 16859 N/A
*Whole-time Equivalent
The trust reported a 12% vacancy rate for nursing assistants, an 8% vacancy rate for registered
nurses and a 19% vacancy rate for consultants. The trust had 794 posts in the recruitment
process, for which 443.74 offers of employment had been made and/or start dates agreed. The
trust told us that the number of posts in the recruitment process was higher than the number of
vacancies to account for staff who had resigned but not yet left the organisation. The trust’s
overall vacancy rate, 7%, was the same as that reported prior to our previous inspection of March
2017.
The trust had a workforce plan that included consideration of the impact of anticipated staff
retirement on specific services. The trust had a number of recruitment and retention initiatives,
including a ‘retire and return’ mentorship scheme, full use of the apprenticeship levy, funded nurse
training for band 4 staff, investment and development of band 5 staff and a partnership with the
Department of Work and Pensions to offer work-based learning to local people.
As at 31 May 2018, the training compliance for trust wide services was 87% against the trust
target of 90% - some courses had a target of 95%. Of the training courses listed, 30 failed to
achieve the trust target and of those, 14 failed to score above 75%. The training compliance
reported for the trust during this inspection was lower than the 90% reported in the previous year.
Action was taken to address behaviour and performance that was inconsistent with the vision and
values, regardless of seniority. We reviewed six staff disciplinary investigations. Each followed the
trust policy. Investigations were thorough, with information from multiple sources being gathered
and reviewed before decisions were made. Staff members were advised of their rights to
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 12
representation and kept informed throughout the process. Five of the investigations had been
resolved in a timely manner. The trust provided valid reasons for the delay in resolving the sixth
investigation.
The culture encouraged openness and honesty at all levels within the organisation, including with
people who use services, in response to incidents. Leaders and staff understood the importance of
staff being able to raise concerns without fear of retribution. Appropriate learning and action was
taken as a result of concerns raised.
The trust had multiple ways for staff to report concerns – through the freedom to speak up
guardian, by following the whistleblowing policy, using ‘tell Joe’ (an email address for the chief
executive) or through their staff side representative. The chief executive told us that this had on
occasion resulted in more than one investigation into the same issue. The trust planned to move to
a single point of triage to ensure consistency.
The trust had two freedom to speak up guardians, a freedom to speak up (whistleblowing) strategy
and a freedom to speak up (whistleblowing) policy. The policy met the standards set out in NHS
Improvement’s ‘freedom to speak up: raising concerns (whistleblowing)’ policy (2016). The
freedom to speak up guardians had the training and experience to be able to perform their roles.
They raised awareness through the trust website/intranet, posters (many of which we saw during
our inspection) and by visiting service sites. Staff we spoke with on inspection and in focus groups
knew who at least one of the guardians were and said that they felt confident to approach them
with any concerns. Staff also told us that they knew how to use the whistleblowing process and felt
confident to raise concerns without fear of retribution.
The trust undertook seven whistleblowing investigations in 2018. We reviewed five of them.
Investigations were thorough and objective. Outcomes and lessons learned were shared with
relevant individuals, including the original whistleblower where their identity was known.
The trust’s culture encouraged candour at all levels and candour was central to organisational and
personal learning. The trust duty of candour policy met the requirements of the regulation. During
our inspection we undertook a detailed review of six incidents where the trust had applied duty of
candour. Staff had followed the trust policy. They had informed people of the incident and provided
an apology, truthful information and reasonable support.
The trust monitored the application of duty of candour against the regulation. Between April 2018
and December 2018, the trust applied the duty of candour to 75 patient safety incidents. There
were 34 deaths, four incidents of severe harm, and 37 incidents of moderate harm. The severe
and moderate harms mainly related to self-harm for the local and secure divisions, and to pressure
ulcers for the community division. A family liaison manager or clinical lead was appointed to
manage each case. A letter of apology was sent to 63 patients or families. There were no contact
details in five of the cases, and no reply to contact from the trust in a further seven cases.
Commissioners told us that they were not confident that the trust was applying duty of candour to
moderate harm incidents. We found some evidence to corroborate this during our inspections of
community health services. When we looked into this further we found that the trust had recently
re-assessed a number of incidents occurring between April 2018 and October 2018. They had
originally identified only two moderate harm incidents; following their review this increased to 28.
The trust had also made some changes to their policy to clarify thresholds for patient safety
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 13
incidents and appointed a single member of staff to manage duty of candour in the community
division.
The trust considered the safety and wellbeing of staff. The trust’s overall sickness rate was 8%,
which was the same as the sickness rate reported prior to our March 2017 inspection. The trust’s
overall sickness rate is higher than the average for mental health and learning disability trusts
(which is 5% according to figures published by NHS Digital). A number of the staff that we spoke
with during our focus groups said that high levels of staff sickness impacted on their workload and
morale. Some staff said that it was difficult to take breaks and holidays as they were required to
cover for colleagues who were absent.
The trust had plans in place to reduce sickness absence. These included the development of a
sickness absence reduction plan based on the Department of Health ‘5 high-impact changes’, an
audit to identify and plan support for individual teams reporting sickness absence higher than 6%,
additional short-term investment in staff support services.
The medical director told us that there had been no breaches of safe working hours for junior
doctors. The British Medical Association representative said that there were very few rota gaps.
However, some of the junior doctors working at the trust told us that they were not encouraged to
report when their actual work had varied from an agreed work schedule. We spoke with the
guardian of safe working hours, who confirmed that he believed that junior doctors were working
over their hours on occasion but not making exception reports. This meant that the trust could not
be assured that risk of staff fatigue was being adequately mitigated against. The guardian stated
that exception reporting was encouraged at the junior doctors’ induction, by email and through the
junior doctors’ forum. The minutes of the most recent junior doctors’ forum confirmed this, however
the meetings were not well-attended.
Equality and diversity were promoted within and beyond the organisation. The trust had an
equality, diversity and human rights strategy and an equality committee chaired by a non-
executive director. The director of workforce was the executive lead for equality and diversity. The
trust had recently undertaken a full review of their equality and diversity strategy in conjunction
with staff networks. All trust policies included an equality impact assessment.
The trust had recognised that having a single equality and diversity network for staff was not
effective, so they had re-established specific networks for Black and minority ethnic staff, LGBTQI
staff, disabled staff and women. At the time of the inspection the Black and minority ethnic and the
women’s network had very recently launched and the LGBTQI was due to launch in January 2019.
Staff within the networks had agreed that part of their role would be to ensure services were
accessible to all, as well as supporting colleagues within the trust. The Black and minority ethnic
staff network was co-producing the workforce race equality standard action plan alongside the
trust’s human resources team.
The trust had a reciprocal mentoring scheme for Black, minority ethnic and disabled staff. The
trust had also invited Roger Kline (author of research into discrimination in the NHS) to speak to
the board and members of the Black and minority ethnic network.
The trust had plans in place to recruit more staff from Black and minority ethnic communities in
Liverpool. The trust was keen to ensure that the ethnic make-up of its staff reflected that of its
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 14
patients, particularly in high secure services where a higher proportion of patients were from Black
and minority ethnic backgrounds.
There were cooperative, supportive and appreciative relationships among staff. Staff and teams
worked collaboratively, shared responsibility, and resolved conflict quickly and constructively.
One of the trust priorities was the ‘just and learning culture’. The aim of the just and learning
culture was to value all safety concerns as integral to learning and improvement. The just and
learning culture had only just been added to the trust vision when we last inspected the trust in
2017. When we returned, we saw that it had become embedded at all levels from board to service
delivery. Trade union representatives told us that they had seen a significant shift in the way that
staff felt about the trust’s approach to serious incidents. The trust told us that the number of
disciplinary investigations had reduced by 54% since 2016. The trust’s just and learning culture
initiative had won the 2018 Healthcare People Management Association award for partnership
working, had been referenced by the British Medical Association and NHS Improvement as best
practice, and had featured in a number of healthcare magazines and a short film.
We spoke with representatives of six different trade unions. Representatives were all positive
about the work that the trust had done to include staff as an integral part of trust strategy and
reduce the numbers of staff disciplinaries. Representatives told us that trust executives always
took the time to listen and explain.
The trust had appointed to a staff side lead ‘just and learning’ post, whose main responsibility
would be to further embed the just and learning culture within community health services.
There were mechanisms for providing all staff at every level with the development they needed,
including high-quality appraisal and career development conversations. The trust’s target rate for
appraisal compliance was 95%. As at 31 July 2018, the overall appraisal rate for non-medical staff
was 86%. Fifteen of the 18 core services achieved the trust’s target appraisal rate. The rate of
appraisal compliance for non-medical staff reported as of 31 July is higher than the 74% reported
for the previous financial year.
Core Service
Total number of
permanent non-
medical staff
requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an
appraisal
% of non-medical
staff who have had
an appraisal
MH - substance misuse 32 32 100%
MH - Other Specialist Services 84 82 98%
MH - Long stay/rehabilitation mental health
wards for working age adults 57 55 96%
CHS - End of Life Care 18 17 94%
MH - Community mental health services for
people with a learning disability or autism 189 175 93%
MH - Wards for people with learning
disabilities or autism 562 520 93%
MH - Community-based mental health 126 116 92%
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 15
Core Service
Total number of
permanent non-
medical staff
requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an
appraisal
% of non-medical
staff who have had
an appraisal
services for older people
MH - Acute wards for adults of working age
and psychiatric intensive care units 306 279 91%
MH - Secure wards/Forensic inpatient 280 255 91%
CHS - Urgent Care 76 69 91%
CHS - Sexual Health 73 66 90%
MH - Wards for older people with mental
health problems 153 134 88%
CHS - Community Dental 71 61 86%
MH - Forensic (high secure) 824 705 86%
MH – Crisis 85 72 85%
CHS - Children, Young People and
Families 210 175 83%
CHS - Adults Community 1629 1343 82%
MH - Community-based mental health
services for adults of working age 790 624 79%
Total 5565 4780 86%
The trust’s target rate for appraisal compliance was 95%. As at 31 July 2018, the overall appraisal
rate for medical staff was 79%. The trust did not supply appraisal data for permanent medical staff
for core services other than those in the table below. One of the three core services achieved the
trust’s target appraisal rate. The one core service failing to achieve the trust’s appraisal target was
CHS Community Dental (77%). The rate of appraisal compliance for medical staff reported as of
31 July 2018 is higher than the 66% reported for the previous financial year.
Core Service
Total number of permanent
medical staff requiring an
appraisal
Total number of permanent
medical staff who have had
an appraisal
% of medical staff
who have had an
appraisal
CHS Sexual Health 7 7 100%
CHS Adult Community 0 0 N/A
CHS Community Dental 26 20 77%
Total 33 27 81%
The trust’s target for staff compliance with clinical supervision was 90%. The relevant trust policy
stated that clinical staff must have a minimum of 6 supervision sessions annually unless there are
mitigating circumstances authorised by the service manager. According to the data the trust
provided to us, as at 31 July 2018, the overall clinical supervision rate was 32%. Excluding
community health services and looking only at the divisions (secure, specialist learning disability
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 16
and local) that had been part of the trust for a substantial period, the overall supervision rate was
48%.
The trust’s target for staff compliance with clinical supervision was 90%. The table below shows
the level of compliance by each core service.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different
ways. It is important to understand the data they provide.
Core Service
Formal supervision
sessions each identified
member of staff had in the
period
Formal supervision
sessions should each
identified member of staff
have received
Clinical
supervision
rate (%)
MH - Substance misuse 15 15 100%
MH - Community-based mental health
services for older people 128 140 91%
MH - Other Specialist Services 142 173 82%
MH – Crisis 153 200 77%
MH - Wards for older people with mental
health problems 181 238 76%
MH - Acute wards for adults of working age
and psychiatric intensive care units 435 626 69%
MH - Forensic (high secure) 1039 1734 60%
MH - Long stay/rehabilitation mental health
wards for working age adults 76 133 57%
MH - Community-based mental health
services for adults of working age 1842 3794 49%
MH - Secure wards/Forensic inpatient 296 646 46%
MH - Community mental health services for
people with a learning disability or autism 50 116 43%
MH - Wards for people with learning
disabilities or autism 333 1932 17%
CHS - Children, Young People and
Families 134 2688 5%
CHS - Adults Community 26 2274 1%
CHS - End of Life Care 0 53 0%
CHS - Sexual Health 0 93 0%
CHS - Urgent Care 0 226 0%
Other 253 0 0%
TOTAL 4850 15334 32%
The data presented above is from a trust system that was in development at the time of
inspection. The trust told us that central collection had only been possible for three months, not 12
months.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 17
We calculate trust staff’s compliance with clinical supervision by comparing the number of
sessions attended with the number that should have been attended over a given period (in this
case, one year). Mersey Care NHS Foundation Trust calculate compliance by comparing the
number of staff who have attended clinical supervision within the last eight weeks to the number of
staff who have not. Mersey Care’s own figures give a compliance rate of 54% for secure, specialist
learning disability and local divisions in June 2018 and a compliance rate of 67% for the same
divisions in July 2018. By December 2018, the compliance rate was 85%.
The trust said that local managers had advised them that the figures relating to August 2017 – July
2018 did not reflect the true picture. Figures for compliance with clinical supervision were held in
individual databases, separate SharePoint systems and manually. During our inspections of core
services, we found evidence that staff were accessing regular clinical supervision. The trust had
recently altered the electronic recording system to allow staff to more easily log unplanned clinical
supervision and supervision of staff who they did not line manage.
The trust was asked to comment on their targets for responding to complaints and current
performance against these targets for the last 12 months.
In Days Current Performance
What is your internal target for responding to* complaints? 3 100%
What is your target for completing a complaint? 25 65%
If you have a slightly longer target for complex complaints please indicate what
that is here N/A N/A
* 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
last 12 months 2313 1 August 2017 – 31 July 2018
Number of complaints referred to the ombudsmen (PHSO) in the
last 12 months 0 1 August 2017 – 31 July 2018
**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
We reviewed six complaints investigations. We found that the trust handled complaints effectively.
Complaints investigators worked with external organisations when there was evidence that this
would help to understand and resolve the issue. Each complaints report had clear outcomes and
actions that had been communicated to the complainant in writing. Any delays in resolving
complaints were monitored through the trust performance report. A new patient experience
working group, chaired by a non-executive, reviewed themes of complaints.
The trust received 157 compliments during the last 12 months from 1 August 2017 to 31 July
2018. The ‘CHS Adult Community’ core service had the highest number of compliments with 119
(76%) followed by ‘CHS Sexual Health’ with 10 (6%).
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 18
Governance
There were effective structures, roles and systems of accountability to support good governance
and management. These were regularly reviewed and improved. The trust had five committees
that reported directly to the board of directors: the audit committee; the executive committee; the
performance, investment and finance committee; and the remuneration and terms of service
committee. A number of sub-committees, project groups and working groups reported into the
committees and were effective in monitoring performance and risk throughout the trust. Terms of
reference for the board and committees were reviewed at least annually. Each committee also
produced an annual report, which the audit committee reviewed against the terms of reference.
There was evidence that people were held to account for delivery of actions.
Trust governors told us that they had received effective induction, training and support to enable
them to carry out their roles. They described a very positive working relationship with the trust
board, and were well-informed on the trust strategy. They understood their role in holding the
board to account. The lead governor attended board meetings and submitted questions for
discussion. However, governors did not routinely get the opportunity to speak with non-executive
directors without executive directors being present.
All levels of governance and management functioned effectively and interacted with each other
appropriately. There was a visible and consistent approach to risk management and board
assurance. The board assurance framework comprehensively described the risks facing the trust,
the relationship between those risks, and the strategy for dealing with them. It was reviewed
regularly and used to determine the board’s cycle of business. The trust’s committee structure
enabled two-way communication of quality information. We reviewed minutes of each of the five
committees, which showed that meetings were well-attended and that agenda items were
escalated and acted upon as appropriate. We tracked a newly identified risk relating to children in
care and saw that it was escalated through the trust’s governance processes and promptly added
to the board assurance framework.
Progress with integration of community health services with the rest of the trust was reported to
the board through the transitions sub-committee in the form of a bi-monthly community services
improvement programme update. The action plan was comprehensive, including 45 issues rated
red, amber or green. Alignment of policies was one of the issues listed, however during our
inspection of core services we found that some of the community health policies had exceeded
their review date.
The trust provided a document detailing their highest profile risks. Each of these have a current
risk score of four or higher. The risks listed in the table below carry a current risk rating of 12 or
higher.
ID Description Risk level
(initial)
Risk score
(current)
Risk level
(target)
Next review
date
SFG03 IF safeguarding children services are not
delivered by North West Boroughs as contracted,
then the quality of services of the organisation
may be compromised, resulting in reputational
12 16 4 28 Oct 2018
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 19
ID Description Risk level
(initial)
Risk score
(current)
Risk level
(target)
Next review
date
and financial implications for Mersey Care
EPRR01 Major outbreak of pandemic flu 20 12 3 1 Nov 2018
EPRR02 (DRAFT) Storms and Gales (Storm force winds
affecting most of region for at least 6 hours)
12 12 6 1 Nov 2018
EPRR09 Flooding in the local community 12 12 3 30 Nov
2018
EPRR10 Loss of Utilities – Gas / Electricity / Water 12 12 4 1 Nov 2018
IT04 If the organisation does not proactively address
by aging IT infrastructure issues. Then it may fail,
resulting in increased downtime, loss of data and
disruption to critical administrative and clinical
systems
12 12 4 17 Sep
2018
IT05 If network, resilience across Trust sites is not
reviewed, then there may be significant network
outages and major disruptions to financial and
clinical systems.
12 12 4 17 Sep
2018
WF09 If the organisational effectiveness plan is not be
implemented effectively, then the quality of care
will be compromised
16 12 8 31 Aug
2018
BI02 If systems do not integrate properly, then
reporting will be inaccurate and confidence in
reporting will be reduced.
15 12 6 31 Jul 2018
All staff at all levels were clear about their roles. They understood what they were accountable for,
and to whom. Responsibilities for oversight of risk mitigation were clearly assigned to board
members and board committees. NHS Improvement told us that the roles of responsibility and
structures for accountability and governance were clearly established, including financial reporting
to the board and budget management throughout the organisation.
The director of patient safety and relevant managerial and clinical staff took ownership of action
plans arising from investigations into deaths and serious incidents. We saw that recommendations
to improve practice had been implemented, both in the service where the incident occurred and
across the wider trust.
Arrangements with partners and third-party providers were governed and managed effectively to
encourage appropriate interaction and promote coordinated, person-centred care.
There were robust arrangements to make sure that hospital managers discharged their specific
powers and duties according to the provisions of the Mental Health Act 1983.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 20
The trust submitted details of seven external reviews commenced or published between 1 August
2017 and 31 August 2018.
Management of risk, issues and performance
There were clear and effective processes for managing risks, issues and performance.
There were comprehensive assurance systems. Performance issues were escalated appropriately
through clear structures and processes. These were regularly reviewed and improved.
Since October 2018, the trust had used a ‘safety huddle’ process to escalate and communicate
risk. This replaced the trust’s previous process, which was an executive ‘stand up’ meeting and
divisional surveillance meeting (as described in our June 2017 inspection report). We observed an
executive ‘safety huddle’, which was attended by executives, chief operating officers and other
relevant staff. The huddle routinely discussed two risks from the risk register, along with all
operational risks that had been escalated through the divisions’ own safety huddles. During the
meeting we observed, risks discussed included waiting lists for low secure services, pressure
ulcers and delayed discharges. Relevant risk and quality data was provided on electronic screens,
allowing the executives to quickly analyse the situation, understand current mitigations, propose
further actions and ultimately gain assurance that risk was being managed effectively.
Staff across the trust knew how to recognise and report safeguarding concerns. The director of
nursing and operations was the executive safeguarding lead, supported by the deputy director of
nursing (who also chaired the safeguarding strategy group). There was a named doctor for
safeguarding, and each service had a dedicated safeguarding lead. The minutes of the
safeguarding strategy group were reviewed by the quality assurance committee, and we saw that
a significant safeguarding concern about delivery of services to children in care had been
escalated effectively to the board. However, the trust did not currently have a non-executive lead
for safeguarding and we could not find evidence of performance on safeguarding being monitored
at board level. Commissioners told us that the trust did not always correctly identify safeguarding
concerns within their serious incidents.
There were processes to manage current and future performance. These were regularly reviewed
and improved. The trust monitored progress on the operational and through the bi-monthly
performance report to divisional leadership teams, the trust board and its committees. The
performance report also included metrics on regulatory targets (CQC’s five domains and NHS
Improvement’s single oversight framework). The trust used performance improvement plans,
reviewed quarterly, to provide assurance around areas of underperformance.
The trust had agreed to undertake a full review of incidents and investigations occurring in
Liverpool Community Health NHS Trust between 2010 and 2014 to comply with the
recommendations of the Kirkup Review. The trust had extended the scope to cover incidents and
investigations up to 2018. The board had made the decision to ensure they were fully aware of the
live risks presented by the acquisition, despite the additional strain on resources and delay in
meeting the Kirkup recommendations that this would entail.
There was a systematic programme of clinical and internal audit to monitor quality, operational and
financial processes, and systems to identify where actions should be taken. We saw evidence of
improvements in practice being made from clinical audit during our inspections of core services.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 21
The trust completed medicines audits on a regular ongoing basis. These included controlled
drugs, antimicrobial utilisation, medicine reconciliation, and safe and secure storage audits. Areas
of concern highlighted in the audits were addressed and re-audits planned to assess changes.
The trust was a member of POMH-UK and participated in their national quality improvement
audits.
However, commissioners told us that they were not fully assured that the trust was conducting
audits to ensure compliance with National institute for Health and Care Excellence guidelines.
There were robust arrangements for identifying, recording and managing risk issues and mitigating
actions. There was alignment between the recorded risks and what staff said was ‘on their worry
list’. Divisional senior managers were able to escalate clinical risks onto the trust risk register
through the safety huddle. Any risk rated 15 or higher went straight up to the board assurance
framework and to the chief executive.
Overall themes from CQC’s Mental Health Act monitoring visits were communicated to the board
through the safety report. Clinical staff within the relevant division monitored and audited actions
from the reports, with oversight from the trust’s mental health law governance group.
Action plans were built in to the risk register and were part of the regular review process.
Potential risks were taken into account when planning services, for example seasonal or other
expected or unexpected fluctuations in demand, or disruption to staffing or facilities.
The trust had a comprehensive business continuity plan, which included considerations of the
impact of the UK’s exit from the European Union. The trust had a dedicated emergency
preparedness, resilience and response team who were in the process of assessing the trust’s
status against the required actions set out in the government’s EU Exit Operational Readiness
guidance for health and care services.
The trust had worked with local acute trusts to develop a plan around increased use of health
services during winter. The trust intended to evaluate the effectiveness of their winter plans at the
end of February 2019. This would inform winter planning for the following year, intended to begin
in April 2019.
The trust assessed and monitored the impact on quality and sustainability when considering
developments to services or efficiency changes.
The trust undertook quality impact assessments for all proposed cost improvements. The trust’s
quality impact assessments effectively identified any potential adverse effects on services and
were underpinned by sound clinical governance systems. They were signed off with the
knowledge and participation of the clinicians who were delivering the services. The trust’s medical
director had responsibility for clinical quality because the director of nursing and operations was
responsible for achieving the cost improvement plans.
There were no examples of financial pressures compromising care. Despite this, NHS
improvement told us that the trust’s that financial performance had been consistently strong. They
said that cash, capital and revenue plans were being delivered in line with plans and national
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 22
requirements, and that review meeting discussions with NHS Improvement had demonstrated that
financial risks have been identified and mitigated by the trust.
Providers must report all serious incidents to the Strategic Executive Information System (STEIS)
within two working days of identifying an incident.
Between 1 August 2017 and 31 July 2018, the trust reported 298 STEIS incidents. The most
common type of incident was ‘Apparent/actual/suspected self-inflicted harm’ with 72. Twenty-one
of these incidents occurred in the ‘MH Community-based mental health services for adults of
working age’, 18 in ‘MH Forensic High Secure’ and 16 in MH Mental health crisis services and
health-based places of safety. Other core services accounted for less than 10 each.
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. This trust reported zero never
events during this reporting period.
We asked the trust to provide us with the number of serious incidents from the same period on
their incident reporting system. The number of the most severe incidents was not comparable with
the number the trust reported to STEIS. There were 298 serious incidents reported to STEIS (as
the per the CQC download of STEIS) but the trust told us about 305 serious incidents in their
RPIR return.
Type of incident reported
on STEIS
MH
Fo
ren
sic
Hig
h S
ecu
re
CH
S A
du
lts
Co
mm
.
MH
Co
mm
. S
erv
ices f
or
Ad
ult
s o
f W
ork
ing
Ag
e
MH
Secu
re / F
ore
nsic
Inp
ati
en
t
MH
Acu
te w
ard
s f
or
ad
ult
s o
f
wo
rkin
g a
ge a
nd
PIC
U
MH
Ward
s f
or
peo
ple
wit
h
learn
ing
dis
ab
ilit
ies o
r au
tism
MH
Men
tal h
ea
lth
cri
sis
serv
ice
s a
nd
HB
Po
S
MH
Ward
s f
or
old
er
peo
ple
wit
h m
en
tal h
ealt
h p
rob
lem
s
To
tal
Abuse/alleged abuse of adult patient by staff
25 1 2 3 31
Abuse/alleged abuse of adult patient by third party
2 2 4 9
Abuse/alleged abuse of child patient by third party
1 1
Accident e.g. collision/scald (not slip/trip/fall)
13 1 15
Apparent/actual/suspected homicide
1 1
Apparent/actual/suspected self-inflicted
18 2 21 1 8 16 3 72
Confidential information 2 1 1 1 2 1 1 14
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 23
Type of incident reported
on STEIS
MH
Fo
ren
sic
Hig
h S
ecu
re
CH
S A
du
lts
Co
mm
.
MH
Co
mm
. S
erv
ices f
or
Ad
ult
s o
f W
ork
ing
Ag
e
MH
Secu
re / F
ore
nsic
Inp
ati
en
t
MH
Acu
te w
ard
s f
or
ad
ult
s o
f
wo
rkin
g a
ge a
nd
PIC
U
MH
Ward
s f
or
peo
ple
wit
h
learn
ing
dis
ab
ilit
ies o
r au
tism
MH
Men
tal h
ea
lth
cri
sis
serv
ice
s a
nd
HB
Po
S
MH
Ward
s f
or
old
er
peo
ple
wit
h m
en
tal h
ealt
h p
rob
lem
s
To
tal
leak/information governance breach
Disruptive/ aggressive/ violent behaviour
6 4 2 2 7 1 1 24
Environmental incident 3 1 4
Major incident/ emergency preparedness, resilience and response/ suspension of services
8 2 10
Medication incident 1
Pending review 9 5 4 4 2 28
Pressure ulcer 36 1 39
Slips/trips/falls 1 2 8 16
Sub-optimal care of the deteriorating patient
1 1
Substance misuse whilst inpatient
6 2 9
Surgical/invasive procedure incident
2 2
Treatment delay meeting SI criteria
1 1
Unauthorised absence 25 11 7 1 20
Total 84 47 32 26 26 24 19 15 298
Type of incident reported
on STEIS
Oth
er
MH
Co
mm
. m
en
tal h
ealt
h s
erv
ice
s
for
peo
ple
wit
h a
lea
rnin
g
dis
ab
ilit
y o
r au
tism
N/A
MH
Su
bsta
nce m
isu
se
CH
S C
hil
dre
n,
Yo
un
g P
eo
ple
an
d
Fam
ilie
s
CH
S C
om
mu
nit
y In
pati
en
ts
MH
Co
mm
. b
ased
men
tal
healt
h
serv
ice
s f
or
old
er
peo
ple
CH
S S
exu
al h
ealt
h
To
tal
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 24
Type of incident reported
on STEIS
Oth
er
MH
Co
mm
. m
en
tal h
ealt
h s
erv
ice
s
for
peo
ple
wit
h a
lea
rnin
g
dis
ab
ilit
y o
r au
tism
N/A
MH
Su
bsta
nce m
isu
se
CH
S C
hil
dre
n,
Yo
un
g P
eo
ple
an
d
Fam
ilie
s
CH
S C
om
mu
nit
y In
pati
en
ts
MH
Co
mm
. b
ased
men
tal
healt
h
serv
ice
s f
or
old
er
peo
ple
CH
S S
exu
al h
ealt
h
To
tal
Abuse/alleged abuse of adult patient by staff
31
Abuse/alleged abuse of adult patient by third party
1 9
Abuse/alleged abuse of child patient by third party
1
Accident e.g. collision/scald (not slip/trip/fall)
1 15
Apparent/actual/suspected homicide
1
Apparent/actual/suspected self-inflicted
1 2 72
Confidential information leak/information governance breach
3 1 1 14
Disruptive/ aggressive/ violent behaviour
1 24
Environmental incident 4
Major incident/ emergency preparedness, resilience and response/ suspension of services
10
Medication incident 1 1
Pending review 2 2 28
Pressure ulcer 2 39
Slips/trips/falls 1 1 2 1 16
Sub-optimal care of the deteriorating patient
1
Substance misuse whilst inpatient
1 9
Surgical/invasive procedure incident
2
Treatment delay meeting SI criteria
1
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 25
Type of incident reported
on STEIS
Oth
er
MH
Co
mm
. m
en
tal h
ealt
h s
erv
ice
s
for
peo
ple
wit
h a
lea
rnin
g
dis
ab
ilit
y o
r au
tism
N/A
MH
Su
bsta
nce m
isu
se
CH
S C
hil
dre
n,
Yo
un
g P
eo
ple
an
d
Fam
ilie
s
CH
S C
om
mu
nit
y In
pati
en
ts
MH
Co
mm
. b
ased
men
tal
healt
h
serv
ice
s f
or
old
er
peo
ple
CH
S S
exu
al h
ealt
h
To
tal
Unauthorised absence 1 20
Total 6 5 4 3 2 2 2 1 298
Providers are encouraged to report patient safety incidents to the National Reporting and Learning
System (NRLS) at least once a month. They do not report staff incidents, health and safety
incidents or security incidents to NRLS.
The highest reporting categories of incidents reported to the NRLS for this trust for the period
August 2017 to July 2018 were ‘self-harming behaviour’, ‘patient accident’, ‘disruptive, aggressive
behaviour’ and ‘implementation of care and ongoing monitoring / review’. These four categories
accounted for 75% of the incidents reported. ‘Self-harming behaviour’ accounted for 24 of the 30
deaths reported.
Ninety percent of the total incidents reported were classed as no harm (62%) or low harm (28%).
Incident type No harm Low harm Moderate Severe Death Total
Self-harming behaviour 1288 915 153 22 24 2402
Patient accident 742 570 148 27 0 1487
Disruptive, aggressive behaviour
(includes patient-to-patient) 856 232 29 3 0 1120
Implementation of care and ongoing
monitoring / review 328 388 267 25 2 1010
Medication 531 34 13 0 0 578
Access, admission, transfer,
discharge (including missing
patient) 512 25 10 1 1 549
Treatment, procedure 212 44 27 3 0 286
Patient abuse (by staff / third party) 167 11 4 0 2 184
Infrastructure (including staffing,
facilities, environment) 149 4 1 0 0 154
Other 73 27 3 0 1 104
Consent, communication,
confidentiality 82 5 0 0 0 87
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 26
Incident type No harm Low harm Moderate Severe Death Total
Documentation (including electronic
& paper records, identification and
drug charts) 45 4 1 0 0 50
Total 5026 2269 656 82 30 8063
According to the latest six-monthly National Patient Safety Agency Organisational Report (April
2017 – September 2017) there is no evidence for potential under reporting by this trust.
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).
Mersey Care NHS Trust reported more incidents from August 2017 to July 2018 compared with
the previous 12 months. While the trust reported more incidents in the most recent 12 months (up
to 8063 from 6890), they reported proportionately more incidents resulting in moderate harm and
severe harm than they did in the previous 12 months. Additionally, the proportion of no harm
incidents reduced from 72.9% to 62.3%.
The rise in moderate and severe harm was due to the acquisition of physical health services,
which record a much higher rate of incidents involving harm (such as pressure ulcers).
Level of harm August 2016 – July 2017 August 2017 – July 2018
No harm 5026 (72.9%) 5026 (62.3%)
Low 1451 (21.1%) 2269 (28.1%)
Moderate 302 (4.4%) 656 (8.1%)
Severe 49 (0.7%) 82 (1.0%)
Death 62 (0.9%) 30 (0.4%)
Total incidents 6890 8063
We reviewed six serious incident cases from the trust. We saw that all relevant details regarding
the incident were recorded, including strategic executive information system numbers, patient
details, and a comprehensive executive summary for each case. Patient and carer involvement
was evident in each case. Where root cause analysis took place we saw evidence of patient,
family and carer involvement in the terms of reference for the investigation. Learning was a key
element of each investigation, with positive practice and learning from negative aspects noted and
considered. Learning was shared using action plans, forums and correspondence. We saw that
investigators took a fair and balanced approach to the investigation. Conclusions were reached
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 27
with consideration of all evidence available. We saw that investigators used input from other
organisations, with assistance from social workers and advocates.
We also reviewed nine investigations into deaths. The reports varied in their quality and level of
detail, but each took a systematic approach to understanding potential causes of the death and
identifying lessons learned. When contact details were known, investigators gave families and
carers the opportunity to be involved. In cases where carers had chosen to be involved, there was
clear evidence of their input into terms of reference and/or the investigation and clear evidence
that reports had been shared with them.
Information Management
Appropriate and accurate information was being effectively processed, challenged and acted on.
There was a holistic understanding of performance, which sufficiently covered and integrated
people’s views with information on quality, operations and finances. Information was used to
measure for improvement, not just assurance. The trust’s executive performance report included
regulatory and operational plan key metrics. It was presented at each meeting of the board,
enabling executives and non-executives to quickly understand the challenges facing the trust at
that time.
Quality and sustainability both received sufficient coverage in relevant meetings at all levels. All
staff had sufficient access to information, and challenged it appropriately. Live data on risk and
quality was visible during safety huddles.
There were clear and robust service performance measures, which were reported and monitored.
NHS Improvement told us that the trust had comprehensive financial information stored and
reported from appropriate financial ledger systems. At service level, managers had access to a
range of performance information.
There were effective arrangements to ensure that the information used to monitor, manage and
report on quality and performance was accurate, timely and relevant. Action was taken when
issues were identified. NHS Improvement told us that the Information the trust provided to them
was consistent, reliable and accurately reflected the organisation. The trust used a ‘kitemark’
system to grade the quality of data on which performance reports were based. A green or mostly
green mark meant that the reader could be highly confident in the data; a red or mostly red meant
less confident. Information staff worked to improve the quality of data.
Information technology systems were used effectively to monitor and improve the quality of care.
The trust was a global digital exemplar (an internationally recognised NHS provider delivering
exceptional care through the use of digital technology). Projects included use of the electronic
prescribing and medicines administration system in high secure services, electronic record sharing
between general practitioners and trust services, and ‘dashboard’ views of caseloads for
community mental health staff.
The trust had not had to seek an out-of-area placement for any patient for over one year. The trust
held daily teleconferences for bed management with active monitoring of potential admissions
through accident and emergency or through stepped up care in community mental health teams.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 28
The trust had also implemented NHS Improvement’s ‘Red2Green’ approach to identify and reduce
delays to discharge.
However, the trust held clinical information in 18 different electronic systems (mainly due to the
acquisition of other organisations). This posed a challenge for both staff and analysts in terms of
being able to input, extract and combine data. The trust was working towards better harmonisation
of systems.
There were effective arrangements to ensure that data or notifications were submitted to external
bodies as required. The trust was proactive in working with commissioners and regulators.
However, commissioners told us that when they asked for additional information about operational
teams, there was often a significant delay before the trust was able to provide this information.
There were robust arrangements (including appropriate internal and external validation) to ensure
the availability, integrity and confidentiality of identifiable data, records and data management
systems, in line with data security standards. Lessons were learned when there were data security
breaches. The trust had a separate senior information risk owner and Caldicott guardian, in line
with best practice. The trust reported nine data breaches to the information commissioner’s office
in 2017/2018, none of which resulted in a fine. When serious data breaches occurred the trust
shared lessons learned with staff through the chief executive’s blog and by sending letters out with
payslips.
Engagement
People who used services, the public, staff and external partners were engaged and involved to
support high-quality sustainable services. This included those with a protected equality
characteristic.
The trust had a programme of service user and carer engagement led by the social inclusion and
participation team. The trust was developing a new approach for patients, carers, staff, Foundation
Trust members and wider communities to work ‘side by side’ with each other to improve
engagement, participation and services. The core principles of ‘side by side’ are empowerment
and seeing things from the patient’s perspective. This approach was integrated with the trust’s
quality improvement plan.
The trust actively sought the views of community health patients. The Community Health
Acquisition sub-committee had approved funding for a 12-month programme of intensive patient
and carer engagement, which had started in May 2018. A report to the Liverpool and Sefton
Physical Community Services Programme in December 2018 stated that the project team had
spoken with nearly 200 patients and family members about the care they received across a wide
range of services. The trust also regularly met with Healthwatch Liverpool and Healthwatch
Sefton. However, community health service patients were not yet involved in the running of the
trust. The December 2018 interim report showed how the trust was considering changing their
approach to co-production to reflect the different needs and interests of these patients.
Board of directors’ meeting agendas included a personal story from a patient, carer or member of
staff. Two patient/carer representatives sat on the quality assurance committee. The trust routinely
included patient and carer experience in their reviews of care quality, for example in the evaluation
of the effectiveness of winter plans for community health services.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 29
However, we found that although some governors attended trust engagement events and were
part of service user groups, they did not always have a strong presence in the wider community
and workplace. This meant that they could not be assured that they were representing the views of
the majority of trust members on matters that may impact on the trust’s strategy.
There were positive and collaborative relationships with external partners to build a shared
understanding of challenges within the system and the needs of the relevant population, and to
delivers services to meet those needs.
Commissioners told us that the trust was very engaged in the Health and Care Partnership for
Cheshire and Merseyside. The trust’s strategy for integrated care involved a range of other local
stakeholders. The trust had also worked closely with two other mental health trusts around
perinatal mental health, and partnered with a local college to help develop young people’s careers
in health and social care.
NHS England selected Cheshire and Merseyside mental health providers to become a pilot site for
a new care model, PROSPECT, for low and medium secure mental health services. The trust was
the lead provider in the PROSPECT partnership, which also included two other local trusts and
two independent sector providers. PROSPECT was in its very early planning stages, but was
intended to bring low and medium secure services together as a coherent, recovery-focused
system ‘rooted in communities and place’.
The trust had opened ‘life rooms’ in Walton, Southport and most recently Bootle. Life rooms
offered recovery college courses, employment advice, and support with computer and literacy
skills to members of local communities (including patients and carers). Life rooms provided non-
stigmatising, social opportunities for recovery from mental health problems. They formed part of
the trust’s overall strategy for community-based care.
There was transparency and openness with all stakeholders about performance. Commissioners
gave positive feedback about the accessibility of the trust’s executive team, particularly the chief
executive and the director of nursing and operations.
Learning, continuous improvement and innovation
There were robust systems and processes for learning and continuous improvement. Quality
improvement and innovation were central to the trust’s vision to strive for perfect care.
Leaders and staff strived for continuous learning, improvement and innovation. This included
participating in appropriate research projects and recognised accreditation schemes.
There was a visible and proactive approach to offering and delivering research within the trust.
There was an associate medical director for research, development and innovation, a research
and development manager and an innovation lead for Perfect Care. The medical director was the
board member responsible for research. The Centre for Perfect Care coordinated and facilitated
individual projects. In April 2018 the trust had 54 research studies underway and a further 21 new
studies pending. The trust’s website included information about the trust’s research strategy and
activity. The website also explained how staff, patients and carers could participate in existing
projects or submit an application to the trust.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 30
There were standardised improvement tools and methods. Staff had the skills to use them.
The trust had a dedicated quality improvement team called the Centre for Perfect Care. The
Centre for Perfect Care supported staff to access national evidence to support their clinical
decision-making, form their ideas for improvement into viable proposals reflecting the strategic
priorities of the trust, and involve patients and carers in a meaningful way. The Centre for Perfect
Care used the Model for Improvement to support the planning and implementation of change.
There was an emphasis on exploring ideas and testing them out on a small scale to evaluate the
benefits before introducing them fully into services. The trust’s quality improvement strategy
focused on six main areas: the just and learning culture, reduction in restrictive practice,
improvements in physical health pathways, zero suicide, reduction of community-acquired
pressure ulcers and learning from deaths.
The trust had identified that staff in community health services were not always using the same
criteria to grade pressure ulcers, leading to inconsistent reporting. The trust’s work with staff had
led to a 19% increase in accurate reporting.
Participation in and learning from internal and external reviews, including those related to mortality
or the death of a person using the service, was effective. Learning was shared and used to make
improvements. The trust had a learning from death policy which reflected national guidance. It had
a dedicated mortality review team, who coordinated the process of triaging deaths, ensuring 72-
hour reviews were completed where appropriate and monitoring action plans. Staff learning from
deaths and other serious incidents took place through quality practice alerts, divisional
newsletters, weekly bulletins, Oxford learning events and team debriefs.
All staff regularly took time out to work together to resolve problems and to review individual and
team objectives, processes and performance. This led to improvements and innovation.
During our March 2017 inspection, we saw that the trust had worked closely with patients and
community providers to ensure that people with a learning disability admitted to the trust’s Whalley
site had the best possible chance of a successful discharge. Since that time, the trust had staffed
a new specialist support team across Lancashire, South Cumbria and Greater Manchester. The
specialist support team worked with people with a learning disability and a history of offending
behaviour and/or behaviour that challenged others, as well as people with autism and no learning
disability. The purpose of the team was to support people in community settings either following
discharge from hospital, or proactively to prevent admission in the first place. We spoke with
members of the new teams in our focus groups. They were highly motivated individuals who spoke
with passion about the work they were doing alongside patients, experts by experience, and trust
colleagues (including the chief executive).
There were systems to support improvement and innovation work, including objectives and
rewards for staff, data systems, and processes for evaluating and sharing the results of
improvement work.
The trust’s guide to reducing restrictive practice had been adopted by the World Health
Organisation. Since our last inspection, the trust had continued to refine and roll out ‘no force first’
across all of its mental health and learning disability services. The trust had achieved a further
20% reduction in physical restraint between October 2017 and October 2018, although was still
keen to make further improvements particularly in the area of staff and patient injury.
Mersey Care NHS Foundation Trust evidence appendix: trust-wide leadership Page 31
The trust had been awarded ‘Best Learning and Development Initiative for the Public Sector’ at the
CIPD People Management Awards 2018. The trust had addressed some of its recruitment and
retention problems by offering opportunities to local communities who were experiencing high
levels of unemployment. The trust worked with the Department of Work and Pensions, the Skills
Funding Agency and Health Education England to deliver a six-week pre-employment values-
based training programme. Candidates were able to obtain certificates in health and social care,
information technology and customer service through a mixture of classroom sessions and work
experience at the trust. Seventy-nine per cent of candidates went on to full employment within the
trust.
NHS Improvement told us that the trust had a strong track record of delivering on its financial
plans, managing cash, capital and revenue effectively. The trust finance department was
accredited by Future Focused Finance as level 3 (the highest level), which reflects comprehensive
systems and engagement for staff development and best practice across a range of measures.
The table below provides information on financial metrics. The trust was on target to deliver their
financial control total in 2018/2019. They had managed a number of financial pressures from non-
recurrent resources. The trust had plans in place to reduce its high spend on locum medics by
reducing the non-clinical responsibilities of its substantive consultant workforce. However, the trust
was facing a potential cost improvement plan gap of £7.6 million in 2019/2020.
Historical data Projections
Financial Metrics Previous financial
year (2 years ago)
Last financial year
(April 2017 – March
2018)
This financial year
Next financial year
(April 2019 – March
2020)
Income 247.703 276.581 368.411 356.200
Surplus 4.831 6.958 5.485 4.100
Full costs -242.872 -269.623 -362.926 -352.100
Budget 4.831 5.162 5.485 4.100
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. This trust was not awarded any accreditations.
NHS Improvement told us that the trust had successfully produced a full business case that was
approved by NHS Improvement and the Department of Health and Social Care for the construction
of a £52m new medium secure unit, demonstrating appropriate management of risk and
production of appropriate analysis for major projects.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 32
Community dental services
Facts and data about this service
The Community Dental Service (CDS) provides dental, clinical and public health services on a
referral basis from a health professional, complementing and supplementing those of the General
Dental Services.
The service covers the geographical areas of Liverpool, Sefton and Knowsley with a number of
fixed dental clinics.
Care is provided in community settings for patients who have difficulty accessing treatment in
high street dental practices and who require treatment on a referral basis which is not available in
a general dental care setting.
The service is strictly by appointment and access to many of the dental services is by referral
from a health professional.
Information about the sites which offer community dental services at this trust is shown below:
Location site name Team/ward/satellite
name Patient group
Number of clinics per month
Geographical area served
Hartington Road Dental Health Education &
Promotion Contract Mixed N/A Liverpool
Hartington Road Dental Health
Promotion Mixed N/A Liverpool
Hartington Road Clinic, Hartington Road, Liverpool,
L8 0SH
Knowsley Orthodontics Dental
Contract Mixed N/A Liverpool
Hartington Road Clinic, Hartington Road, Liverpool,
L8 0SH
River Alt Paediatric Dental Contract
Mixed 128 Liverpool
Vauxhall Health Centre Vauxhall Paediatric
Dental Service Contract
Mixed 117 Liverpool
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 33
Is the service safe?
Mandatory and Statutory Training
The trust set a completion target for training courses of 90% for some courses and 95% for others.
The overall training compliance for this core service was 95%.
A breakdown of compliance for mandatory courses between April 2017April 2017 and March
2018March 2018 for medical/dental and nursing staff in community dental services is shown
below:
Training course Grand Total %
830|LOCAL|Complaint & Claims (Once only)| 100%
NHS|MAND|Fire Safety - 3 Years| 100%
NHS|MAND|Harassment and Bullying Awareness - No Renewal| 100%
NHS|MAND|Moving & Handling for Inanimate Load Handlers - 3 Years| 100%
NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 100%
NHS|MAND|Safeguarding Children Level 1 - 3 Years| 100%
830|LOCAL|Investigation of Incidents Using RCA (Once )| 100%
NHS|MAND|Safeguarding Children Level 3 - 3 Years| 100%
830|LOCAL|ILS - 1 Year| 100%
NHS|MAND|Equality, Diversity and Human Rights - 3 Years| 98%
NHS|MAND|Prevent WRAP - 3 Years| 98%
NHS|MAND|Safeguarding Children Level 2 - 3 Years| 97%
830|LOCAL|Prevent Training for Clinicians| 97%
NHS|MAND|Health and Safety - 3 Years| 95%
NHS|MAND|Conflict Resolution - 3 Years| 94%
NHS|MAND|Information Governance - 1 Year| 93%
830|LOCAL|Health Record Keeping 3 Yearly Compliance| 93%
NHS|MAND|Infection Control - Level 2 - 1 Year| 93%
NHS|MAND|Safeguarding Adults Level 2 - 3 Years| 93%
NHS|MAND|Consent - 3 Years| 92%
NHS|MAND|Mental Capacity Act - 3 Years| 92%
NHS|MAND|Resuscitation - 1 Year| 89%
NHS|MAND|Infection Control - Level 1 - 3 Years| 86%
NHS|MAND|Moving & Handling for People Handlers - 1 Year| 85%
NHS|MAND|Moving and Handling - 1 Year| 78%
NHS|MAND|Medicines Management Awareness - 3 Years| 77%
Core Service Total 95%
The service laid out what the expected staff to complete as mandatory training. This included
infection control, moving and handling, health and safety and fire safety. Training was booked
through the trusts learning and development team. Training was a mixture of online or face to face
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 34
courses. For example, manual training was completed as both a face to face course which was
supported by on-line learning. Staff told us that the infection prevention and control training was
dental specific and was done on-site. Staff demonstrated to us how they arranged courses
provided by the trust. Staff told us that there was a three day block each month where they could
complete training. This was considered protected time.
Mandatory training was monitored by both management and individual staff. Staff showed us the
electronic system they used to monitor their own training. They told us that they were sent e-mails
to prompt them to complete training as and when it was required. Managers also had oversight of
training levels and prompted staff to complete training at staff meetings.
We were told that the dental service did not hold its own training budget which posed problems
when staff required specific training which was not provided by the trust. External training courses
required authorisation from management outside of the dental service. We were told that on
occasion the payment for these courses had been delayed preventing staff applying for courses
which demand payment at the point of application. In addition, we were told that evidence of
completion of training had been withheld by external organisations until payment for the courses
had been received.
Safeguarding
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 its 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 dental services made one safeguarding referral between 1 August 2017 and 31 July
2018. This occurred in May 2018.
The trust had policies and procedures relating to the safeguarding of children and vulnerable
adults. We were shown there were contact details within these polices for the trusts safeguarding
team and the local authority. The dental clinical manager attended bi-monthly trust safeguarding
meetings and had good links with the safeguarding team. Staff told us they felt comfortable to
contact the safeguarding team for advice, guidance or help when required. We were shown an
example of when they sought advice from the safeguarding team relating to concerns identified.
These concerns had been well documented and reported as significant event through the trusts
electronic incident reporting system.
If the dentists had concerns about a child or vulnerable adult, then they could access their medical
records to see if there was any other information recorded about the patient. In addition, we were
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 35
told that at Maghull Health Centre there were health visitors and school nurses based there who
they could liaise with if they had concerns about any children.
As part of mandatory training all staff were required to complete safeguarding of children and
adults level one and two. In addition, the specialist paediatric dentist had completed level three
safeguarding children training. As of March 2018, 93% of staff had completed level two
safeguarding children and adult training.
Staff had a good awareness of the signs and symptoms of abuse and neglect. These included
modern day slavery and the prevention of radicalisation. Staff had completed PREVENT training
as part of the mandatory training. They were also aware of the issues of children or vulnerable
adults who were not brought to appointments. All means possible would be made to contact the
parent or carers to arrange another appointment. If multiple appointments were missed, then a
safeguarding referral would be considered on an individual basis.
Cleanliness, infection control and hygiene
The service used a system of local decontamination at each clinic for the reprocessing of used
dental instruments and equipment. They followed guidance issued by the Department of Health -
Health Technical Memorandum 01-05: Decontamination in primary care dental practices (HTM 01-
05).
Used dental instruments and equipment were initially decontaminated using an automated washer
disinfector. If the automated washer disinfector failed, then staff resorted to manual scrubbing of
instruments. We saw evidence of this during the inspection and the process and staff followed the
guidance issued in HTM 01-05. After decontamination, instruments were then inspected under
illuminated magnification to check for any residual debris or damage prior to being placed in an
autoclave for sterilisation. After sterilisation instruments were bagged and stamped with a “use by”
date of one year from the date of processing. At River Alt Resource Centre, we noted that
sterilised instruments were left out for over two hours before being bagged. We highlighted this to
staff on the day of inspection and were told that they would ensure more timely bagging of
sterilised instruments.
Staff described the regular testing of equipment used for decontaminating and sterilising used
dental instruments and equipment. We saw logs of the daily, weekly and three-monthly checks
carried out. These were in line with guidance issued in HTM 01-05.
Hand washing facilities and alcohol hand gel were available throughout the clinic areas. Personal
protective equipment (PPE) such as gloves and masks were readily available throughout the
clinics. However, we noted that staff did not always wear a visor and a disposable apron when
carrying out decontamination duties. We observed staff followed the “arms bare below the elbow”
guidance.
Infection prevention and control audits were carried out every six months. We saw that the results
of the audits were discussed at the six-monthly management review meetings. The results of
these audits ranged from 96% to 99% compliance.
We saw that there were suitable arrangements for the handling, storage and disposal of clinical
waste, including sharps. Safer sharps use was in accordance with the European Directive for the
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 36
safer use of sharps. Sharps injury protocols were displayed in surgeries and the decontamination
rooms.
Staff described the process for managing dental unit water lines. This included flushing the water
lines for two minutes at the beginning of the session and end of session. Legionella management
including water temperature testing and flushing of infrequently used outlets was carried out by an
external contractor.
Environment and equipment
Premises and equipment were clean, hygienic and well maintained. There was sufficient
equipment to support safe and effective care. These included dental handpieces and other dental
instruments.
The service was based in premises which were managed by a building management company
who were responsible for the up keep and maintenance at the premises including general
cleaning. We saw daily checklists for the dental nurses to follow to ensure the surgeries and bays
were clean prior to starting a session and after a session had been completed.
The service had a system in place to ensure equipment was maintained appropriately and in line
with regulation or manufacturers guidance. A spreadsheet was kept with dates of when equipment
was last serviced and when it was due to be serviced again. This ensured that all equipment was
correctly maintained.
We found that at each site we inspected equipment was present for dealing with medical
emergencies. This included an automated external defibrillator (AED), emergency medicines and
medical oxygen. Emergency medicines and equipment were in line with guidelines issued by the
British National Formulary (BNF) and the Resuscitation Council UK. We noted that at Maghull
Community Dental centre the bags which some of the oropharyngeal airways were in had been
opened. We raised this issue on the day of inspection and we were told it would be addressed.
We viewed records relating to the safe use of X-ray machines. We saw evidence that these were
maintained according to the Ionising Radiation Regulations 2017. We noted that the routine test of
the X-ray machines at River Alt Resource Centre had recommended that a system was put in
place to ensure that both X-ray machines cannot be operated at the same time. This had not been
done.
A radiation protection advisor (RPA) and radiation protection supervisor (RPS) had been
appointed. We saw local rules for each X-ray machine outlining how each machine should be
operated. These were in line with the Ionising Radiation Regulations 2017.
When X-rays were taken they were justified, reported on and quality assured every time. Dental
care records which we reviewed supported this. This ensured that the service was acting in
accordance with the Ionising Radiation (Medical Exposure) regulations IR(ME)R and protected
staff and patients from receiving unnecessary exposure to radiation.
When domiciliary visits were carried out the premises was risk assessed to ensure they were
suitable to provide treatment. An initial telephone risk assessment was carried out. Then at the
first visit a more detailed risk assessment was completed. Emergency medicines and equipment
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 37
were taken on domiciliary visits. An automated external defibrillator was not taken on these visits;
however, this was risk assessed.
Assessing and responding to patient risk
The service took a pro-active approach to reducing the risks associated with the carrying out of the
regulated activities.
We look at examples of dental care records. We were told and saw evidence that the clinicians
recorded patient safety alerts. Medical histories were taken and updated as necessary. Medical
histories included any allergies or conditions which may affect treatment. There was a system in
place for flagging patients with a medical condition.
The clinicians completed a Tooth Extraction Safer Surgery Checklist (TESCC) for any extractions
which were carried out either under local or general anaesthetic. This involved recording the teeth
to be extracted on a sheet and double checking them with another member of staff prior to
extracting them. These were used to reduce the chance of wrong site surgery. The use of TESCC
was actively monitored through audit and discussed at meetings to ensure compliance.
We attended a general anaesthetic session. We saw that a safety huddle was carried out at the
start of the session. This involved a staff introduction, identification of roles and responsibilities
and to discuss the patients who were to be seen and any associated risks or potential
complications. This included patient co-operation or any medical conditions. Checks were
completed on the equipment prior to getting the patient into the surgery. The dentist completed a
TESCC for each patient and recorded the teeth to be extracted on a white board in the surgery.
We witnessed the dentist double checking the teeth which needed to be extracted prior to placing
the forceps on the tooth.
The service used hoists to assist wheelchair users to get into the dental chair. We discussed with
staff about the process for doing this. They had completed both hands on and online training about
the use of hoists. We asked if there was a set protocol or procedure for the use of hoists. Staff told
us that there was not one and felt this would be beneficial as there were some staff who used the
equipment infrequently.
Patients and their parents or carers were provided with written and verbal information about pre
and post-operative instructions about treatments. This minimised the risk of the patient suffering
from post-operative complications such as post extraction haemorrhage or infections. Information
leaflets were given to patients and chaperones with details about what to do after having treatment
under inhalation sedation or general anaesthesia.
Staff were aware of the process to follow in the event of a medical emergency. There were always
adequate numbers of appropriately trained staff at each clinic to deal with a medical emergency. If
a patient became acutely unwell then they would be treated by trained members of staff and an
ambulance would be called if considered necessary. There was a policy in place which provided
staff with guidance about the signs and symptoms of sepsis. This also included what steps to take
in the event of a patient presenting with sepsis.
The dentists used rubber dams in line with guidance from the British Endodontic Society when
providing root canal treatment.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 38
Mercury and blood spillage kits were readily available at all locations which we visited.
The service had a process for receiving national patient safety alerts such as those issued by the
Medicines and Healthcare products Regulatory Agency (MHRA). Where relevant, these alerts
were shared with all members of staff at staff meetings.
Staffing
Total numbers – Planned vs Actual
This data was not provided for community dental services.
Vacancies
Between August 2017 and July 2018, the trust reported an overall vacancy rate of 12% in
community dental services.
Staff group Total number of substantive staff Total % vacancies overall (excluding seconded staff)
Qualified Nurses 0.0 -
Nursing Assistants
0.0 -
Other 16.4 12%
Core service total 16.4 12%
Turnover
Between August 2017 and July 2018, the trust reported an overall turnover rate of 5% in
community dental services.
Staff group Total number of substantive staff
Total number of substantive staff leavers in the last 12 months
Total % of staff leavers in the last 12 months
Qualified Nurses 0.0 0.0 0%
Nursing Assistants
35.7 0.6 5%
Other 36.2 0.5 4%
Core service total 71.8 1.1 5%
Sickness
Between August 2017 and July 2018, the trust reported an average sickness rate of 5% for the
last 12 months for community dental services.
Staff group Total number of substantive staff Average sickness over 12 months
Qualified Nurses 0.0 -
Nursing Assistants 35.7 4%
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 39
Other 36.2 6%
Core service total 71.8 5%
Nursing – Bank and Agency Qualified Nurses and Healthcare Assistants
Between August 2017 and July 2018, this core service did not use any bank or agency staff.
Medical locums
The trust did not provide any data for this core service.
Consultant cover
The trust has advised that for community dental services there was no consultant cover.
Suspensions and Supervisions
During the reporting period, this core services reported that there were zero cases where staff
have been either suspended or placed under supervision.
We were told that recently the service was experiencing high levels of sickness. This had
impacted on other staff members especially dental nurses. We were told that it had been tough
recently due to staff shortages and they were often moved around different clinics to provide cover
if there were gaps. Staff told us that they felt “a bit frazzled” as a result of staffing issues.
There was a process in place to ensure clinics such as general anaesthesia were not cancelled as
these were high priority. The dental nurse managers would also work in surgery to cover any staff
shortages. It was clear that the resilience and maturity within the workforce always put patients’
best interests first. Staff were proud to tell us that they do not cancel patients because of staff
shortages. We were told that they were actively recruiting for new dental nurses to help ensure
better staffing levels.
Appropriately trained dental nurses supported the dentists carrying out sedation. All staff had
completed immediate life support training.
Quality of records
Dental care records were mainly computerised. Computers were password protected and backed
up to secure storage to keep patient details safe. There were also paper records held. These were
stored in locked filing cabinets in a secure area. If domiciliary visits were carried out, then either a
lap top computer was taken on the visit or records were recorded on paper and then transferred to
the electronic system when the staff returned to the clinic.
The electronic record keeping system was available at all sites included where general
anaesthesia was carried out.
A record keeping audit had not yet been carried out under the new provider. We saw evidence of
one which had been completed approximately a year ago under the previous provider. We were
shown evidence of a record keeping audit which was planned to be completed soon. This audit
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 40
had been amended to ensure it covered the key areas which need to be included in the dental
care records.
We looked at a selection of dental care records and these were clear, concise and well
maintained. They included details of an oral examination, any special tests such as X-rays,
consent and any treatment which had been carried out.
Medicines
Medical gases used for the provision of inhalation sedation were stored securely. They were either
chained to the wall or attached to the machines used in the provision of inhalation sedation. Staff
carried out checks on the medical gas cylinders prior to carrying out inhalation sedation to ensure
there was sufficient amounts of gas to provide the treatment. We saw that a recent incident had
been raised at St Chads Community Dental Clinic regarding the storage of medical gases. They
were stored in a cage outside the building. Staff had identified that the area inside the cage had
become littered with leaves and general waste as it was in a public area. It was also open to
inclement weather conditions. As a result of this, staff had moved these cylinders to inside the
dental service to ensure they were stored safely.
NHS prescription pads were stored securely and there was a process in place to actively monitor
their use. An antibiotic prescribing audit had been carried out by the foundation dentist. The first
audit had identified that not all the clinicians were recording a diagnosis and justification for
prescribing an antibacterial. A follow up audit was completed which showed improvements had
been made.
Safety performance
There had not been any never events at the community dental services in the previous 12 months.
Never events are serious patient safety incidents that should not happen if healthcare providers
follow national guidance on how to prevent them. Each never event type has the potential to cause
serious patient harm or death but neither need have happened for an incident to be a never event.
An example of a never event in dentistry is a wrong tooth extraction.
Staff were familiar with the concept of a never event and described to us the process for reporting
these.
Incident reporting, learning and improvement
Serious Incidents - STEIS
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include ‘never events’ (serious patient safety incidents that are wholly preventable).
In accordance with the Serious Incident Framework 2015, the trust reported zero incidents (SIs) in
community dental services between August 2017 and July 2018.
Serious Incidents – SIRI (trust data)
Between 1 August 2017 and 31 July 2018, trust staff in this core service reported zero serious
incidents.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 41
Staff described to us how incidents, accidents and near misses were reported. The main pathway
was to record these on the trusts electronic reporting system. Any incidents or accidents which
were reported on the trusts electronic reporting system were sent to the clinical directors, the
operations manager and the dental clinical manager. These were discussed at the weekly
operations meetings. We reviewed incidents which had been recorded and saw that these had
been investigated and where applicable actions put in place to prevent reoccurrence. Incidents
were also discussed at the weekly safety huddle meetings which the operations manager attended
with other services. Staff told us that the trust put pressure on the service to close down incident
reports within three weeks even if the actions identified had not yet been completed.
The community dental service also had a system in place to feedback any learning from incidents.
These were called “Notification Of Clinical Improvement” (NOCI). This system worked hand in
hand with the trusts electronic reporting system. Staff were able to submit concerns, near misses
or incidents through this system. These would be investigated by the assistant clinical director. If
the notification was deemed to require documentation on the trusts electronic reporting system,
then this was done. We saw evidence of when this had been done for an incident. If the incident
was something which was deemed to require further dissemination to staff, then a “Clinical
Improvement Notice” (CIN) was produced and sent by e-mail to all staff. There was also “Golden
Clinical Improvement Notices” which were sent out with read receipts to ensure all staff had read
them. Staff told us that they had confidence in the NOCI system as they knew that anything which
they submitted would be read, considered and discussed where appropriate. We were told that
this system had increased reporting. They told us that this system had provided stability in times of
uncertainty through changes of organisations. We discussed the system in detail with staff and
identified that when a staff member submitted a NOCI then this was only sent to one individual.
This would pose a problem if this member of staff was ever away for a long period of time. In
addition, the policy relating to the use of NOCI had not been updated since 2002.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 42
Is the service effective?
Evidence-based care and treatment
The clinicians provided care, treatment and advice in line with national guidelines to ensure
patients received the most appropriate care. This included the guidance produced by the British
Society for Disability and Oral Health, the National Institute for Health and Care Excellence and
the Royal College of Surgeons. Staff we spoke with were fully aware of these guidelines and the
standards which underpinned them. We looked at a selection of dental care records which
confirmed this.
When providing inhalation sedation, the clinicians followed guidance set out by the Royal Colleges
of Surgeons and the Royal College of Anaesthetists ‘Standards for Conscious Sedation in the
Provision of Dental Care’ 2015.There was a policy in place to support the provision of inhalation
sedation which referenced the guidance. We looked at a selection of dental care records which
evidenced that the clinicians titrated the level of sedation on an individual basis to ensure it was
provided safely.
Nutrition and hydration
Patients undergoing general anaesthesia were given appropriate information by staff of the need
to fast before undergoing their procedure. The patient, parent or carer were given a pre-operative
instruction sheet emphasising the importance of fasting prior to the procedure.
Children having treatment under inhalation sedation were advised to eat and drink normally but
ensure the meal before the appointment should be kept small and at least two hours before the
appointment. This was detailed in the instruction sheet provided to patients.
Pain relief
The dentists told us that they discussed different methods of pain and anxiety management.
These were assessed on an individual basis for patients. They took in to account the patients age,
level of co-operation and complexity of treatment required. For example, where a young, nervous
child attended requiring multiple extractions where local anaesthesia was not possible then a
general anaesthetic was provided.
We saw evidence in dental care records that different methods were discussed such as local
anaesthetic alone, inhalation sedation and general anaesthesia.
We were told that topical anaesthetics were always used prior to any injections. This helps reduce
any pain associated with the injection.
Patient outcomes
Audits – Changes to working practices
The trust have participated in zero clinical audits in relation to this core service as part of their
Clinical Audit Programme.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 43
The service used quality assurance processes to monitor and improve patient outcomes and
ensure quality and safety were not compromised. The service took a proactive approach towards
audit. We saw audits of X-rays, antibiotics prescribing and infection prevention and control. These
audits all had results and action plans associated with this. Staff were aware of the results of these
audits as they were discussed at team meetings. However, we were told that individual results of
the X-ray audits were not provided to the clinicians. The service also audited the proportion of
fluoride varnish applied to patient’s teeth. The results for September 2018 (after exception
reporting) showed that 100% of children and 83% of special care adults received fluoride varnish.
Competent staff
Clinical Supervision
No clinical supervision information was provided for this core service.
Appraisals for permanent non-medical staff
Between April 2018 and July 2018, 86% of permanent non-medical staff within the community
dental core service at the trust had received an appraisal compared to the trust target of 95%. This
is higher than the 80% appraisal rate reported for the previous financial year.
Total number of permanent non-medical staff requiring an appraisal
Total number of permanent non-medical staff who have had an appraisal
% appraisals
71 61 86%
Appraisals for permanent medical staff
Between April 2018 and July 2018, 77% of permanent medical staff within the community dental
core service at the trust had received an appraisal compared to the trust target of 95%. This is
higher than the 67% reported for the previous financial year.
Staff were encouraged to complete additional training relevant to their roles. This was to cater for
the ever-increasing complexity of the patient base.
Many dental nurses told us that they had completed additional qualifications including radiography,
fluoride varnish, oral health education, clinical photography and sedation. They told us that these
Total number of permanent non-medical staff requiring an appraisal
Total number of permanent non-medical staff who have had an
appraisal % appraisals
26 20 77%
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 44
had been utilised within the service. For example, we were told that the dental hygiene therapist
had been applying fluoride to children’s teeth. After one of the dental nurses had completed the
fluoride application course and started their own clinic then this freed up time for the dental
hygiene therapist and increased access for them.
Staff told us that they had annual appraisals where they discussed training needs. They told us
that as a result of the appraisal they developed a personal development portfolio. Staff told us that
they felt the appraisal process was positive and beneficial.
Some of the dentists were on the specialist register with the General Dental Council for paediatrics
and Special Care Dentistry.
The service used dental hygiene therapists. Dental hygiene therapists are qualified dental
professionals who can carry out treatments such as fillings and extraction of deciduous teeth.
They had also received training in the use of inhalation sedation and often used this. Staff told us
that they played an important role and patients appreciated them.
Multidisciplinary working and coordinated care pathways
The service worked well with other healthcare professionals to understand and meet the range
and complexity of people’s needs.
Multidisciplinary team (MDT) meetings were held for patients who lacked capacity or for those who
had complex medical or clinical needs. Staff provided us with example of when they worked
collaboratively with other healthcare professionals. These included staff from the maxilla-facial
team at the local dental hospital, GPs and other surgical departments. They worked together to
ensure to ensure the best possible outcome for the patient.
Referrals were received into the service through an online referral management service. These
came from dentists, GPs or other healthcare professionals. These referrals were initially triaged in
the referral administration centre and then allocated to the most convenient and appropriate clinic
for the patient. Referrals for special care dentistry were triaged by the specialist. Once a course of
treatment had been completed the patient would be referred back to their own dentist (if
appropriate) for continuing treatment.
Health promotion
Staff were aware of and applied the principals of the Department of Health’s ‘Delivering Better Oral
Health’ toolkit 2013 when providing preventative advice to patients on how to maintain a healthy
mouth. This is an evidence-based tool kit used for the prevention of the common dental diseases
such as dental caries and periodontal disease. Fluoride varnish was applied to patient’s teeth on a
risk-based approach. We saw evidence in dental care records that they discussed oral hygiene
advice, toothbrushing instruction and dietary advice with patients. High fluoride toothpaste would
be prescribed for those at high risk of dental caries. At some of the clinics the dental nurses who
had completed the oral health education training held clinics where they discussed toothbrushing
and diet with patients. They also applied fluoride varnish at these appointments.
We were told that the service had recently done some work about oral cancer awareness. One of
the dental nurses had been to the Mersey Care headquarters where they had a stand raising
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 45
awareness of oral cancer and the contributing factors. They spoke to Mersey Care staff and
visitors to raise awareness. This had been featured in the most recent Mersey Care staff bulletin.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Deprivation of Liberty Safeguards
Mersey Care NHS Trust told us that 97 Deprivation of Liberty Safeguard (DoLS) applications were
made to the Local Authority between 1 August 2017 and 31 July 2018. None of which were
pertinent to community dental services.
There was a trust wide consent policy in place to provide guidance to staff. Staff were fully aware
of the need to obtain and record consent when providing treatment to patients. They told us how
they obtained consent. This involved discussing the different treatment options available and any
risks associated with them. This enabled patients to make an informed decision about treatment.
Patients comments confirmed that they were fully involved in the consent process. The service
used NHS consent forms and treatment plans. A copy of the consent form and treatment plan was
provided to the patient and a copy held with the patient’s dental care records. We saw evidence of
completed consent forms
Patients undergoing inhalation sedation had a pre-assessment appointment where consent was
obtained. This is in line with guidance set out by the Royal Colleges of Surgeons and the Royal
College of Anaesthetists ‘Standards for Conscious Sedation in the Provision of Dental Care’ 2015.
Consent was re-confirmed on the day of treatment.
Staff had a good understanding of the legal requirements of the Mental Capacity Act 2005. Staff
were required to complete training about the Mental Capacity Act. They told us that best interest
decision meetings were carried out for patients who lacked the capacity to make decisions for
themselves. We were provided with an example of such a situation and reviewed documentation
relating to it. This had been completed correctly.
Staff were aware of the concept of Gillick competence in respect of the care and treatment of
children under 16. Gillick competence is used to help assess whether a child has the maturity to
make their own decisions and to understand the implications of those decisions.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 46
Is the service caring?
Compassionate care
We observed staff treating patients with dignity and respect. It was clear through discussions with
patients and staff that the service aimed to provide a comfortable and compassionate experience
for all patients. Patient feedback was overwhelmingly positive about the service. Patients told us
that staff were kind, helpful, friendly and caring. Patients also commented that staff were
particularly good at treating children and nervous patients.
Staff provided us with example of how they provided compassionate care. These included going
out to greet and escort patients to and from the car park, bringing them straight into the clinic to
avoid them waiting in a busy and noisy shared waiting area.
Privacy and confidentiality were maintained throughout the service. We saw that no confidential
details were discussed at the reception desk. We were told that if a patient required more privacy
then a spare room would be found to have a confidential conversation. Surgery doors were kept
shut whilst treatment was carried out.
At River Alt Resource Centre, they provided undergraduate training for dental students and dental
therapy students. This was an open clinic arrangement. Patients were made aware of this situation
prior to their appointment. There were privacy curtains on this clinic to improve patient
confidentiality. A separate room was also available if a patient requested this.
Emotional support
Staff were clear on the importance of emotional support needed when delivering care. Patients
told us that staff were sensitive to their needs and made them feel relaxed and at ease prior to and
during treatment.
We were told and saw evidence that when staff were treating children who were nervous and
requiring treatment under inhalation sedation that an acclimatisation visit was carried out. This
simply involved the patient sitting in the dental chair and having the sedation without any
treatment. We were told that this helped improve compliance with treatment at subsequent visits
as the patient was familiar with the sensations they experience whilst having sedation.
We attended a general anaesthetic session and we witnessed positive interactions between staff
and the patient. In addition, we saw that the staff took into account the emotional needs of the
parents. It was clear they took a holistic approach to providing care to patients and their family in
what is a difficult and emotional situation for both patient and parent.
Appointment length and times would be adjusted to individual patient need. For example, for more
nervous patients longer appointments could be booked to ensure staff had time to provide
emotional support to the patient. Staff told us they worked with patient’s carers to determine the
best time when they could be treated most effectively. The clinicians confirmed that they had
adequate time to provide safe, effective and compassionate treatment to their patients.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 47
Understanding and involvement of patients and those close to them
Patients and their families were appropriately involved in and central to making decisions about
care options and the support needed. Patients confirmed that they were fully involved in decisions
and able to ask questions about treatments.
Staff told us, and we saw evidence on dental care records that they involved patients, their parents
or carers about treatment options. They described different treatment options including the risks
and benefits associated with the different treatments. They used models and pictures to assist with
explanations. They also used X-rays which had been taken to assist with understanding. There
were numerous information leaflets about different treatments available at the service.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 48
Is the service responsive?
Planning and delivering services which meet people’s needs
The dental service was commissioned by NHS England. Services were planned to meet the needs
of people who could not access primary dental care services. These included patients with
medical, physical or social issues and patients with dental anxiety.
Reasonable adjustments had been made at all the locations which we visited. These included step
free access, automatic doors, accessible toilets and lowered reception desks. The service used
hoists to assist wheelchair users to get into the dental chair. Staff had received training in their
use. The service did not have facilities to treat bariatric patients. We were told that the local dental
hospital had a bariatric chair where these patients could be treated.
Translation services were available for patients who did not have English as a first language. We
saw notices in the reception areas, written in languages other than English, informing patients
translation service were available. In addition, hearing loops were available for use by people with
hearing aids.
There was generally adequate seating facilities at each location. However, at Everton Road
Community Dental the waiting area was shared with another service. This had restricted the
amount of seating available for patients. This issue had been raised with the estates team.
Meeting the needs of people in vulnerable circumstances
The service was configured to reflect the needs of vulnerable people. It was a referral service
providing either continuing care or a single course of treatment to children or patients with special
needs due to physical, mental, social and medical impairment. Referrals for patients with special
needs were initially triaged by the specialist in special care dentistry. Any reasonable adjustments
could be discussed prior to their first appointment at the clinic.
Domiciliary visits were carried out by the service. These visits were reserved for patients who
could not access the service due to medical, physical or social issues.
Since the merger staff told us that there had been an increased focus on mental health issues.
Staff were keen to gain more access to mental health teams, knowledge and resources already in
the trust to help them to cater better for patients with mental health issues. Staff saw the move to
the current trust as a positive opportunity to be able to provide highly personalised and specialised
care for very vulnerable patients.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 49
Access to the right care at the right time
Accessibility
The largest ethnic minority group within the trust catchment area is ‘White other’ with 1.75% of the
population.
Ethnic minority group Percentage of catchment population (if known)
First largest White Other 1.75%
Second largest Chinese 0.8%
Third largest Other 0.7%
Fourth largest Black African 0.7%
No referrals data was provided for this core service.
General dental practitioners and other health professionals could refer patients for short-term
specialised treatment as well as long term continuing care to the community dental service. Once
a course of treatment had been completed the patient was referred to primary dental care for
ongoing care with their own dentist if appropriate.
Waiting times were actively monitored by the service. The current waiting time for and assessment
for paediatric special care dentistry and paediatric exodontia was approximately six weeks. In
addition, the waiting time from assessment to treatment was six weeks for a dentist and four to six
weeks with a dental therapist.
Waiting times for general anaesthetic had previously been on the risk resister as a result of a high
levels of nitrous oxide being identified at a clinic held in a local hospital in February 2018. This
resulted in the service being suspended. The waiting times had now been reduced and this issue
had been removed from the risk register.
During the inspection we observed that appointments ran smoothly, and patients were not kept
waiting. Staff told us that patients would be kept informed if there were going to be any delays with
their appointment.
Learning from complaints and concerns
Complaints
Community dental services received two complaints between 1 August 2017 and 31 July 2018.
Total Complaints
Fully upheld
Partially upheld
Not upheld Withdrawn Under
investigation Other
Referred to Ombudsman
2 0 0 1 0 1 0 0
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 50
Compliments
The trust received 314 compliments during the last 12 months from 1 August 2017 to 31 July
2018. None of these related to community dental services.
The service took complaints and concerns seriously, and we were told they aimed to address
them in house initially to the patient’s satisfaction. Staff told us that if any patients attended and
wished to make a complaint they would try and resolve the issue at the clinic with the assistance
of the dental operations manager. If the patient was not satisfied with the response, then they
were provided with the trust complaints procedure and the number for the Patient Advice and
Liaison Service (PALS). Staff at the service would liaise with the PALS team to help dealing with
any patient complaints.
There were details of how a patient could make a complaint including the details of PALS
displayed in the main reception area and in the waiting area. There were also details of how to
make a complaint on the trusts internet page.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 51
Is the service well-led?
Leadership
We found leaders had the capacity and skills to deliver high-quality, sustainable care. They were
knowledgeable about issues and priorities relating to the quality and future of services. They
understood the challenges and were addressing them.
Clinical leadership was provided by the clinical directors. They were supported by the assistant
clinical director. They were responsible for overseeing the dentists and dental therapists. The
dental operation manager and dental clinical manager were responsible for the day to day running
of the service. They were supported by dental nurse managers at each location.
Staff felt valued and appreciated in their role. They told us that leaders were visible, supportive
and approachable. They told us that since the move to the current trust the human resources
director had visited the service to speak with staff.
Vision and strategy
The trust had a vision of what it wanted to achieve after the merger. This included, operating with
a ‘One Team’ ethos, uniting primary, social, community physical and mental health services and
creating ways for hospital specialists to provide care in community settings.
The dental service also had a vision. This included succession planning for the service by
engaging with the human resources and workforce team, ensuring commissioning stability by
working with the commissioners and maintaining regular communication with the dental staff to
ensure they are updated with any changes which may occur.
Both the trust and divisional visions were displayed within the service for staff to reference.
The trust values were continuous improvement, accountability, respect, enthusiasm and support. It
was clear through the inspection that staff upheld these values.
Culture
Staff were proud and passionate about their work. Many of the staff had worked for the service for
many years and had seen a great deal of change. There was a strong team spirit and they
supported each other through difficult and uncertain times.
Staff described a more positive culture since the move. They gave us examples of this change.
For example, we were told the trusts approach towards staff sickness was more compassionate
and caring and any correspondence was more sympathetic.
Staff morale was generally good. However, issues with staffing had impacted moral somewhat.
We were told that the service was actively recruiting new members of staff to fill in any gaps.
Staff were aware of their responsibilities to raise concerns if the need arose. They were aware of
the whistleblowing process and could easily access the policy. They were aware of the freedom to
speak up guardian and there were posters in the waiting rooms about this.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 52
Governance
The trust provided policies and procedures to provide guidance for staff. These were generic and
covered all services provided by the trust. These included how to deal with a complaint,
safeguarding and equality and diversity. Because of the specialised nature of the dental service
they had developed their own policies and procedures called “code of practices” (COP). The
dental service was responsible for updating and reviewing these. These were available on the
trusts intranet for staff to reference. These included conscious sedation and infection prevention
and control. We noted that the COP relating to the use of the NOCI had not been updated or
reviewed since 2002. In addition, we were told that the process to send NOCI only involved it
being sent to one individual. We were told that this would be addressed to ensure these were
received by multiple persons. All other COPs were up to date.
Quality assurance processes were used within the service to continually improve the quality and
safety of the service. For example, audits had been carried out on X-rays, infection prevention and
control and antibiotic prescribing. These had associated results and action plans. Staff told us that
the results of the X-ray audit had been discussed at a team level, but individual clinicians had not
been given their own results or feedback.
Matter relating to clinical governance were discussed at monthly locality governance meetings
which the dental operation manager attended. There were effective systems in place to
disseminate information through a system of meetings. These included at a local level and patch
level. In addition, there were bi-monthly dental nurse managers meetings which were chaired by
the dental clinical manager. There were meetings held every four months for all clinical staff.
There were six-monthly management review meetings held which included the clinical directors,
assistant clinical director, band B and C dentists and the dental clinical manager. These were well
attended and minuted with actions identified to improve standards.
Management of risk, issues and performance
The service maintained a risk register which was regularly reviewed. This was used to monitor
known risks associated with the service and put in place actions to reduce the risks. Currently on
the dental service risk register were issues around procurement (including supplies, maintenance
and training) and the lack of service level agreements at certain sites where general anaesthetics
were provided. Where risks had been identified then actions were put in place to mitigate the risk.
We saw that actions were completed in a timely manner to ensure risks were well managed. The
risk register was discussed at the monthly operations meetings and also the six-monthly
management review meetings.
Information management
Staff told us they had access to all the information they needed to provide care to patients. They
had completed training in information governance and were aware of the importance of protecting
patients’ personal information.
Dental care records were a mix of computerised and paper records. We saw computers were
password protected and were told these were backed up to secure storage. Any paper records
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 53
were stored in lockable cabinets. We saw staff locked computers when they moved away from
their workstations.
Engagement
One of the dentists was the chair of the local managed clinical network (MCN) for special care
dentistry. In addition, several other of the dentists attended the MCN meetings for special care
dentistry and paediatrics. MCNs are groups of professionals from primary, secondary and tertiary
care who work together to ensure the equitable provision of high quality effective services. These
networks enable the clinicians to engage with general dental practitioners and other providers of
secondary care about how services can be improved.
The service also met with the NHS England commissioners on a quarterly basis. This was to
discuss performance and the contract. We were told they had a good relationship with the
commissioners.
Patients were encouraged to complete the NHS Friends and Family Test (FFT). This is a national
programme to allow patients to provide feedback on NHS services they have used. Results and
feedback from the FFT was disseminated to staff through meetings.
Learning, continuous improvement and innovation
Accreditations
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.
This core service has not been awarded any accreditations.
All locations had achieved the British Dental Association Good Practice award. This is a quality
assurance scheme that demonstrates a visible commitment to providing quality dental care to
nationally recognised standards.
The service provided training to undergraduate dental students and dental hygiene therapists from
another NHS trust. They also provided educational supervision to a foundation dentist (FD). A FD
is a newly qualified dentist in their first year of qualification. Dentists wanting to work in the NHS
are required to complete a year of foundation training prior to obtaining an NHS performer number.
Many of the dental nurses had completed additional training in order to enhance their skills to
cater for the increasing demand of the local population. These included special care dentistry,
radiography, fluoride varnish application, oral health education and sedation. The service
organised an annual study day. This covered topics such as sedation and how to deal with
complaints. It also offered an opportunity for peer review and to discuss complex cases.
Mersey Care NHS Foundation Trust evidence appendix: community dental services Page 54
The service was currently working with Public Health England to carry out epidemiology surveys.
The current survey was to assess the dental health of five-year olds in the local area. All data was
due to be collected by June 2019 and the report is due to be published in December 2019.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 55
Community health services for adults
Facts and data about this service
Mersey Care NHS Foundation Trust provides specialist inpatient and community mental health,
learning disability and substance misuse for adults in Liverpool, Sefton and Kirkby. Mersey Care
NHS Trust was established on 1 April 2001 and granted NHS Foundation Trust status on 1 May
2016.
On 1 July 2016, Mersey Care completed the acquisition of Calderstones Partnership NHS
Foundation Trust.
In July 2017, the trust acquired a number of services previously provided by Liverpool Community
Health NHS Trust (LCH) in the South Sefton locality. Mersey Care acquired the remainder of the
former LCH community services on 1 April 2018. These community health services are provided
across Liverpool to a population of approximately 1.2 million. Mersey Care currently delivers
these services across more than 70 locations including health centres, clinics, walk-in centres and
GP practices.
For the provision of community health services, Mersey Care operates a locality based operational
model, with multidisciplinary clinical teams, geographically aligned and focused around GP
practice populations. The previous leadership team from Liverpool Community Health are working
collaboratively with senior management at Mersey Care in leading the Community Health Services
Division.
There are three localities under Mersey Care, these are North Liverpool, Central Liverpool and
South Liverpool. Each locality is led by an associate director and clinical lead. Community
services offered by Mersey Care include, district nursing, physiotherapy, occupational therapy,
dietetics and nutrition, speech and language therapy, podiatry, rehabilitation at home teams and
integrated community reablement and assessment services (ICRAS). ICRAS encompasses
intensive community care teams (ICCT), emergency response teams (ERT) and frailty.
Our inspection was short notice announced which meant that staff and management knew we
were coming. This ensured that staff we needed to speak to were available and clinics were open
for review. We inspected community adult services provided by the Trust over a three-day period
from Tuesday 20 November to Thursday 22 November 2018.
During our inspection we visited nine areas, two of which included clinical areas. We spoke to a
number of staff in various specialities which included, district nurses, physiotherapists,
occupational therapists, community matrons, skin care specialists and senior management.
We spoke to ten patients and carried out five home visits. We also reviewed twenty-two patient
records that were a mixture of paper and electronic documentation
Information about the sites which offer community health services for adults at this trust is shown
below:
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 56
Location Site Name Team/ward/satellite name Patient group
Number of clinics per month
Geographical area served
Netherton Health Centre, Magdalen Square, Liverpool,
L30 5SP
Adult SALT Mixed N/A Liverpool
Livingstone Drive Adult Speech & Language
Therapy Mixed No Clinics held South Sefton
Bootle Health Centre, Park Street, Liverpool,
L20 3RF Bootle Green District Nurses Mixed No Clinics held South Sefton
Bootle Health Centre, Park Street, Liverpool,
L20 3RF Bootle Yellow District Nurses Mixed
SS Comm Cardiac Total = 9
(Maghull 2; Thornton 2; Bootle 2; Sefton Rd 2;
Netherton 1;)
North Sefton Cardiac Clinics Total = 4
(Ainsdale 1; Churchtown 1; Formby
1; Southport 1)
South Sefton & North Sefton
South Sefton Litherland Town Hall,
Hatton Hill Road, Liverpool, L21 9JN
North Sefton Curzon Road,
Southport PR8 6PL
Community Cardiac (Heart Failure) Teams - South / North
Sefton Mixed No Clinics held South Sefton
Litherland Town Hall, Hatton Hill Road,
Liverpool, L21 9JN
Community Intermediate CareTeam (CICT)
Mixed N/A Liverpool
Goodlass Road Community Matrons Mixed N/A Liverpool
Old Swan Walk In Centre
Community Matrons Mixed N/A Liverpool
Queens Drive Community Matrons Mixed No Clinics Held South Sefton
Thornton Health Centre, Bretland
Road, Liverpool, L23 1TQ
Community matrons No Clinics held South Sefton
Innovation Park Community Occupational
Therapy Mixed No Clinics held South Sefton
Netherton Health Centre, Magdalen Square, Liverpool,
L30 5SP
Community Occupational therapy
Mixed N/A Liverpool
Queens Drive Community Occupational
Therapy Mixed N/A Liverpool
Innovation Park Community Physiotherapy Mixed N/A Liverpool
Innovation Park Community Physiotherapy Mixed N/A
Netherton Health Centre, Magdalen Square, Liverpool,
L30 5SP
Community Physiotherapy Mixed 60 Liverpool
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 57
Location Site Name Team/ward/satellite name Patient group
Number of clinics per month
Geographical area served
Goodlass Road Continence (Bladder & Bowel) Mixed South Sefton
Litherland Town Hall, Hatton Hill Road,
Liverpool, L21 9JN Diabetes Mixed 76 plus 68 HCA South Sefton
Netherton Health Centre, Magdalen Square, Liverpool,
L30 5SP
Dietetics Mixed 80 Liverpool
Queens Drive Clinic, Moor Lane, Liverpool,
L4 6XG Dietetics & Nutrition Mixed N/A Liverpool
Goodlass Road District Nursing Mixed N/A Liverpool
Old Swan Walk In Centre
District Nursing Mixed N/A Liverpool
Queens Drive District Nursing Mixed N/A Liverpool
Innovation Park District Nursing (Out of Hours
& Evenings) Mixed N/A Liverpool
Innovation Park Emergency Response Team
(ERT) Mixed N/A Liverpool
Innovation Park Intensive Community Care
Team (ICCT) Mixed N/A Liverpool
Innovation Park Intermediate Community Reenablement Access
Services (ICRAS) Mixed N/A Liverpool
Innovation Park IV Therapy Team Mixed 20 Litherland HC / 20
Netherton HC South Sefton
Litherland Town Hall, Hatton Hill Road,
Liverpool, L21 9JN IV Therapy Team Mixed N/A Liverpool
Innovation Park Liverpool Community Frailty
Service Mixed N/A Liverpool
Innovation Park Liverpool Out of Hospital
Service (LOOHS) Therapy Team
Mixed No Clinics held South Sefton
Maghull Health Centre, Westway,
Liverpool, L31 0DJ Maghull District Nurses Mixed N/A Liverpool
Queens Drive Medicines Management: GP
Support Mixed
Netherton Health Centre, Magdalen Square, Liverpool,
L30 5SP
Podiatry Team Mixed N/A Liverpool
Queens Drive Podiatry Team Mixed N/A Liverpool
Goodlass Road Practice Nurse Development
Team Mixed
Netherton Health Centre, Magdalen Square, Liverpool,
L30 5SP
Rehab at Home - South Sefton
No Clinics held South Sefton
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 58
Location Site Name Team/ward/satellite name Patient group
Number of clinics per month
Geographical area served
Litherland Town Hall, Hatton Hill Road,
Liverpool, L21 9JN Respiratory Service Mixed No Clinics held South Sefton
Sefton Road Clinic, 20 Sefton Road,
Liverpool, L20 3TA
Seaforth & Litherland District Nurses
Mixed No Clinics held South Sefton
Sefton Road Clinic, 20 Sefton Road,
Liverpool, L20 3TA Sefton OOH District Nurses N/A Liverpool
Innovation Park Single Point of Contact (SPC) Mixed N/A Liverpool
Innovation Park Skin Care Service Mixed N/A Liverpool
Abercromby Health Centre
Social Inclusion Mixed N/A Liverpool
Innovation Park Social Work Team Mixed N/A Liverpool
Innovation Park Telehealth Mixed No Clinics held South Sefton
Thornton Health Centre, Bretland
Road, Liverpool, L23 1TQ
Thornton District Nurses 75 South Sefton
Sefton Road Clinic Treatment rooms Mixed No Clinics held South Sefton
Litherland Town Hall, Hatton Hill Road,
Liverpool, L21 9JN Urgent Care Team Mixed N/A Liverpool
Innovation Park Vaccination & Immunisation
Team Mixed N/A Liverpool
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 59
Is the service safe?
Mandatory training
The trust set a completion target for training courses of 90%90% for some courses and 95% for
other. The overall training compliance for this core service was 90% against this target.
A breakdown of compliance for mandatory courses between April 2017April 2017 and March
2018March 2018 for medical/dental and nursing staff in community health services for adults is
shown below:
Training course Grand Total %
830|LOCAL|Complaint & Claims (Once only)| 100%
Role Specific Mandated Training - Deprivation of Liberties - Level 1 (Every 3 Years) 100%
Role Specific Mandated Training - Mental Health Act - Level 1 (Every 3 Years) 100%
830|LOCAL|Safeguarding Adults Level 3 for Senior Managers - 3 years| 100%
NHS|MAND|Safeguarding Adults Level 3 - 3 Years| 100%
830|LOCAL|Safeguarding Adults Level 4 - 3 years| 100%
Continuous Professional Development - Complaints (Every 3 Years) 99%
NHS|MAND|Harassment and Bullying Awareness - No Renewal| 99%
NHS|MAND|Prevent WRAP - 3 Years| 99%
Role Specific Mandated Training - Basic Prevent Awareness (1 Time) 98%
Continuous Professional Development - Adverse Incidents (Every 3 Years) 98%
Continuous Professional Development - Suicide Prevention & Safety Planning (Every 3 Years)
98%
830|LOCAL|Prevent Training for Clinicians| 97%
Continuous Professional Development - Fraud Awareness (Every 3 Years) 97%
Role Specific Mandated Training - Mental Capacity Act - Level 1 (Every 3 Years) 97%
Continuous Professional Development - Smoking Cessation (1 Time) 96%
Mandatory Training (IG) - Information Governance - Refresher (Every Year) 96%
NHS|MAND|Safeguarding Children Level 1 - 3 Years| 96%
NHS|MAND|Moving & Handling for Inanimate Load Handlers - 3 Years| 95%
NHS|MAND|Safeguarding Adults Level 1 - 3 Years| 95%
NHS|MAND|Fire Safety - 3 Years| 95%
NHS|MAND|Health and Safety - 3 Years| 95%
830|LOCAL|Investigation of Incidents Using RCA (Once )| 95%
NHS|MAND|Safeguarding Children Level 3 - 3 Years| 95%
NHS|MAND|Conflict Resolution - 3 Years| 94%
NHS|MAND|Equality, Diversity and Human Rights - 3 Years| 94%
NHS|MAND|Infection Control - Level 1 - 3 Years| 94%
NHS|MAND|Safeguarding Children Level 2 - 3 Years| 93%
830|LOCAL|Health Record Keeping 3 Yearly Compliance| 93%
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 60
Training course Grand Total %
NHS|MAND|Consent - 3 Years| 93%
NHS|MAND|Mental Capacity Act - 3 Years| 93%
NHS|MAND|Safeguarding Adults Level 2 - 3 Years| 93%
NHS|MAND|Medicines Management Awareness - 3 Years| 92%
Mandatory Training - Infection Control (Every 3 Years) 91%
Mandatory Training (IG) - Information Governance - Introductory (1 Time) 91%
NHS|MAND|Moving and Handling - 1 Year| 90%
830|LOCAL|Infection Control Domestic Staff - 1 Year| 89%
Continuous Professional Development - Dementia Awareness (1 Time) 89%
NHS|MAND|Information Governance - 1 Year| 88%
NHS|MAND|Infection Control - Level 2 - 1 Year| 88%
NHS|MAND|Resuscitation - 1 Year| 88%
Mandatory Training - Safeguarding Adults - Level 1 (Every 3 Years) 86%
Mandatory Training - Safeguarding Children - Level 1 (Every 3 Years) 86%
Mandatory Training - Fire Safety (Every 3 Years) 85%
Mandatory Training - Conflict Resolution (Every 3 Years) 84%
Role Specific Mandated Training - MHA/DoL's Level 2 (Every 3 Years) 84%
Mandatory Training - Health & Safety (Every 3 Years) 83%
Role Specific Mandated Training - Safeguarding Adults Level 2 -Trust Model (Every 3 Years)
82%
Role Specific Mandated Training - Safeguarding Children Level 2 - Trust Model (Every 3 Years)
82%
830|LOCAL|ILS - 1 Year| 80%
Mandatory Training - Equality, Diversity and Human Rights (Every 3 Years) 79%
NHS|MAND|Moving & Handling for People Handlers - 1 Year| 79%
830|LOCAL|IR(ME)R Ionising Radiation Medical Exposure Regulations| 74%
830|LOCAL|Safeguarding Children & Young People L3 Senior Managers - 3 years| 70%
Role Specific Mandated Training - Safeguarding Children Level 3 - Trust Model (Every 3 Years)
69%
Mandatory Training - Moving & Handling (Every 3 Years) 67%
Role Specific Mandated Training - Safeguarding Adults Level 3 - Trust Model (Every 3 Years)
65%
Role Specific Mandated Training - Basic Life Support (Every Year) 51%
Role Specific Mandated Training - Moving and Handling of People (Every Year) 38%
Role Specific Mandated Training - Safe and Effective Use of Medicines (Every 3 Years) 16%
Role Specific Mandated Training - Controlled Drugs & High Risk Medicines 14%
Role Specific Mandated Training - Medicines Calculations (Every 3 Years) 13%
Role Specific Mandated Training - MUST Adapted Nutritional Screening 0%
Core Service Total 90%
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 61
All team leaders within each locality had access to staff training records via an electronic system.
Staff told us that they received reminders electronically to highlight to them that they were due to
complete their mandatory training modules. These reminders were also emailed to the team
leaders so that they could monitor staff compliance and address any training and development
needs as they occurred. In addition to this, data was fed into a monthly governance report which
was monitored by the matrons and the assistant director of nursing. We saw that there was a
Trust induction, statutory and mandatory training policy (Version 2, HR28, review date January
2019) in place at the time of inspection.
During our inspection we observed staff training records for current compliance in all three
localities. We noted that all mandatory training was 100% compliant for North and South localities
in physiotherapy, however in Central compliance was 78%. This was due to the recording of
information governance. Information governance was disbanded and staff had to complete data
security and suicide prevention. We saw evidence that staff were booked onto these courses.
We were told by management in the dietetics department that their mandatory training was input
onto two different systems. One system was before the merger of the Trust and this showed that
all staff were compliant, however the new electronic system for the Trust was showing that staff
were non-compliant. This had been raised to senior management and at present the two systems
could not be linked as they were not compatible.
We were told and shown by management in the district nursing service in the South Sefton area
that the staff were 80% compliant with their mandatory training and the remainder were booked
onto sessions. We were also told that the electronic system was showing that the department was
not compliant. This had been raised with senior management who had told staff it would be
updated.
We saw that mandatory training demonstrated 100% compliance in the speech and language
therapy (SALT) team in South Sefton, however we saw that dementia awareness was not
completed and therefore compliance could not be 100% as stated on the electronic system. The
team manager was not available during inspection and it was highlighted to staff to raise this on
their return.
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.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 62
Community health services for adults made 317 safeguarding referrals between 1 August 2017
and 31 July 2018, of which 315 concerned adults and two children.
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. The Trust had a safeguarding team who were available five days per week (Monday to
Friday). We saw that there was a Trust safeguarding adult’s policy and procedure (version 6,
LCH-116, review date April 2016). We noted that the policy had a new Trust cover sheet on the
front of the policy and we raised the review date with senior management and were told that all
policies and protocols were being reviewed at the present time during the transitional process.
Guidance in the policy was up to date at the time of inspection.
All staff in each locality were trained to safeguarding level three. We observed training logs in all
three localities and compliance was 100%.
We reviewed two safeguarding incidents in the district nursing service, both had clear and concise
documented evidence following NHS England guidance (Safeguarding Adults 2017). Relevant
internal and external parties were contacted in line with Trust policy. Discussions were held with
staff on the two incidents and we saw evidence of duty of candour being applied. The duty of
candour is a statutory (legal) duty to be open and honest with patients and their families, when
something goes wrong that appears to have caused or could lead to significant harm in the future.
We were told by staff in all community service areas that if they had any safeguarding concerns
they would contact their line managers and the safeguarding team for advice in the first instance.
In addition to this we were told by the out of hours district nursing service that they would first
contact the on-call duty manager for advice.
All staff would report their safeguarding concerns via the Trust electronic incident reporting
system.
Cleanliness, infection control and hygiene
These self-assessments are undertaken by teams of NHS and private/independent health care
providers, and include at least 50 per cent members of the public (known as patient assessors).
They focus on the environment in which care is provided, as well as supporting non-clinical
services such as cleanliness, food, hydration, the extent to which the provision of care with privacy
and dignity is supported and whether the premises are equipped to meet the needs of people with
dementia against a specified range of criteria.
There was no information regarding PLACE assessments for the locations within this core service.
The service controlled infection risk well. Staff kept themselves and equipment clean. They used
control measures to prevent the spread of infection. Infection prevention and control was included
Referrals
Adults Children Total referrals
315 2 317
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 63
as part of the Trust mandatory training and all staff we spoke with were compliant with this at the
time of inspection.
The Trust had an infection prevention and control policy (version 2.2, IC01, review date December
2019) that included guidance on hand hygiene, safe handling and disposal of sharp items, person
protective equipment , indwelling medical devices and guidance on infectious diseases. The
current document had a front cover added to the policy to make the reader aware of any changes
following the organisational changes in the Trust. Staff we spoke to in all three localities were
aware of the policy and knew how to access it via the Trust intranet and the Trust website.
We looked at staff competency files in each locality and there was documented evidence that they
had all had training in infection prevention and control.
We saw posters displayed in all treatment rooms and toilet areas promoting hand hygiene. All
staff we spoke to and observed in clinic areas were aware of and carried out good hand hygiene.
There were hand sanitiser gel dispensers in reception and treatment areas in all localities. We
observed both patients and staff using the gel upon entry to the various locations.
We were told by the district nursing team that personal protective equipment was carried in their
bags at all times. In addition to this we saw that there was personal protective equipment
available to staff in the treatment areas.
We observed staff using appropriate personal protective equipment. All staff washed their hands
pre, during and post patient home visits as well as during clinics.
We looked at treatment rooms that the dieticians, podiatrists and district nurses used in each
locality and all were visibly clean. A cleaning checklist for infection prevention and control was
undertaken and had been completed. We saw that the curtains used for privacy and dignity had
been recently changed and were dated.
All store rooms were coded entry. We looked at a random sample of equipment, for example
dressings in the district nursing and skin care service, all were in date and stored in chronological
order. In addition, we looked at single use of equipment as no sterilising of equipment was
undertaken. All were in date.
We observed seven patients having treatment in the district nursing service clinics. We observed
good hand hygiene and personal protective equipment was worn when required. We observed
aseptic non-touch techniques where appropriate. However, on one home visit we observed a
wound dressing and the healthcare professionals non-touch technique could have been better.
This indicated to us that additional training was relevant in this area. This was raised and
addressed at the time of inspection.
Uniforms appeared clean and tidy on all staff within each locality. All staff were bare below the
elbow in treatment areas.
Management told us that patients with suspected methicillin-resistant Staphylococcus aureus
(MRSA), Clostridium difficile (C. diff) or carbapenemase producing Enterobacteriaceae (CPE) that
presented in treatment areas, a deep clean would be carried out as per Trust policy. There were
no incidents of either of these bacteria at the time of inspection.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 64
There were good waste and sharps management in place. We observed sharps bins correctly
labelled and assembled with the temporary closure in place which was fully compliant with
Department of Health (DoH) HTM 07-01. Waste was appropriately separated and disposed of as
per Trust policy.
We looked at a box of syringe drivers in the district nurse’s office in the South Sefton locality which
had an ‘I am clean’ label on the box. However, on inspection the box was evidently not clean
inside and this was raised with staff and resolved at the time of inspection.
Environment and equipment
Premises used in the provision of care and treatment were visibly clean and tidy.
Clinical areas had hard flooring which was washable and compliant with Department of Health
(DoH) HBN 00-10.
All chairs in the treatment room areas were found to be wipeable, clean and fully compliant with
Department of Health (DoH) HBN 00-09.
Fire exits were clearly signposted in all clinics in each locality. Fire break glass points were
observed at each exit that complied with BS EN 54-11 and review of all fire extinguishers within
reception areas were in date with their annual service.
Management in the dietetics department showed us a professional patient scale that had been
purchased as an additional resource which helped to promote quality of care and treatment. This
had been invaluable for when patients attended clinic.
We were told by staff in all three localities that there was access to specialist equipment for use in
patient’s homes. This equipment was ordered from the community equipment store and for high
risk patients the equipment could be accessed straight away. told by management in the
physiotherapy department that there were delays in the delivery of equipment. This had been
escalated to senior management who told that this was due to capacity issues and was now on
the Trust risk register.
We were told by the out of hours district nursing service that essential equipment could be
accessed up to 10pm every day.
Staff in the occupational therapy department told us that on patient home visits they would
complete a training needs analysis. If there was a risk identified the patient would not be able to
use the equipment until the occupational therapist had fitted it. We did not carry out a patient visit
with the occupational therapists during this inspection.
We were told by management in the rehabilitation at home team that they had a well-stocked
equipment store within the centre. In addition to this they could order equipment from the
community equipment store and have this delivered to all localities.
Equipment in the ICRAS team was checked annually and monitored by the administration team.
This was stored on a spreadsheet electronically. We did not see this at the time of inspection. We
requested information post inspection on effective records for medical devices and were told that
there was no overarching database for medical devices. The Trust had commissioned a database
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 65
to be built to ensure that effective records of all medical devices and their maintenance and
service requirements were identified. This was on the Trust risk register and would be
commenced in January 2019 with a plan to be embedded within 12 months.
We spoke to management about the key concerns following the nurse bag audit carried out on 3
October 2017. The key concerns were that items of equipment such as stethoscopes, paper
towels and pen torches were not always available in nurse bags. This had been fed back to staff
via team meetings and on a one-to-one basis. Spot checks had been being carried out following
this audit to ensure staff were accountable for their equipment and a re-audit had been carried out
in October 2018, however the results were not available at the time of inspection.
Fridge temperatures were checked daily in all clinic areas in each locality. All readings were in the
agreed parameters, dated and signed.
We examined a box of syringe drivers based in the district nurse’s office in the South Sefton
locality and found that a number of items were missing. For example, one x SAF T ITIMA 24
gauge and one SAF T INTIMA 22 gauges. This was raised with management at the time of
inspection.
We observed a wound dressing in a district nursing clinic in the South Sefton locality. No sterile
scissors were available for the nurse to complete the task. The nurse explained to the patient that
they had to dress their wound with a different dressing as no sterile scissors were in stock. We
observed that the bandage applied was ill-fitting as unable to cut to size. The nurse apologised to
the patient for this event and explained that there was difficulty in obtaining sterile scissors at the
present time. This was raised with management in the service and senior management at the
Trust at the time of inspection.
Assessing and responding to patient risk
The service identified and managed risk well.
Each service in all three localities held morning safety huddles. Discussions took place on
caseloads, staffing, incidents and any safeguarding concerns. In addition to this, lone working
was discussed and joint visits carried out if required.
We were told by management in the dietetics department that regular discussions took place in
the department on patient’s needs and care plans. One session per month was allotted to each
staff member for continuous professional development.
Patient referrals were triaged by senior staff and pathways were in place to help identify the level
of patient risk and clinical need.
Red, Amber and Green (RAG) ratings were utilised throughout the Trust. This ensured that
patients were monitored safely and care provided to the need required.
Risk assessments were carried out as part of the patients first home visit and subsequent follow-
up visits within the physiotherapy, occupational therapy and district nursing teams. These were
completed on the electronic information management system by the physiotherapist and
occupational therapists in the patient’s homes, however the district nurses told us these
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 66
assessments are completed on paper in the patient’s homes and then input into the electronic
information management system on their return to the office. This increased the risk of error as
district nurses were duplicating patient records. There were no incidents reported at the time of
inspection in relation to risk assessments.
We looked at twenty-two patient records and saw evidence that initial risk assessments had been
carried out and care plans implemented, for example wound care, visual phlebitis score (VIP) and
malnutrition universal screening tool (MUST). These assessments were all completed correctly,
dated and signed.
Staff were aware of how to recognise a deteriorating patient and all were compliant with the
mandatory basic life support training. We saw that the Trust had a resuscitation and deteriorating
patient policy (LCH-23) but this was overdue for review and documented that it should have been
reviewed in April 2017. This was raised with senior management at the time of inspection and we
were told it would be reviewed that afternoon in their divisional governance meeting.
We reviewed two patient records in the ICRAS team and observed the use of the National Early
Warning Score 2 (NEWS 2). A national early warning score is a guide used by medical services to
quickly determine the degree of illness of a patient based on their vital signs such as pulse rate,
blood pressure and temperature. It also provides guidance for staff to follow if a patient’s vital
signs are outside of normal parameters. The score allows the teams to monitor, detect and
respond to clinical deterioration of patients and this not only improves outcomes it is key in
maintaining patient safety.
We were told by management that the service had not always used the national early warning
score to identify patients who were at risk of deterioration as this had not always been a
requirement for this to be done in most community areas. However, the Trust had plans in place
to roll out the NEWS 2 system across all services by April 2019.
We saw that seventy new pressure sores had been reported in the community area. Senior
management told us that they were concerned that new staff members were not experienced in
pressure ulcer care. A pressure ulcer prevention programme had been implemented with target
dates for band five, six and seven staff to complete training and competencies.
We saw results for November 2018 of the falls risk assessment tool (FRAT) and the malnutrition
universal screening tool (MUST) for the district nursing service. Falls risk assessment scores in
the Central and North locality was 79.3% and 79.1% and the MUST was 82.2% and 79.7%. The
South localities were all above 95%. The Trust target was 95%.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 67
Staffing
Vacancies
Between August 2017 and July 2018, the trust reported an overall vacancy rate of 9% in
community health services for adults.
Staff group Total number of substantive staff Total % vacancies overall (excluding seconded staff)
Qualified Nurses 224.1 9%
Nursing Assistants
52.5 13%
Other 148.5 7%
Core service total 425.1 9%
Turnover
Between August 2017 and July 2018, the trust reported an overall turnover rate of 12% in
community health services for adults.
Staff group Total number of substantive staff
Total number of substantive staff leavers in the last 12 months
Total % of staff leavers in the last 12 months
Qualified Nurses 490.5 31.4 13%
Nursing Assistants
119.2 5.6 9%
Other 88.1 6.4 13%
Core service total 697.7 43.4 12%
Sickness
Between August 2017 and July 2018, the trust reported an overall average sickness rate of 8% for
this core service.
Staff group Total number of substantive staff Average sickness over 12 months
Qualified Nurses 490.5 7%
Nursing Assistants 119.2 11%
Other 88.1 6%
Core service total 697.7 8%
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 68
Nursing – Bank and Agency Qualified nurses
Between August 2017 and July 2018, the core service reported that 5942 registered nursing shifts
were filled by bank staff, 38811 shifts were filled by agency staff and 2242 shifts were unfilled.
Total Number of Shifts available
Total Shifts Filled by Bank Staff
Total shifts Filled by Agency Staff
Total shifts NOT filled by Bank Staff
69494 5942 38811 2242
Nursing - Bank and Agency Healthcare Assistants
Between August 2017 and July 2018, the core service reported that 2247 healthcare assistant
shifts were filled by bank staff, 339 shifts were filled by agency staff and 924 shifts were unfilled.
Total Number of Shifts available
Total Shifts Filled by Bank Staff
Total shifts Filled by Agency Staff
Total shifts NOT filled by Bank Staff
5139 2247 339 924
Medical locums
The trust did not provide any data for this core service.
Consultant cover
The trust has advised that for community health services for adults there was no consultant cover.
Suspensions and supervisions
During the reporting period, this core service reported that there were no cases where staff have
been either suspended or placed under supervision.
The Trust ensured that staff had the right qualifications, skills, training and experience to keep
people safe from avoidable harm and abuse to provide the right care and treatment. However, the
service did not always have enough staff due to sickness and pockets of vacancies in the three
localities. The Trust covered this workforce problem with the use of bank and agency staff and
management told us that they also doubled up on bank and agency staff to support the
recruitment of newly qualified staff.
We were told by senior management that no acuity tool was used for staffing levels. A nominated
band seven nurse had been appointed to co-ordinate staffing on a daily basis. This would be
completed by 9.30am every morning and the band 7 nurse would be empowered to get staff from
other locations if available and if not available escalate it to senior management via the escalation
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 69
management system in each of the localities. This would also then be escalated to the Trust
division.
We were told by senior management that a divisional huddle was held daily to look at staffing. A
report would be taken of the Trusts electronic management system and shared with secondary
care and the local clinical commissioning group (CCG). A bronze and silver on call team member
was available twenty-four hours a day, seven days per week and they were empowered to make
decisions around staffing issues. We were told by senior management that teams might pick up
additional workloads instead of moving staff out of their own areas.
Senior management told us that the Trust was offering development posts for band 6 nurses to
ensure good skill mix in teams. In addition to this the Trust was fast-tracking specialist nurses into
district nursing posts, for example a motor-neurone specialist nurse was currently in the process of
joining a district nursing team.
Staffing was on the Trusts risk register and actions and deadlines were in place, for example a
recruitment event for nurses had taken place following an action identified, this had taken place on
a weekend and this had seen a footfall of 70 people, of which 20 had been interviewed for the
community sector. At the time of inspection, we did not see evidence that these interviewees had
been employed.
We were told by management in the rehabilitation at home team that staffing was good at the
present time. The team had the right skill mix to provide a good service. The sickness and
absence rate for the team was 4.5% against the Trust average of 7%. However, we were told that
there had been a band 5 physiotherapy vacancy for the previous two years. Management would
meet with the finance team each month and identify budgets and where availability allowed they
would employ a locum physiotherapist.
Staffing in the speech and language team in South Sefton consisted of one band 7, one band 6
and one band 4 assistant practitioner. There was one vacancy for a band 6 nurse and this was
out for recruitment. Due to the small numbers, staffing was on the Trust risk register. If staff
members were off sick, appointments had to be cancelled and rescheduled. We were told that
since the merger of the new Trust, funding had been granted for another member of staff. Staff
welcomed this and were very positive about the Trust vision and strategy.
Management in the ICRAS team were struggling to recruit physiotherapists. This has been an
ongoing issue for the previous two years. We were told that they had tried to recruit from abroad
and had completed a number of skype interviews, however did not recruit due to sponsorship
problems. Human resources are currently in the process of looking to recruit from Ireland,
however, management are in the process of looking at advertising at the mid-point band six scale
to comply with minimum income requirements set by immigration.
In the ICRAS team we were told by management that they were particularly short of staff on night
shifts and caseloads were difficult to cover, particularly as two of the staff were non-drivers. This
was recorded each shift on the electronic management information system.
Staff in the ICRAS team were regularly transferred out to help with other teams that were short
staffed and this raised concerns as their own workloads were full. Staff told us that they regularly
worked extra hours to complete their own caseloads.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 70
Quality of records
The Trust had a health records policy and procedure (IT06, version 1.6, review date July 2020)
and was accessible for staff via the Trust intranet. All records were electronic in the community
adult services apart from the district nursing service, dietetics and the rehabilitation at home
service.
Records management remained a running agenda item at the quality meetings and we saw
evidence of minutes discussing the current issues and risks associated with the use of hybrid
record keeping. We spoke to senior management who gave us reassurance that the process was
being monitored continuously. Management also provided us with evidence demonstrating the
Trust paper-lite programme which demonstrated services were progressing well against the
Programme plan, with the exception of the district nursing service. This service is the largest of
the community division and a significant amount of work is still to be undertaken to transfer the
current paper based documents to electronic.
District nursing records were predominantly paper. We were told that paper records, for example
care plans and syringe driver checklists were kept in the patient’s homes and the evaluation and
assessment documentation would come back to the office for input to the electronic management
information system . However, staff told us that due to their workloads and no protected time for
administration, notes were not being put onto the electronic management information system in a
timely manner. This raised a risk that notes not entered onto the electronic management
information system would not be accessible to other allied health professionals. We were shown a
spreadsheet by management that demonstrated waiting times of up to 20 days for notes not being
input onto the system. However, staff told us these figures were not a true picture as some staff
had notes for more than 90 days that had not yet been put into the electronic management
information system . We raised this with management and were informed that they would be
auditing these times but at the present time could not provide us with data to corroborate staff
concerns.
We were also told by the district nursing out of hours team that patients’ notes must be entered on
to the electronic management information systems within 24 hours and this was not being
achieved. Staff told us they had raised this with management but nothing had yet been fed back
to them. We did not see documented evidence to corroborate the waiting times at the time of
inspection. We requested this information post-inspection but had not received it at the time of
reporting.
We carried out four home visits with the district nursing teams and reviewed patient records that
were based in the patient’s home. The paper records were clear and legible, however on one
home visit we reviewed a patient record and some pages within the folder were not signed or
dated. All patient records demonstrated full completed assessments, for example, wound
management and wound care plans, pressure ulcer prevention management plans and
malnutrition universal screen tool care plans were in place and filled in correctly. However, one
record had a dementia screen commenced but wasn’t fully completed. We also reviewed a
shared decision tool document which fully explained the risks to the patient by not having pressure
relieving aids in their home.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 71
We carried out a home visit with the community matrons and the electronic information
management system was being used. However, community matrons could not access test results
or GP consultations, they could only access basic entry documentation. The nurse had taken a
written note of the patient’s information that they had gathered from an EMIS printout in the office,
continued to use this paper record to document notes on and then when back at the office would
input the details onto the EMIS system. This added extra administration time to the nurse’s
workload.
We spoke to management in the physiotherapy department in the Central locality who told us they
were taking the lead on the paper-light initiative in their area to ensure that templates were more
robust which would make triaging more effective.
We looked at three electronic patient records in the physiotherapy department in the South Sefton
area and all were completed correctly. We noted on one record that an advanced care directive
had been completed and documented clearly as per Trust policy SD19, advance statement,
advance decision policy.
We were told by management in the occupational therapy department that a summary paper note
was kept in the patient’s home in case the hand held electronic device failed when on a patient
visit. We were also told that a paper copy of a patient’s demographics and triage details was kept
in the office in case the electronic system crashed. These copies were shredded once the patient
was discharged from the service. We raised this with management at the time of inspection and
advised them that keeping copies of patient details did not adhere to the Trust paper-lite
programme and did not follow the Trust health records policy and procedure (IT06, version 1.6)
which stated that creating duplicate records could pose a risk to the service user and should not
be carried out.
We were told by management in the dietetics department that although they had access to the
electronic management system in the office, they were keeping paper records as they were
waiting on the hand held electronic devices to be supplied. In addition to this, management told us
that they were working collaboratively with all dieticians in the localities and that the general
consensus at the time of inspection was that domiciliary patients would remain on paper records
until they were discharged from the service. For patients that had a percutaneous endoscopic
gastrostomy (PEG) tube their records for the previous twelve months would be scanned into the
electronic management information system when the hand-held devices were made available.
We reviewed five patient records in the dietetics department. All were clear, legible, dated, signed
and in chronological order. Three of the records had a comprehensive checklist for assessment of
patients with a percutaneous endoscopic gastrostomy tube and two records had a comprehensive
assessment of patients receiving oral nutrition. Both checklists were clear and completed fully.
Staff told us in the ICRAS team that the local NHS Trust team were relying on paper copies of
discharge summaries as they were unable to access the electronic management information
system. We looked at a paper patient record in this team and it was clear, legible and
chronological in order which demonstrated a good patient history process.
We looked at one patient electronic record in the ICRAS team and it demonstrated a concise,
clear assessment with a clear documentation of the plan of action. A full consent process was
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 72
evident which documented that the patient’s own views and preferences had been adhered to. In
addition to this we saw that the referral had met its response time of forty-eight hours.
We were told by the advanced nurse practitioners that records are updated electronically at point
of contact. However, there had been issues with the mobile hand-held devices and staff had been
unable to get access to patient records.
Medicines
The Trust had a handling of medication policy (SD12, version 3.0, review date March 2019). Staff
we spoke to told us that they knew how to access it via the Trust intranet if required.
The service prescribed, administered, recorded, dispensed and stored medicines well. Patients
received the right medication at the right dose and was given at the right time in the right route.
Controlled drugs (CDs) were not prescribed or held by the community service. Community
pharmacists supplied these and the drugs were stored in patients’ homes. We spoke to staff in
the district nursing service on their roles and responsibilities of controlled drugs and noted that
these drugs were not always destroyed and disposed of in line with the Trust policy and
procedures. Staff told us that it was common practice for family members to return their relatives’
controlled drugs to the local pharmacy as the drugs had been prescribed by the community
pharmacy and not the Trust. Records did not always reflect the procedures and processes
outlined in the policy for recording the destruction of controlled drugs. We raised this with senior
management at the time of inspection and we were provided post-inspection of the process of
destroying controlled drugs and a quality practice alert was issued by the medicines safety support
manager to all adult community teams to reiterate the requirement of following all aspects of the
Trust policy and operating procedure.
We saw evidence of Trust wide medicine safety meetings. In these minutes we saw for example,
discussions on incidents and the learning gained from these and bulletin updates. We also saw
actions to be completed and future meetings planned.
We were told by management in the dietetics department that they had no non-medical
prescribers at the time of inspection. However, this was an area they would be looking at in the
future as it would save time on waiting for a GP to prescribe the nutritional drinks.
There were six non-medical prescribers in the ICRAS team. Updates for skills and theoretical
knowledge were regularly undertaken. Staff also kept themselves updated via electronic websites,
for example the British National Formulary (BNF) and the National Institute for Health and Care
Excellence (NICE).
We were told by management in the ICRAS team that a pharmacist and a pharmacist technician
undertook medicine reconciliation with patients. We did not see evidence of this during the
inspection. We saw a pharmacy cupboard on site which held anaphylaxis medications,
intravenous fluids, sub-cutaneous treatments and medications for nebulisers. All were in date and
stored in chronological order. The co-ordinator for the team held the key and this was kept in a
locked drawer.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 73
We spoke to an advanced nurse practitioner (ANP) who told us that prescriptions were completed
electronically and that medications were kept in locked boxes in the patient’s home if they had
concerns. In addition to this we saw that prescription pads were stored in a locked cupboard and
taken out if required. The ANP also told us the process for ordering prescription pads and the
process of reporting lost prescriptions to pharmacy.
We observed podiatry clinics and saw that local anaesthetics were locked in a cupboard in the nail
surgery treatment room. The key was kept in a locked drawer in another room.
We were told by the out of hours district nurses that prescriptions were hand written on FP10’s
and yellow prescription sheets for end of life care patients. GP practices were informed of any
new prescriptions and relatives had to pick the prescriptions up to take to their local pharmacy for
dispensing. FP10’s in the district nursing service were securely locked away in a key cupboard as
per Trust policy.
We spoke to community matrons who told us that there was a non-medical prescribing lead in the
Trust and updates were given on line. Post-inspection we were provided with documentation
confirming attendance to non-medical prescribing forums and refresher training sessions. In
addition, we were also provided with evidence that the Divisional Medicines Management
Pharmacist screened the electronic prescribing data on a monthly basis and presented this to the
Medicines Optimisation Group and Antimicrobial Resistance Group that met on a bi-monthly basis.
Adrenaline was carried by district nursing staff and taken home at night when it was not feasible to
return to their base. This was in line with Trust policy that stated that the drug must be stored
securely either at the individual member of staff’s home or, if feasible, at their base.
Safety performance
Safety Thermometer (September 2017 to September 2018)
The NHS Safety Thermometer allows teams to measure harm and the proportion of patients that
are ‘harm free’ during their working day. For example, at shift handover or during ward rounds.
This is not limited to hospital; patients can experience harm at any point in a care pathway and the
NHS Safety Thermometer helps teams in a wide range of settings, from acute wards to a patient’s
own home, to measure, assess, learn and improve the safety of the care they provide. Safety
Thermometer data should also not be used for attribution of causation as the tool is patient
focussed.
Caveat: the information relates to community services only.
New Pressure Ulcers
The trust reported 70 new pressure ulcers between September 2017 and September 2018.
The most number of new pressure ulcers was reported in August 2018 with 12 (1.44% prevalence
rate). However, the highest prevalence rate occurred in May 2018 with 2.55% (five new pressure
ulcers)
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 74
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
1.53 0.40 0.41 0.51 2.55 1.74 1.33 0.68 1.38 0.73 0.81 1.44 1.29
No 3 1 1 1 5 4 4 6 11 6 6 12 10
The service used safety monitoring results well. Staff collected safety information and shared it
with staff, patients and visitors. The service used the information collated to make improvements.
We were told by senior management that they had a clinical strategy to improve the prevention of
pressure ulcers and had implemented a pressure ulcer reduction programme. We were provided
evidence of this plan post inspection which demonstrated interventions, actions and progress
statements of where the Trust was at in a certain timeframe.
We saw a Trust-wide newsletter ‘PURPLE’ (Pressure Ulcer Reduction Programme Learning and
Education) that provided staff of various news items, for example dates for training days,
resources that staff could access, workstream updates and updates on the task and finish group
that would review current guidelines and practice surrounding end of life care and the
management of pressure ulcers.
We saw a pressure ulcer dashboard in each of the localities that demonstrated acquired and
avoidable pressure sores. We were provided copies of these dashboards post inspection which
demonstrated that there was a significant decrease in Grade 4 pressure ulcers from March 2018,
however there had been a sudden increase in the previous three months We saw two cases
reported of grade four pressure ulcers. We requested the root cause analysis post inspection but
had not received the data at time of reporting. A root cause analysis is a method of problem
solving used for identifying the root causes of faults or problems.
In addition to the pressure ulcer dashboards we were told by senior management that in the trust
quality accounts they were now adding grade two pressure sores to monitor themes and trends.
Catheter & UTI
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 75
The trust reported three catheter & UTI between September 2017 and September 2018.
The most number of catheter & UTI’s were reported between April and July 2018 with one each.
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.11 0.00 0.12 0.13 0.00 0.00
No 0 0 0 0 0 0 0 1 0 1 1 0 0
Falls with Harm
The trust reported 62 falls with harm between September 2017 and September 2018.
The most number of falls with harm was reported in June 2018 with 17 (2.07% prevalence rate).
However, the highest prevalence rate occurred in September 2017 with 3.06% (six falls with
harm).
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 76
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
3.06 1.59 0.00 0.00 1.53 0.43 0.00 1.25 0.88 2.07 1.48 0.12 0.77
No 6 4 0 0 3 1 0 11 7 17 11 1 6
Harm Free Care
The trust reported 6227 cases of harm free care between September 2017 and September 2018.
The most number of harm free care instances was reported in April 2018 with 847 (96.47%
prevalence rate). However, the highest prevalence rate occurred in December 2017 with 98.98%
(184 instances of harm free care).
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 77
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
94.90 97.62 97.65 98.98 93.88 96.52 97.67 96.47 95.00 95.00 96.24 96.88 95.74
No 186 246 239 194 184 222 294 847 770 779 716 808 742
Incident reporting, learning and improvement
Serious Incidents - STEIS
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include ‘never events’ (serious patient safety incidents that are wholly preventable).
In accordance with the Serious Incident Framework 2015, the trust reported 4747 serious
incidents (SIs) in Community health services for adults, which met the reporting criteria, set by
NHS England between August 2017 and July 2018. Of these, the most common type of incident
reported was ‘Pressure Ulcer’ with 36 (77%).
Incident Type Number of Incidents
Pressure ulcer 36
Pending review 5
Apparent/actual/suspected self-inflicted harm 2
Surgical/invasive procedure incident 2
Confidential information leak/information governance breach 1
Treatment delay 1
Core Service Total 47
Serious Incidents (SIRI) – Trust data
Between 1 August 2017 and 31 July 2018, trust staff in this core service reported 52 serious incidents.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 78
Of these, zero involved the unexpected death of a patient.
The most common type of serious incidents was ‘pressure ulcer’ with 38.
The number of the most severe incidents recorded by the trust incident reporting system is not
comparable with that reported to Strategic Executive Information System (STEIS). The trust told
us that the reason for the discrepancy was that some STEIS incidents had been removed at the
request of the clinical commissioning groups, which is normal practice.
Incident Type Number of Incidents
Pressure ulcer 38
Other 5
Treatment delay 3
Pending review 2
Apparent/actual/suspected self-inflicted harm 1
Confidential information leak/information governance breach 1
Medication incident 1
Accident e.g. collision/scald (not slip/trip/fall) 1
Core Service Total 52
We were told by senior management that safety dashboards were not being used at the present
time to see team profiles. These dashboards would encompass the National Health Service
(NHS) safety thermometer and display topics such as medication safety indicators, early warning
systems of patient safety issues or deteriorating performance, mortality as a patient safety metric
and infection prevention and control measurements. The implementation of these dashboards for
each team in each locality was now part of the Trust trajectory plan.
The service managed patient safety incidents well. Staff recognised incidents and reported them
appropriately. Managers investigated incidents and shared lessons learned with all teams in the
community services.
The Trust used an electronic incident reporting system. There was a positive culture around the
reporting of incidents and staff were encouraged to report incidents regardless of the level of
harm. Staff we spoke to told us that following the unification of Mersey Care there had been a
much better atmosphere around reporting incidents and they felt that things were improving
greatly.
Incidents were reviewed at a local level and discussed at divisional meetings. Incidents that met
the Serious Incidents Framework 2015 underwent a root cause analysis investigation. These
were then presented at a corporate level to the serious incident never event panel (SINE) who met
weekly and discussed a maximum of two serious incidents.
Senior management also told us that they worked closely with the governance leads at the Trust
and that a report from the Trusts electronic incident reporting systems was run off daily. In
addition to this a seventy-two-hour structured review was held twice a week for discussions on
incidents that were reported as moderate harm and above.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 79
Serious incident reviews were undertaken as part of the SINE panel. Staff were involved in
undertaking root cause analysis investigations. Outcomes and lessons learnt were shared with
staff in team meetings and seven-minute briefings.
We spoke to management in each locality and were shown evidence of lessons learnt following
incidents. A seven-minute briefing detailing incidents and lessons learnt was given to staff. We
also saw newsletters sent to staff to keep them informed.
We reviewed six clinical incidents in the district nursing service. All six incidents were categorised
into minor or no harm and we saw evidence that all had been investigated, action plans were in
place, lessons had been shared via the teams seven-minute briefing.
Oxford learning events were held for staff so that reflections on incidents could be discussed. This
gave wider learning to the team in all localities and staff could add a theme that they wanted to
reflect on. Management told us that the current documentation of pressure ulcer care would
continue for a few months due to the number of incidents they were seeing in the teams. We saw
dates set for these training events in December 2018 and January 2019.
Staff told us that incidents would be reported on the Trusts electronic incident reporting system
and that feedback was given via emails and team meetings. Staff also told us that incidents were
discussed in safety huddles every morning and also at the business hub every Tuesday. A staff
member would attend this and then cascade the information back to their team.
There were no incidents within the dietetics department. Management and staff we spoke to told
us that they knew how to report an incident via the Trust electronic incident reporting system and
were aware of the duty of candour. Management also told us that a weekly breakfast meeting was
carried out at the Trust for band seven and band eight staff and incidents would be discussed and
this would be cascaded back to staff via team meetings and emails.
We were shown details of an incident reported in the rehabilitation at home team. Lessons learnt
were identified and fed back to staff from their manager and the governance teams.
We were told by management in the ICRAS team that the pharmacists investigated medicine
incidents which was in line with the Trust policy.
We were shown an incident that had been reported by a staff member as a preventative incident.
The staff member had identified that no plans were made to remove a patient’s clips following an
orthopaedic procedure. This was followed up to ensure the clips were removed.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 80
Is the service effective?
Evidence-based care and treatment
The service provided care and treatment based on national guidance and evidence of its
effectiveness.
Care was provided in line with national guidance from the National Institute of Health and Care
Excellence (NICE), National Health Service (NHS), Department of Health (DoH) and other
professional bodies that promoted best practice and professional standards.
We saw evidence of standard operating procedures (SOPs) and patient assessments that were in
line with national guidance, for example assessments were carried out utilising Waterlow scores
for pressure care, national early warning scores (NEWS) and malnutrition universal screening
tools (MUST).
Guidance from the national health service for people who drink alcohol and guidance for the
treatment of dysphagia (NHS 2018) had recently changed and we saw evidence that the dieticians
had changed this guidance in their patient information booklets so that evidence based practice
was given. We also saw updates from a National organisation in the dietetics office for patients
with motor neurone disease (MND).
Staff in the rehabilitation at home service provided gold standard care and followed the Chartered
Society of Physiotherapy guidance to keep up-to-date with advances in practice. We saw
evidence of assessment templates used that were in line with Trust policies and guidance.
The community service had a range of care pathways in place to ensure that patients received the
appropriate treatment for their condition.
Nutrition and hydration
The service assessed and monitored patient’s nutritional needs effectively. New patient
assessments incorporated patient lifestyles and cultural preferences. These were evident on the
patient records that we reviewed.
Patient nutritional needs were assessed using a malnutrition universal screening tool (MUST).
This is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (or
undernutrition), or obese. It also includes management guidelines which can be used to develop a
care plan. We saw evidence of patients being referred to dieticians and speech and language
therapists (SALT) after being identified as high risk. Nutritional assessments were re-visited if
there were any changes in the patient’s condition.
We were told by the district nursing out of hours service that percutaneous endoscopic
gastrostomy (PEG) feeding regimes varied between each locality and there were concerns raised
to us by staff that this could be a risk to patients as there was no continuity of care in this service.
We were told that as there was only one out of hours service that covered a large geographical
area staff were seeing patients that were not on their own team caseloads and due to the variation
of feeding regimes in different areas they felt under-confident in carrying out these treatments. We
raised this with management and we were told that senior management were looking into putting
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 81
out of hours services back to each locality so that continuity of care would be achieved. We did
not see evidence that it was on the Trust risk register.
Pain relief
Staff told us that they would use a pain scoring system of zero to three (Zero = no pain, 1 = mild
pain, 2 = moderate pain and 3 = severe pain) if they had any concerns. However, during our
inspection, out of the twenty-two records reviewed, only two pain scores were evident and these
were documented on the NEWS 2 charts.
Pain was assessed and reviewed during patient interactions and this was evident in the patient
clinics that we attended. We spoke to staff and asked them what they would do with a patient who
was recording a high pain score and was told that they would speak to a doctor or nurse
consultant in the acute sector for advice whilst in the clinic environment but if they were visiting a
patient in the home environment they would speak with the patients GP. Staff also told us that a
follow-up appointment would be undertaken either by telephone or home visit dependent on the
treatment and advice given.
For patients with a cognitive impairment, staff told us that they would us the Abbey pain scale for
the assessment of pain.
Patient outcomes
Audits – changes to working practices
The trust had participated in 11 clinical audits in relation to this core service as part of their Clinical
Audit Programme.
Audit Date completed
Pressure Ulcer Audit Report Q2 (July 2017 to September 2017) 20/10/2017
Cellulitis Audit Report 07/12/2017
Pressure Ulcer Audit Report Q3 (October 2017 to December 2017) 09/03/2018
Sefton Community Respiratory Team -Smoking Cessation 29/03/2018
Pressure Ulcer Audit Report Q4 (January 2018 to March 2018) 27/04/2018
Wound Assessment CQUIN Audit 27/04/2018
South Sefton Community Cardiac Team Patient Survey 16/05/2018
Community Matron Antibiotic Audit 06/06/2018
Diabetes Education Report 21/06/2018
IV Antibiotics for Cellulitis Report 21/06/2018
Venous Leg Ulcer Audit 26/07/2018
The service monitored the effectiveness of care and treatment and their findings to improve
outcomes.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 82
A red, amber and green (RAG) rating tool accredited by the Queens Nursing Institute (QSI 2008)
was used in the community services to monitor outcomes. Patients were categorised into colours,
for example, red (very poorly patients), amber (improving patients), green (social care package),
blue (package of care equipment). Completion of the RAG rating tool was necessary for the
caseload holder to highlight areas of concern and access caseload holder review dates easily. In
addition to this, caseloads were discussed weekly by the senior leadership team on Mondays,
Wednesdays and Fridays to ensure that they were fully informed and any areas of concern
escalated. We attended a MDT meeting in the district nursing service and observed discussions
on packages of care, treatment plans and external party summaries. We were told by
management that an audit was currently being carried out on the implementation of this tool and
data would be available in May 2019. Figures to date are demonstrating that patient home visits
have been reduced and patients are being seen in a timely and efficient manner.
We were shown evidence of the involvement of the dieticians in the National Diabetes Audit and
Diabetes Prevention Programme (NDA-DPP) pilot study. This audit was to identify how non-
diabetic hyperglycaemia information was recorded and to get an understanding of the number of
non-diabetic hyperglycaemia patients were in the localities. Results demonstrated that when a GP
practice enrolled onto the programme and recorded high risk patients under the correct coding, the
prevention programme was able to extract the data and identify the suitability of patients for
referral onto the programme. Management told us that they gave talks three times per week in
their locality and that they were funding this initiative themselves.
We saw evidence of a do not attend (DNA) audit by the dietetics department which demonstrated
a high number of DNA rates. Clinic numbers were small and patients who did not attend
highlighted a high DNA percentage rate. In addition to this, management told us that due to the
small number of patients being seen in clinics, the key performance indicator (KPI) set by the Trust
would need reviewing. Management did not know what the national average KPI was for DNA
targets in dietetic clinics. This had been raised with senior management and no decision had yet
been made in altering the KPI target. However, in an attempt to reduce DNA rates, management
were looking into sending text messages to patient’s mobile phones to remind them of their
appointments.
Management in the frailty team shown us an adapted questionnaire taken from a local government
regulator. This was given to patients on admission to the frailty unit at the local NHS trust and
then given again on discharge. The team were in the process of collating pre and post results
from the questionnaires. At the time of inspection we did not see any outcomes of these results.
We were told by management in the district nursing service that they carried out a large wound
care audit twice a year as part of the CQUIN. This would encompass one hundred and fifty patient
notes. Results were not yet collated at the time of inspection.
We reviewed an audit that was undertaken by the rehabilitation at home service where therapy
assistants had been upskilled because of recruitment issues. The audit was to see if there was an
impact on staff and the patients by upskilling these health care workers. Results demonstrated
that there was no adverse effect on patients and staff felt more confident in visiting patient’s
homes.
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We saw evidence that the rehabilitation at home service were collaboratively involved in the
National Hip Sprint audit that captured data on services, pathways, frequency and types of
rehabilitation for hip fracture patients over sixty years of age. This service was being delivered
within the expected parameters of the chartered service of physiotherapy.
We reviewed audits in the physiotherapy department on face to face consultations, joint
consultations, telephone encounters, triages and referrals. These audits were ongoing and results
not yet collated. However, preliminary results demonstrated clinic times were reduced which
allowed more patients to be seen in a timely manner.
We were shown evidence by management in the occupational therapy department of an ongoing
audit by the falls team. Results were not yet available.
We were shown an audit in the occupational therapy team on patients with multiple-sclerosis that
included details of cognitive problems and how staff assess these needs. The results highlighted
that training and confidence in treating these patients was required. This audit would now be used
as a benchmark for further audits in this area.
Staff in the Telehealth team told us they completed monthly and quarterly audits to monitor the
impact of the Telehealth service for patients and carers. They reported positive outcomes from
service users who stated that they had benefited from the service and had developed improved
confidence in managing their health conditions. We did not see evidence of the results to
corroborate this at the time of inspection.
Competent staff
We were told by staff in the district nursing service that competencies were not completed.
However, we were provided post inspection with syringe driver and pressure ulcer care training
competencies. Figures were variable throughout localities, for example the out of hours service
were 100% compliant for their syringe driver training compared to Kensington district nurses
whose compliance was 0%. In addition to this all areas in each locality were not compliant with
their pressure ulcer training and competencies. We saw the pressure ulcer prevention programme
and was told by senior management that pressure ulcer training for band 5, 6 and 7 staff would be
completed by 31 December 2018 and the competencies would be achieved by 31 March 2018.
Management in the district nursing service told us that all new band 5 nurses received a
supernumerary capacity period and would spend time in treatment rooms for pressure ulcer care.
Senior management told us that competencies used to be at team level only but they are now
looked at Trust level so that areas that are not compliant can be identified. We were told that a
new competency framework was being implemented and the Trusts trajectory plan had a deadline
of 31 March 2019 for these to be in place. In addition to this permanent night staff would not have
to fully complete this new competency framework unless they were going to work day shifts. We
raised this with management and were told that wound dressings and clinic treatments were
completed during days shifts and night workers would not need these skills to carry out their roles.
Senior management told us that they had recently developed a competency framework for agency
and bank staff which included an induction pack with a self-assessment framework in place. This
had recently been implemented in the district nursing service on 15 November 2018.
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We saw evidence of the Trust trajectory plan for nursing core competencies which was presented
to the divisional safety huddle. A plan was put in place to collate a divisional sign off for all district
nursing day services and we saw actions and timeframes for these competencies to be completed.
Band 6 nurses were now being offered the opportunity to obtain a specialist qualification (SPQ) in
district nursing and that only 24% of the district nursing staff currently held this certification. Senior
management confirmed that they had ten district nurses completing a specialist qualification at the
time of inspection. In addition to this the Trust was offering band 6 nursing staff the opportunity to
obtain a leadership module at Masters level which was being ran by a local university.
The physiotherapy department staff rotated within the service to keep their skills up-to-date. Band
4 staff would rotate annually, band 5 staff would rotate eight monthly and band 6 staff would rotate
six monthly. There was also in-house training provided for staff, for example chair based
exercises.
There was only one band 5 nurse in the IV team who was trained to complete blood transfusions
and the team were struggling to respond to transfusion referrals. This had been escalated to
management and staffing had been put onto the Trusts risk register. In addition to this we were
told that training would become a priority when vacancies were filled.
We were told by administration and reception staff in all localities that protected time was given for
e-learning training.
Staff in the rehabilitation at home team told us that competencies were undertaken prior to
completing any pre-operative assessments in patient homes. We reviewed a competency
checklist that had been fully completed which incorporated the use of equipment and how to use it
correctly. The list was dated, signed and had action plans documented with review dates. We
also spoke to a therapy assistant and was told that they would like to rotate to different teams to
update and learn new skills.
We reviewed a development plan for a new starter in the community assessment team. The plan
was not fully completed and we spoke to their mentor who agreed that the plan was not
adequately completed and would action this straight away. In addition to this we spoke to another
new starter within the team who told us that they did not have one. There was also no evidence of
a skills matrix in place and staff could not articulate what skill sets were required for each band of
staff.
We were told by the community matrons that ‘Advanced Clinical Practice’ was not accessible and
this had been raised as a big concern to senior manager when seeing community patients. In
addition to this community matrons told us that there was no known framework that they had to
work to and that the Trust could not benchmark this to see if the skills they had were adequate.
Staff with non-medical prescribing qualifications kept updated using websites such as BNF.org
and NICE guidance. Staff told us that they also received regular updates from the
communications team at the Trust.
We saw a training needs analysis in the district nursing office, including for example blood
pressure monitoring, blood glucose monitoring, ear syringing and pressure ulcer training.
However, we noted that there was no system in place to ensure safe practice of the Doppler
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system. Staff told us that there was no re-assessment for training on this piece of equipment. A
Doppler ultrasound is a test that uses high-frequency sound waves to measure the amount of
blood flow through arteries and veins, usually those that supply blood to arms and legs.
Not all staff we spoke to in the district nursing team felt supported. We spoke with staff who told us
that requests for further training which was documented on their personal development plans had
not been actioned. We raised this with management and was told that due to capacity issues
additional training had not been a priority of the service.
Management in the dietetics department told us there was no supernumerary period for new
starters. However, there was a good buddy system in place and a local induction checklist that we
reviewed. We were also told that band five staff could shadow an acute dietician to gain
confidence and improve their clinical skills in the Trust if required.
Dietitians’ were all registered with the British Dietetic Association (BDA) and regular updates and
forums were attended to ensure evidence based care was given to patients and their families.
Clinical Supervision
Between 1 May 2018 and 31 July 2018, the clinical supervision rate for the core service was 1% -
the trust target was not provided.
Staff Group Clinical Supervision
Target Clinical Supervision
Delivered Clinical supervision rate
(%)
Allied Health Professionals - 3 3%
Other ST&T - 3 2%
Registered Nursing Midwifery and Health visiting staff
- 14 <1%
Core Service Total - 20 1%
We were told by senior management that the Trust had an electronic system to record clinical
supervision and that each team leader submitted an overview of their team. We observed that this
was carried out inconsistently throughout each locality.
We saw evidence of electronic templates, however staff in the district nursing service told us that
their templates were not a true reflection of what staff were receiving. For example, new starters
received clinical supervision but other staff were not receiving it due to capacity issues. The out of
hours district nursing staff who were full time workers would access clinical supervision sessions
during the day when possible. However, we were told by staff who were permanent night workers
that they were unsure how they could access this and had not received any clinical supervision at
the time of inspection.
Community matrons told us that the multidisciplinary meetings were classed as their clinical
supervision. No formal or informal meetings were held or recorded for this. The service managers
stated that clinical supervision was available via a community geriatrician but staff told us that this
did not happen.
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We spoke to management in the physiotherapy and occupational therapy departments and were
shown clinical supervision templates. We were told that joint visits, weekly supervision for band 4
and 5 staff, fort-nightly supervision for band 6 staff and monthly supervision for band 7 staff was
carried out. We saw evidence of this in four staff records. In addition to this we were told by staff
that a buddy system was in place and this was welcomed as it ensured all staff were supported at
all times.
Clinical and management supervision was regularly carried out in the ICRAS team. Three sets of
patient notes were audited as part of the supervision process. We saw evidence of the
supervision template being used within the team. In addition to this, every Thursday morning was
protected for one hour for training purposes. Staff told us they felt very supported by their peers
and by management. However, staff in the Telehealth team told us that clinical supervision had
not been carried out for the previous twelve months and with no manager in place for the previous
eighteen months they had felt very unsupported.
We were provided post inspection of the Trusts clinical/managerial safeguarding supervision and
reflective practice policy, number SD33, Version 4 that stated supervision should be monitored
annually through staff appraisals. In addition to this, Trust policy stated that protected time (one
and a half hours, every eight weeks) which is in line with the Nursing and Midwifery Council (NMC)
guidance should be allowed for supervisees to access clinical supervision. Although appraisals
were up to date, the clinical supervision had not been addressed.
We were told by staff in the rehabilitation at home team that although clinical supervision was not
given at the present time, there was reflective practice in the team.
Appraisals for permanent non-medical staff
Between April 2018 and July 2018, 82% of permanent non-medical staff within the community
health services for adults core service at the trust had received an appraisal compared to the trust
target of 95%. This is already better than the 66% appraisal rate reported for the previous financial
year.
Total number of permanent non-medical staff requiring an appraisal
Total number of permanent non-medical staff who have had an appraisal
% appraisals
1629 1343 82%
Appraisals for permanent medical staff
Between April 2018 and July 2018, 0% of permanent medical staff within the community health
services for adults core service at the trust had received an appraisal compared to the trust target
of 95%. This is the same as the 0% reported for the previous financial year.
Total number of permanent medical staff requiring an appraisal
Total number of permanent medical staff who have had an appraisal
% appraisals
1 0 0%
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Appraisal rates for each team were recorded by management and reported monthly to senior
management.
We saw an example of a personal achievement and contribution evaluation that was completed by
a staff member and also by a manager. Results from both parties were then compared when
completing the appraisal together. This demonstrated how each person perceived their
development and was a good starting block to the appraisal process.
Data provided by the Trust up to July 2018 demonstrated that appraisals were 82% compliant.
During our inspection in November appraisals and personal development plans were up to date.
However, two staff members in the district nursing service had not had their appraisals but were
booked in with their team leaders for this process. The physiotherapists in the Central and South
localities were 100% compliant but the North regions appraisal rate was 78%. This was due to
sickness and capacity issues and had been raised to management.
Multidisciplinary working and coordinated care pathways
Staff in different specialities worked together as a team to benefit patients and their families.
Doctors, nurses and other healthcare professional supported each other to provide good care.
We saw evidence of multidisciplinary team minutes and forums with external parties.
Community teams were split into localities and neighbourhoods. Teams were based in buildings
that were shared with a range of other services, for example general practitioners (GPs), social
care, walk-in-centres and social care. The patients under their care often used the range of
services within these localities which encouraged collaborative working which enhanced patient
care.
We saw evidence of multidisciplinary team (MDT) meetings that district nurses attended. These
were attended by GP’s, specialist palliative care nurses, allied healthcare professionals and
external charity members.
Joint visits were carried out to patients with palliative care nurses, these were usually carried out
weekly which cemented strong links between the teams.
A tissue viability nurse from the skin care team would rotate to each locality. This not only
supported the district nurses but allowed training to be provided on skin care.
A mental health practitioner would attend safety huddles twice a week in the district nursing
huddles. We saw evidence of this in their safety huddle meeting minutes for the previous three
months prior to inspection. We also saw a shared care tool in the district nursing service which
demonstrated good collaborative working between different specialities.
We were told by management in the physiotherapy department that they used to attend the
palliative care MDT meetings to ensure good links between specialities, however to make for
effective use of time they would now only attend if invited to review a specific patient.
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Management in the physiotherapy and occupational therapy departments told us that to avoid
admissions to the acute trust more preventative work was being carried out. For example, a care
home project was being implemented which included asking care homes to complete risk
assessments for their patients. This initiative was welcomed both internally and externally to the
Trust.
The occupational therapy and dietetics departments had established links outside the trust with
other specialities, for example, diabetes specialist groups, neurological specialist groups and local
charities. Staff said these were invaluable resource points and good networking enhanced patient
care as ideas and skills could be shared.
Management in the dietetics department had a task and finish group between the localities which
ensured good communication and continuity of care.
The dietetics department also had support from an external provider for percutaneous endoscopic
gastrostomy (PEG) tube care. The external provider would complete tube changes in the patient’s
home which avoided admissions to hospital.
The ICRAS team provided a service to optimise health and delay the impact of frailty. This service
encompassed numerous teams, for example urgent care, home first, emergency response,
intensive community care, outreach, social work, rehabilitation at home and discharge planning.
This provided a multidisciplinary approach to patient care.
Pharmacists attended the integrated community reablement and assessment team meetings to
enable medications to be discussed, particularly around discharge. A member of the ICRAS team
would attend ward rounds at the local NHS Trust to identify patients requiring their service.
Staff in the rehabilitation at home team during winter pressures would work with the integrated
community reablement and assessment team (ICRAS) to see patients requiring therapy services.
Collaborative working was carried out with dietetics on the International Dysphagia Diet
Standardised Initiative (IDDSI) to reduce referrals to the SALT team. We saw evidence of this in
the dieticians training records.
We were told by the ANPs that multidisciplinary meetings were carried out five days per week and
that the whole team’s caseloads were discussed. We did not see evidence of these meetings
during the inspection.
Community matrons attended multidisciplinary meetings every Thursday and would review
patients and co-ordinate care appropriately. We were told by staff that workloads were shared
over the three localities and that there was great collaborative working between care homes and
nursing homes.
District nursing staff told us they had named link nurses allocated to each nursing home in their
area to ensure a consistent point of contact and good collaborative working with other specialities.
Seven Day Services
The physiotherapy department and the occupational therapy department provided services five
days per week. These ran from Monday to Friday. Physiotherapy, 8am to 4pm and Occupational
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Therapy 8am to 5.30pm. There was no out of hours service however, we were told weekend
cover and out of hours cover was available if required.
The ICRAS team provided a seven-day service from 8am to 9pm. Out of hours was covered by
the outreach service.
The speech and language therapy team provided a service which ran from Monday to Friday, 9am
to 5pm. This was not an urgent service and care was not provided out of hours.
The out of hours district nursing service provided cover seven days a week, 4.30pm to 8.30pm for
the twilight shift and 8.30pm to 8pm for the night service.
Health promotion
Staff across the community service encouraged patients to make healthy lifestyle changes and
promoted ways for patients to manage their own health. This included referrals to smoking
cessation services and wellbeing services.
We were told by management in the dietetics departments that there was a wellbeing healthy
eating event every Wednesday at the local library. The department ran this event with help from
public health to promote healthier lifestyles and this was open to staff and the public.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental
Capacity Act 2005. The Trust had a mental capacity act and deprivation of liberty safeguards
policy (version 3, LCH-119, review date May 2019) in place which was available on the Trust
intranet and internet.
We spoke to staff and they knew how to support patients experiencing mental ill health and those
who lacked the capacity to make decisions about their care.
We were told by staff that if they had concerns of a patient suffering fluctuating capacity they
would speak with their line manager for advice and they would also analyse the situation with their
colleagues. Staff would also direct patients to GP’s, mental health services and local and national
voluntary charities for support.
We saw a mental health capacity assessment completed in a patient record within the dietetics
department. The form was fully completed with a clear and concise assessment and a summary
was input onto the electronic management information system. However, we were told that the
mental health team could not access the electronic system and therefore would not see the full
assessment unless it was emailed to their department. This had been raised to senior
management and staff were told to continue with this process as the electronic systems between
the departments were not yet unified.
Staff were aware of their responsibilities in relation to consent. We observed staff obtaining verbal
consent during patient home visits and documenting this both on paper and on EMIS.
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Consent to record sharing with other internal and external parties was taken at each patient visit
and this was evident on the electronic patient records that we reviewed. However, it was not
always clear from the paper records that consent was gained on each subsequent visit.
Deprivation of Liberty Safeguards
Mersey Care NHS Foundation Trust told us that 97 Deprivation of Liberty Safeguard (DoLS)
applications were made to the Local Authority between 1 August 2017 and 31 July 2018. None of
which were pertinent to community health services for adults.
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Is the service caring?
Compassionate care
We observed patients being supported in a caring, compassionate and kind manner by staff in
clinic and treatment room areas as well as in patient home environments. Staff took time to
interact effectively with people using the service and treated patients and their families in a
dignified and respectful way. For example, we observed excellent care given to a patient in the
podiatry clinic. Full explanations were given to the patient throughout their treatment and time was
given for the patient to relay any concerns that they had regarding their current issues.
We observed staff introducing themselves to patients and relatives in a friendly and engaging
manner and clear explanations being given for their visit or appointment. We also observed staff
being encouraging, sensitive and supportive towards patients and their families.
Staff listened attentively to patient concerns and responded appropriately with clear and concise
explanations. For example, one patient was concerned about experiencing side effects from a
prescribed medication; the nurse explained in a way that the patient could understand on how the
treatment may affect them and gave reassurance on when to seek medical attention.
Staff demonstrated empathy and compassion towards patients and their families and showed
concern and sensitivity when discussing difficult or personal issues.
Staff gave us examples where teams had gone above and beyond normal duties. For example,
staff in the IV therapy team had downloaded music for a patient who had dementia so that it could
be played during visits, this helped to put the patient at ease during treatment. Staff had collected
prescriptions on route to housebound patients who did not live within a delivery radius of a
pharmacy and staff had self-funded supplies of tea and biscuits so all patients visiting the
department were offered refreshments.
Patients we spoke to confirmed that staff treated them respectfully and with kindness. They also
told us that they felt supported and were happy with the care they had received. In addition to this,
patients told us that not only did they feel listened to but they were offered support so that they
could fully understand their condition. One long standing patient told us “I know I am going to get
good treatment here, they are like my family and have really good understanding of my condition”.
We saw evidence that staff had great knowledge about their patients and their medical histories
and this ensured great communication between all parties.
We carried out two home visits with the rehabilitation at home team. We observed full holistic
assessments of patients prior to being admitted to the acute site for surgery. Both patients were
fully informed of what would happen following surgery and what equipment would be available for
them. We spoke to both patients and were told that they found the visits invaluable and it had
alleviated some of their concerns regarding their recovery process.
We observed five treatment clinics within the district nursing service. Each patient visit was clear
and informative. Patients details were checked at the beginning of the appointment and consent
for the treatment obtained. Full explanations were given to the patients throughout the
appointment.
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Emotional support
Staff provided emotional support to patients and their families to minimise their distress.
Staff demonstrated that they understood the importance of providing patients and their families
with emotional support. Staff showed an awareness of the emotional impact of conditions and
treatment on patients and provided support to minimise their distress.
We observed staff providing reassurance and comfort to patients and their relatives during home
visits and clinic appointments. We also saw clinic staff meeting patients in clinic waiting areas and
engaging with patients in a welcoming and approachable manner to put them at ease.
Patients were encouraged to get comfortable before treatments commenced and we observed
staff responding in a compassionate, timely and appropriate way when people experienced
physical pain, discomfort or emotional distress. We heard staff asking patients about their support
networks and observed patients being offered reassurance and encouragement was given on
when to seek further medical advice and support if they had concerns about their condition.
We observed staff ensuring that privacy and dignity of patients was maintained. Staff
demonstrated they had developed trusting relationships with some long-standing patients. One
patient said “I know I can always come here. I feel totally supported here and people fall over
themselves to be nice”.
Understanding and involvement of patients and those close to them
Staff had an excellent knowledge and understanding of their caseloads. We saw staff supporting
patients and their families and encouraging them to manage their own health and care so that they
could maintain independence. For example, we saw a district nurse explaining the patients
planned treatment and care pathway so that the patient would feel confident in undertaking
appropriate self-care procedures.
We observed staff delivering pressure ulcer awareness to patients and their families.
We observed staff actively encouraging patients to be involved in making decisions on their care
and treatment. For example, on a home visit with the rehabilitation at home team we observed
discussions on post-surgery care which helped to develop a better understanding of the potential
impact on their independence post-discharge. We spoke to a patient during a home visit and was
told that they found the pre-admission visit extremely useful as it helped them understand what
would happen following surgery and what equipment they were likely to need during the recovery
process.
We observed staff taking into account the health and well-being of a carer, for example, a patient’s
carer appeared unwell and was shown compassion and empathy from the staff member. The
carer was also encouraged to access their GP.
We saw treatment room staff explaining to patients why particular approaches were beneficial and
patients were consulted on their preferred choices of treatment. Staff also involved family
members in the patient’s treatment discussions with the patient’s consent. Patient feedback was
positive. One patient stated “I feel very supported and I know I am going to get great care. They
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discuss my treatment options with me and I’m a lot more confident in making decisions about my
future treatment”. Another patient said, “the treatment room nurses are good”.
We saw evidence of shared care plans in place for some patients receiving support from district
nursing teams. Staff told us that plans were offered to patients where complex issues existed to
develop a shared agreement of the level of care the patient was happy to accept. We saw
examples of plans that had been developed for patients who had rejected health advice from the
district nursing team and risked a deterioration in their health condition. We also saw evidence of
patients who were deemed as having capacity, but whose carer had rejected district nursing
advice. The plans documented the specific decision that had been made; the patients view and
goals; the level of information given to the patient including treatment options, risks, benefits and
alternatives to treatment. Staff told us that the shared care plan approach enabled patients (and
carers) to feel listened to and enabled appropriate support to be made available to help the patient
understand all the risks associated with the decision. Staff stated the final decision was always
made by the patient and situations where a shared plan could not be agreed would be escalated
via the incident report system.
Language line was used for patients whose first language was not English. An interpreter could
also be booked in advance if required. However, we were told by the out of hours district nursing
service that they had no access to the language line during the night and this had been a
challenge on occasions.
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Is the service responsive?
Planning and delivering services which meet people’s needs
The Trust planned and provided the majority of services in a way that met the needs of local
people. Management were aware of local priorities and service priorities were aligned to these.
We were told by the dietetics department that they did not provide weekend or out of hour
services. If there was a problem with the patient’s percutaneous endoscopic gastrostomy (PEG)
tube then the patient would have to attend accident and emergency.
The community assessment team provided a five-day service, from Monday to Friday, 8.30am to
4.30pm. This team only covered patients who had a Liverpool GP and had a Liverpool address.
Pathways that they worked to were, twenty-eight-day pathway, one to one care pathway and a
fast-track pathway. We were told that due to operational hours any fast track referrals outside
these hours would have to wait, for example referrals received on a Friday evening would have to
wait until a Monday morning.
We inspected a health technology service (Telehealth) that was run by the Trust. This was a
nurse led service that worked together with GP practices to support adults with long term
conditions to live at home and be self-caring. Referrals would be received from GP’s, community
matrons, specialist nurses or allied health professionals. A nurse assessment would then be
completed at the patient’s home. Telehealth empowered patients to monitor their own health, for
example a patient could measure their own blood pressure, pulse, body weight or oxygen levels at
home, input them onto their hand-held tablet and the information was then received and looked at
by a healthcare professional which gave patients the peace of mind that their condition was being
monitored. Education videos were available on the devices and we were told by management that
they were currently in the process of looking into providing this service in other languages.
We were told by staff in the ICRAS team that if they took blood from a patient then they would
deliver this to the local health centre or local NHS trust. This service was invaluable to patients
and reduced waiting times on blood test results.
Information leaflets were available to patients on various conditions. We only observed leaflets in
English but were told by staff that they could obtain leaflets in other languages. We were also told
by the administration staff that the friends and family test cards could be supplied in other
languages if required.
We saw a display board in one of the clinic areas highlighting what the speech and language
therapy team do. This was very informative and a great resource for patients and their families.
Meeting the needs of people in vulnerable circumstances
The service took account of patient’s individual needs. We saw good examples of personalised
care.
Staff in the community care team told us they were having difficulties in obtaining mental health
input during the continuing health care (CHC) process. We were told by staff that inpatients may
have had a mental health assessment but there was a gap in service for follow up of mental health
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care. In addition to this staff told us that they had difficulty in accessing mental health services if a
patient on the twenty-eight-day pathway deteriorated
For patients who had complex needs, learning disabilities or a cognitive impairment, staff would
work collaboratively with patients and their families to develop a relevant package of care. They
would also use a care navigator from mental health services.
Patients who were unable to leave their homes were provided with home visits where possible.
We were told that podiatry would only carry out home visits if patients were housebound. The
team would work closely with district nurses around pressure ulcer care.
We observed ramps for wheelchairs and pushchairs in all service areas as well as lifts to other
floors for patients who required them. Disabled facilities were available in all areas.
For patients whose first language was not English, translation services were available if required.
The translation telephone number was in all staff mobile phones so that it was accessible to them
whilst in patient homes.
We saw advertisements in clinical areas for memory cafes ran by a National charity.
Access to the right care at the right time
We were told by management in the physiotherapy department that if a patient with complex care
needs was deteriorating in health they would either ring a more experienced team member for
advice, escalate to a consultant geriatrician or arrange a joint consultation with them.
Accessibility
The largest ethnic minority group within the trust catchment area is ‘White other’ with 1.75% of the
population.
Ethnic minority group Percentage of catchment population (if known)
First largest White Other 1.75%
Second largest Chinese 0.8%
Third largest Other 0.7%
Fourth largest Black African 0.7%
Referrals
No referrals data was provided for this core service.
Service referrals in each locality were received from numerous sources, for example, care homes,
district nurses, community matrons, GP’s and virtual wards (health centres).
We were told by staff in the district nursing service that there were no criteria in place for referrals
and that management were not supportive in enforcing this. Staff told us that they were seeing
patients that did not have district nursing needs. We spoke to senior management and were told
that this was being addressed at the time of inspection and that referral criteria were being looked
at.
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Staff in the district nursing service told us that the continuing health care (CHC) process was
behind target by approximately two months. In addition to this staff were being asked to undertake
the CHC process assessment for patients that were inappropriate to their service, for example
mental health needs. We were not shown data to corroborate this at the time of inspection.
We were told by staff in the district nursing service that when patients were deferred in order to
manage caseloads there was no systematic way of monitoring the deferment and no agreed limit
of how many times a patient could be deferred. We were told that this had been raised to
management but we saw no evidence documented at the time of inspection.
Staff in the district nursing service felt that the RAG rating system used on the electronic
management information system was not working as efficiently as it could be. For example, Amber
patients were deemed the normal rating for the whole service and was accepted practice for the
day to day running of the service. Staff in the service were also struggling to refer patients to the
emergency response type services to prevent admission as these teams were always operating
on a RAG rating of red and so unable to respond in a timely manner.
The out of hours district nursing service had to cover a large geographical area and a lot of their
time was spent travelling which not only affected timely visits to patients but reduced patient
contact time as there was a rush to see patients in the timeframe given. In addition, there was no
continuity of care in this service as it did not belong to one locality. Management told us that
senior management are looking into putting this service back to individual localities.
There were times when clinics had to be cancelled by the district nursing service due to staff
capacity. During the week of 12 November 2018 five clinics had to be cancelled. Patients were
offered clinics in other areas but found this difficult due to the distance that had to be travelled on
occasions. We asked senior managers how this was going to be addressed as staff had raised
these concerns but had not received any information at the time of writing the report. We also
requested information on clinic closures but this had not been received at the time or writing the
report. Therefore, we were not assured that this was being monitored effectively.
We observed staff offering patients choice of appointment times and venue and facilitated this as
much as possible
Community matrons no longer undertook phlebotomy procedures and this sometimes caused a
delay as the patient had to be referred to other teams to undertake this procedure.
Referrals in the physiotherapy service were triaged from the Central management office and
differentiated into care homes, neuro-rehabilitation and community. The referrals sat in an
inbound box on the electronic management system. This would show when they were booked
and how long they had been waiting. The referrals would then be triaged by the band 7 team
leader. We
were told by the team leaders that they were in the process of training the band 6 staff to triage.
Each month capacity and acuity was looked at so they could monitor waiting times. At the time of
inspection, the department was reaching their waiting times target of eight weeks.
Staff in the intravenous therapy team told us that they had reduced the number of referrals
accepted due to capacity and training issues. Referrals for antibiotic regimes were currently being
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 97
deferred to the district nursing teams. Blood transfusion and cellulitis referrals were considered as
urgent referrals and if received before 1.30pm then a same day visit was required. All GP referrals
were prioritised to reduce risk of hospital admissions. A band 6 nurse would triage and make the
decision if a patient could be visited.
Referrals to the dieticians were input onto the electronic management information system by the
administration staff. A band 6 nurse would triage the referrals. The timeframe for patients to be
seen was eighteen weeks from referral and we saw evidence that these timeframes were being
met.
Referrals to podiatry were from a universal referral system. Patients would complete a referral
form, submit it and then it was triaged by the team leader. Each referral was placed in a category,
either urgent, high, moderate or low. For example, diabetics with ulcers would be high and nail
cutting would be low. In addition to this, referrals were risk rated and appropriate action taken
dependent on the score.
Patients referred to the frailty team were only accepted from accident and emergency and had a
seventy-two-hour discharge target using the Bournemouth criteria. We were told that this target
was not always met due to capacity and demand.
We spoke to staff in the ICRAS team regarding medical practitioner access and was told that
during the hours of 9am to 5pm a medical practitioner could be accessed quickly, however out of
hours it was difficult at times.
Learning from complaints and concerns
Complaints
Community adult services received 21 complaints between 1 August 2017 and 31 July 2018. The
main complaints themes were patient care which accounted for 13 (62%) of the complaints.
patient care which accounted for 13 (62%) of the complaints.
Total Complaints
Fully upheld
Partially upheld
Not upheld Withdrawn Under
investigation Other
Referred to Ombudsman
21 3 0 9 1 6 2 0
Compliments
The trust received 314 compliments during the last 12 months from 1 August 2017 to 31 July
2018. Two hundred and thirty-eight of these related to community health services for adults, which
accounted for 76% of all compliments received by the trust as a whole.
The service treated concerns and complaints seriously, investigated them and lessons learnt were
shared with all staff. Complaints and compliments were reported as part of the divisional monthly
meetings and discussed daily in local team safety huddles.
Staff and management told us that they would try to deal with complaints at a local level. We were
given an example of how the service learnt from a complaint and took appropriate action to
prevent similar concerns. The action included further training and support for staff.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 98
If a patient or family member raised a complaint, staff would direct them to the community patient
advice and liaison service. In addition to this, they would inform their line manager so that an
attempt could be made to resolve the issues locally and promptly.
We saw thank you cards in all service areas and in the occupational therapy department in the
Central locality we were shown a letter from a patient to an individual staff member stating that she
was amazing at their job. Staff in all areas told us that compliments were shared monthly in their
team meetings. However, verbal compliments were not being monitored.
We were told by staff in the district nursing team that they had received numerous verbal
complaints regarding clinic closures but these were dealt with at the time and not recorded.
We saw leaflets and information on notice boards in service and clinic areas for patients and staff
on how to make a complaint.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 99
Is the service well-led?
Leadership
The service had managers at all levels with the right skills and abilities to run a service providing
high-quality sustainable care.
Management were aware of the challenges to maintaining high quality services and developing
services to meet the changing needs of the population. Articulated plans and actions identified
were in place for the future development of services.
The divisional and service leads had a range of experience and came from a variety of
backgrounds. Staff told us that senior management were visible and approachable. This was
particularly beneficial to staff during the transformation of the Trust community services.
Vision and strategy
We were shown documented plans of the service strategy. The service had a clear vision and set
of values of continuous improvement, accountability, respect and enthusiasm. These values also
followed the National Health Service England (NHSE) 6C’s of care, compassion, competence,
communication, courage and commitment. The Trust knew what it wanted to achieve and
workable plans to turn it into action, developed with involvement from staff, patients, families and
key groups representing the local community.
We saw the Trusts operational plan for 2018-2019 which highlighted key priorities of reducing
community acquired pressure ulcers and reducing staff sickness.
Staff were aware of the Trust strategy and were fully informed of the transformation of the
community services.
Posters were in place in all service and clinical areas demonstrating the Trusts values.
The service had appointed a transformation lead for community services who had consulted staff
in all localities so that they could contribute their ideas or add any concerns to the plans of the
service. Staff we spoke to said they were encouraged by the new management structure and
were looking forward to working in the new Trust.
We saw an update in November 2018 of the service transformational plan for district nursing and
community matrons. This demonstrated plans to align ICRAS with community nursing to ensure
patients remained at the centre of care. We were shown step up and step-down pathways that
would be the key in delivering consistent integrated evidence based care.
We were told by senior management that they were looking at a weighting tool for caseload
management. This would assist managers to distribute caseloads equitably which would help
teams manage their workloads.
We were told by management that there were plans to bring in a practice development mentor for
district nursing staff. This would aid clinical skills training and competencies.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 100
We were also told by staff that the patient experience team was to visit patients receiving support
at home and to attend staff meetings. We did not see plans in place for this initiative at the time of
inspection.
Culture
Although managers across the service were promoting a positive culture that supported and
valued staff to create a sense of common purpose based on shared values. There were variances
to this when speaking to staff.
Most staff told us that they felt supported by their managers and were listened to when raising any
issues or concerns. We were told by management in the physiotherapy department that there had
been concerns in the past of discriminatory and abusive behaviour by staff. However, since
moving to the Trust this has not happened and staff felt more at ease. We were told that if these
behaviours did occur an informal get together would happen to try and resolve the situation. If not,
it would be escalated as per Trust policy.
There was a freedom to speak up guardian at the Trust for staff to approach and raise concerns to
if required. However, we were told by some staff in one locality that they were frightened of
speaking up due to the fear of reprisals. We were told that managers take it personally if issues
are raised. In addition to this some staff stated they were reluctant to speak up to ‘freedom to
speak up champions’ due previous experiences.
Although most staff we spoke to felt supported we were told by staff in the district nursing service
in all three localities that there was a lack of visibility by senior and middle management and they
felt there was a lack of recognition and acknowledgement for the work they were doing. We were
also told by staff in the ICRAS team that they were not being involved in the decision-making
process for the future. They felt that they were being told what was happening with no views
being taken from the team. This was very disconcerting for staff as they there was no clear
direction from management.
We were told by community matrons that they felt communication from senior management was
poor, for example they felt there was a lack of communication on the potential changes to the
service and their roles.
Staff in the district nursing service felt that the Trust was using their goodwill to see patients that
were not suitable for their service.
However, there were examples of where management had supported staff. For example when
concerns had been raised about B12 injections and getting blood results as some GPs were not
updating prescriptions and the injections continued without evidence of a review. The
management worked collaboratively and supported staff to resolve these issues.
Staff told us about the ‘Tell Joe and Ask Joe’ initiative that had been implemented so that anyone
could speak up about any concern or idea they may have. This process was also highlighted on
Trust welcome boards so that it was accessible to service users, carers and visitors.
We were told by the dietetics team that the freedom to speak up guardian had visited their
department and left a contact number for staff.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 101
We saw a positive attitude within all teams in each locality and staff told us that now all services
were under the new Trust, staff morale had improved dramatically.
Governance
There was a clear reporting and governance structure in place. There were monthly divisional
meetings in which performance, risk, incidents and complaints were reviewed. However, there
were areas that required improvement.
We observed that a range of policies were overdue for review. For example, Liverpool Community
Health (LCH) 6 – Clinical Handover of Care (March 2017), LCH 18 Bed Rail Policy (December
2017), LCH 23 Resuscitation (April 2017). These policies did have a Trust front cover with the
new Trust logo on but the forms were not all completed. We also saw that the responsible owner
of these documents was no longer employed by the Trust. We spoke to senior management
regarding the policies and were told that a policy group had been established to look at policies
and protocols during the transition process to the trust. We were also told on the day of inspection
that an operations meeting was taking place that afternoon and policies would be discussed but
they could not give a timeline as to when these would be resolved. Senior management told us
that this was not on the Trust risk register at the time of inspection.
We were told by senior management that policies and protocols were discussed in breakfast
meetings. We did not see evidence of these meetings at the time of inspection.
We looked at five policies in the district nursing service, for example Falls, Blood Glucose
Monitoring, Syringe Driver, Pressure Ulcer and Wound Guidance. All these were dated, version
controlled and easy to access on the intranet for staff.
We saw evidence of a variety of standard operating procedures, for example pre-op assessment,
trauma patient referrals, first visits to patient homes and caseload management. All were dated
and version controlled.
We were told by management that the lone working policy was being removed as it would now be
included in the security policy of the Trust. We saw that lone working devices were on the Trust
risk register due to the ongoing management and monitoring of devices. Staff had been told to
check their devices prior to leaving the office and ensure that their colleagues and managers knew
where they were going at all times.
We saw minutes of the monthly governance meetings. We saw for example that team leaders,
care managers and allied health professionals attended. Discussions took place on performance,
outcomes, risks, incidents and complaints.
We saw evidence of team meetings in all specialities. The values of the Trust were evident in all
minutes and action plans and timelines were documented. Monthly team meetings were carried
out in the district nursing clinics for the Sefton area, however August 2018 had to be cancelled due
to lack of capacity within the team.
Staff told us that patient experience reports were discussed at team meetings and patient
comments were shared. This was evidenced in the team meeting minutes we observed.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 102
We were told by management in the district nursing service in Sefton that they had put a service
review together and had a project team to take this forward. In addition to this staff were
encouraged to put their views forward into the vision of the service. We did not see evidence of
this service review at the time of inspection.
We reviewed a guideline for treatment by the dieticians to patients who required nutritional
support. However, although the guideline was informative and in date with the National Institute of
Health and Care Excellence (NICE), it was not dated, not version controlled and not available on
the intranet or internet. We queried this at the time of inspection and management told us they
were not sure whose responsibility it was to update it. Therefore we were not assured that staff
would be following the correct version to provide care in line with up to date guidance.
We saw evidence of the local division workshop ‘Green Light Toolkit’ which gave participants an
overview of gaps in assurance and agreed actions put in place following the audit in 2017. The
Green Light Toolkit is a guide to auditing and improving mental health services so that it is
effective in supporting people with autism and learning disabilities.
The Trust was disbanding the module of information governance and replacing it with data
protection and suicide prevention modules. This would help to prioritise safe care across all the
divisions.
Management of risk, issues and performance
The Trust had systems in place for identifying risks, planning to eliminate or reduce them and
coping with both the expected and unexpected.
The Trust used an electronic reporting system to record the risk register. We saw departmental
and divisional risks recorded on the register. We were told by management that having the risks
on an electronic register allowed incidents to be linked to the risks recorded. This was invaluable
when looking at themes and trends.
Senior management told us that they were currently in the process of implementing a dashboard
to demonstrate, staffing, management, incidents. This was currently being piloted in the Central
region. At the time of inspection, we did not see evidence of this.
Senior management told us that a community matrons implementation plan was in the process of
being actioned to look at staffing and flexible working. This would be profiled for the next five
years. We saw evidence of this in the Trust trajectory plan.
Staff in all the community adult services had a lone working device that was used when out on
patient visits. This was welcomed by staff as they felt safer knowing that their peers and
management knew where they were at all times when out of the office environment. We were told
by management in the dietetics department that in addition to this, staff would write on a white
board where they were going for that day.
We were told by management in the dietetics department that the Trusts key performance
indicator (KPI) of 8% for the do not attend (DNA) rates was unachievable. This had been
escalated to senior management and the team were waiting on a decision.
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 103
Dieticians did not offer a weekend or out of hours service and if a patient had a problem with their
percutaneous endoscopic gastrostomy (PEG) tube they would have to attended accident and
emergency. We did not see evidence during the inspection that this was on the Trusts risk
register.
At the time of inspection, the service had reviewed all unexpected deaths and minutes of meetings
we observed demonstrated that these had been discussed. However, senior management told us
that this was an area for improvement as expected deaths were not routinely reviewed and this
was not in line with National guidance on learning from deaths. We were told that every expected
and unexpected death would now be reported via the electronic incident reporting system and this
had been cascaded to staff via team meetings and emails. Going forward regular meetings would
be held to discuss morbidity and mortality reviews.
We were told by management in the rehabilitation at home team that there was no risk register for
their service. They told us that risks are placed on to the risk and governance template monthly
and that it only contained what the risk is and no detail on mitigating actions or risk scores
identified.
Data was provided from the Trust on their serious incidents. However we observed that the
number of most severe incidents recorded by the Trust incident reporting system is not
comparable with that reported to Strategic Executive Information System (STEIS). The trust told
us that the reason for the discrepancy was that some STEIS incidents had been removed at the
request of the clinical commissioning groups, which is normal practice.
We saw local and divisional dashboards identifying the divisions financial performances and
recommendations.
Information management
The trust collected, analysed, managed and used information to support all its activities, using
secure electronic systems with security safeguards.
The service used paper records and an electronic management information system for patient
records. There was a sharing agreement in place for access to patient information from external
healthcare providers such as GP’ who used the system for patient records and information. Staff
had access via login details and passwords.
We saw confirmation of scheme cover for the Trusts employer’s liability, public liability, products
liability and professional indemnity for the period 01 April 2018 to 31 March 2019.
We saw a standard operating procedure for caseload management which was in place to ensure
staff prioritised time to cleanse their caseload and update the red, amber and green (RAG) rating
tool on a weekly basis. However, we were told by staff in the district nursing service that due to
the weighting of caseloads and capacity this was not being achieved. We were told that the
average weightings were twenty-four plus. We did not see evidence of weightings during our
inspection. We requested evidence of this post inspection but had not received data at the time of
reporting.
Engagement
Mersey Care NHS Foundation Trust evidence appendix: community health services for adults Page 104
The trust engaged with patients, staff, the public and local organisations to plan and manage
appropriate services and collaborated with partner organisations.
The service provided patients with a friends and family survey which identified if patients would
recommend the service to friends and family. Results collated were positive. However, staff told
us that the response rate was not good. This had been raised with senior management, but no
feedback had been received.
The physiotherapy department undertook a patient satisfaction survey in addition to the friends
and family survey. Patient feedback collated demonstrated positive results.
A rehabilitation at home survey had recently been completed and the results demonstrated were
very positive.
Staff had regular team meetings and were encouraged to contribute ideas for development and
improvement of the service. In addition to this we observed a web-based question and answer
page that offered staff the opportunity to ask the chief executive questions on any subject matter.
Learning, continuous improvement and innovation
Lessons learnt and shared were embedded into practice throughout the localities. For example,
Oxford learning events, seven-minute briefings and seventy-two-hour structured reviews.
Complaints and compliments were discussed in team meetings to aid continual improvement of
the services offered.
The Trust had employed a transformation lead to help support the delivery of the new service.
The lead was working across all localities and was supporting staff through the new structure.
Accreditations
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.
This core service has not been awarded any accreditations
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 105
Community health services for children, young people and families
Facts and data about this service
Mersey Care NHS Foundation Trust provides specialist inpatient and community mental health,
learning disability and substance misuse services for adults in Liverpool, Sefton and Knowsley.
Mersey Care NHS Trust was established on 1 April 2001 and granted NHS Foundation Trust
status on 1 May 2016.
In July 2017, the trust acquired a number of services previously provided by Liverpool Community
Health NHS Trust in the South Sefton locality. Mersey Care NHS Foundation Trust acquired the
remainder of the former Liverpool Community Health NHS Trust services on 1 April 2018. These
community physical health services are provided across Liverpool to a population of approximately
11 million people. Mersey Care NHS Foundation Trust currently delivers these services across
more than 70 locations including health centres, clinics, walk-in centres and GP practices.
Mersey Care NHS Foundation Trust delivers a range of community based health services to
children, young people and families across Liverpool in a variety of community settings including
home visits, at schools and health centres. Mersey Care NHS Foundation Trust operates a locality
based operational model, with multidisciplinary clinical teams, geographically aligned and focused
around GP practice populations and schools. The localities the services operate from are, North
Liverpool, Central Liverpool and South Liverpool. Each locality is led by an associate director and
clinical lead. Community services offered include; health visiting, school nursing, healthy families
programme, child health inclusion and family nurse partnership.
Our inspection was short notice-announced which meant that staff knew we were coming a short
time before visiting to ensure everyone we needed to speak with was available. We inspected
community health services for children, young people and families provided by the trust over a
three-day period from 20 November 2018 to 22 November 2018.
During our inspection, we visited four office bases and two clinic sites. We spoke with 53 members
of staff including; school nurses, health visitors, nursery nurses, assistant practitioners, support
workers, team leaders, administration staff, clinical leads, care managers and a safeguarding
nurse specialist.
We spoke with three patients, attended one home visit and observed care at two school
questionnaire sessions, involving over 52 children. We reviewed 15 patient records and three
safeguarding referral records. We attended one team safety meeting and conducted a focus group
which was attended by over 44 staff members from across the community division.
Information about the sites, which offer services for children, young people and families at this
trust, is shown below:
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 106
Location site
name
Team/ward/satellite name Patient
group
Number of
clinics per
month
Geograp
hical
area
served
Hartington Road
Clinic,
Adult & Paediatric Special Care
Community Dental Contract (Liverpool,
Sefton & Knowsley)
Mixed - Liverpool
Burlington House Child Health Information System (CHIS) Mixed N/A Liverpool
Goodlass Road Children's 0-5 years Health Visiting Mixed N/A Liverpool
Innovation Park Children's 0-5 years Health Visiting Mixed N/A Liverpool
Queens Drive Children's 0-5 years Health Visiting Mixed N/A Liverpool
Vauxhall Health
Centre Childrens Health Inclusion Team Mixed N/A Liverpool
Based in the
hospital Children's Health Visiting Liaison Team Mixed N/A Liverpool
Goodlass Road Education Health Care Plans Mixed N/A Liverpool
Old Swan Walk
In Centre Education Health Care Plans Mixed N/A Liverpool
Queens Drive Education Health Care Plans Mixed N/A Liverpool
Dovecot Health
Centre Family Nurse Partnership (FNP) Mixed N/A Liverpool
Innovation Park Healthy Families Mixed N/A Liverpool
Bayliss at LIP School Nursing Team Mixed N/A Liverpool
Goodlass Road School Nursing Team Mixed N/A Liverpool
Queens Drive School Nursing Team Mixed N/A Liverpool
Goodlass Road Special Schools Mixed N/A Liverpool
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 107
Is the service safe?
Mandatory training
Mandatory training was facilitated by a combination of face to face and e-learning. All base leads
had access to each member of the team’s training record via the electronic staff records. This
meant that base leads could monitor staff compliance and address any training or development
needs or issues with compliance.
Mandatory training compliance was discussed at monthly team meetings across all teams and
monthly divisional performance meetings to cover the three localities. An integrated quality and
performance operational report was produced each month for each locality which detailed the
compliance level for mandatory training.
During our inspection, all staff we spoke with across a variety of teams were up to date with
mandatory training and staff told us they were reminded when the training was due and were
given time to complete it.
Following our inspection, we reviewed the integrated quality and performance reports which
covered the period September 2017 to September 2018 which showed that mandatory training
compliance was 95% across the three localities.
The trust set a target of 95%95% for completion of mandatory training and their overall training
compliance was 79% against this target. This was because continuous professional development
training (non-mandatory) and role specific mandated training had been included within the overall
compliance figures despite many role specific training modules being completed as NHS
mandatory training modules. Therefore, the service was achieving the target of 95% for mandatory
training across the three localities.
A breakdown of compliance for mandatory courses between August 2017 and July 2018 for all
staff in community services for children, young people and families is shown below:
Training courses Grand Total %
Role Specific Mandated Training - Mental Capacity Act - Level 1 (Every 3 Years) 100%
830 Local Complaint & Claims (Once only) 100%
NHS Mandatory Harassment and Bullying Awareness - No Renewal 100%
830 Local Investigation of Incidents Using RCA (Once) 100%
Continuous Professional Development - Complaints (Every 3 Years) 98%
830 Local Prevent Training for Clinicians 96%
NHS Mandatory Health and Safety - 3 Years 94%
NHS Mandatory Prevent WRAP - 3 Years 94%
NHS Mandatory Resuscitation - 1 Year 94%
NHS Mandatory Fire Safety - 3 Years 93%
NHS Mandatory Safeguarding Adults Level 2 - 3 Years 93%
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 108
Training courses Grand Total %
NHS Mandatory Safeguarding Children Level 3 - 3 Years 93%
Mandatory Training - Infection Control (Every 3 Years) 92%
830 Local Health Record Keeping 3 Yearly Compliance 92%
NHS Mandatory Consent - 3 Years 92%
NHS Mandatory Mental Capacity Act - 3 Years 92%
NHS Mandatory Conflict Resolution - 3 Years 91%
Mandatory Training - Conflict Resolution (Every 3 Years) 90%
Mandatory Training - Fire Safety (Every 3 Years) 90%
Mandatory Training - Safeguarding Children - Level 1 (Every 3 Years) 90%
NHS Mandatory Equality, Diversity and Human Rights - 3 Years 90%
Mandatory Training - Moving & Handling (Every 3 Years) 88%
Mandatory Training - Safeguarding Adults - Level 1 (Every 3 Years) 88%
NHS Mandatory Infection Control - Level 2 - 1 Year 88%
NHS Mandatory Medicines Management Awareness - 3 Years 88%
NHS Mandatory Information Governance - 1 Year 86%
Mandatory Training - Equality, Diversity and Human Rights (Every 3 Years) 85%
Mandatory Training - Health & Safety (Every 3 Years) 83%
NHS Mandatory Moving and Handling - 1 Year 83%
Continuous Professional Development - Adverse Incidents (Every 3 Years) 76%
Role Specific Mandated Training - Basic Prevent Awareness (1 Time) 76%
830 Local ILS - 1 Year 75%
Continuous Professional Development - Smoking Cessation (1 Time) 71%
Continuous Professional Development - Fraud Awareness (Every 3 Years) 70%
Continuous Professional Development - Suicide Prevention & Safety Planning (Every 3 Years) 70%
Role Specific Mandated Training - Basic Life Support (Every Year) 56%
Role Specific Mandated Training - Safeguarding Adults Level 2 -Trust Model (Every 3 Years) 47%
Role Specific Mandated Training - Safeguarding Children Level 2 - Trust Model (Every 3
Years) 47%
Mandatory Training (IG) - Data Security Awareness - Level 1 (Every Year) 40%
Role Specific Mandated Training - Safeguarding Adults Level 3 - Trust Model (Every 3 Years) 38%
Role Specific Mandated Training - Safeguarding Children Level 3 - Trust Model (Every 3
Years) 38%
Role Specific Mandated Training - Moving and Handling of People (Every Year) 36%
Continuous Professional Development - Dementia Awareness (1 Time) 21%
Role Specific Mandated Training - MHA/DoL's Level 2 (Every 3 Years) 21%
Role Specific Mandated Training - Safe and Effective Use of Medicines (Every 3 Years) 21%
Role Specific Mandated Training - Controlled Drugs & High Risk Medicines 20%
Role Specific Mandated Training - Medicines Calculations (Every 3 Years) 18%
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 109
Training courses Grand Total %
Role Specific Mandated Training - Mental Health Act - Level 1 (Every 3 Years) 0%
Role Specific Mandated Training - MUST Adapted Nutritional Screening 0%
Role Specific Mandated Training - Witness to Medication (Every 3 Years) 0%
NHS Mandatory Safeguarding Children Level 2 - 3 Years 0%
NHS Mandatory Moving & Handling for People Handlers - 1 Year 0%
Core Service Average 79%
Safeguarding
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 its 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 health services for children, young people and families made 11 safeguarding referrals
between 1 August 2017 and 31 July 2018, of which none concerned adults and 11 children.
There were three peaks identified in child referrals across the period in April (three), June (three)
and July (three).
There were clearly defined and embedded systems in place to manage safeguarding. Staff
understood how to protect patients from abuse and the service worked well with other agencies to
do so.
The safeguarding policy was current and accessible to staff electronically. Procedural pathways
were clear for referral to the local authority. The electronic patient administration system had a
flagging system to identify and alert staff to children on child protection plans, looked after children
and high-risk families. Procedures were in place to identify and manage female genital mutilation
and child sexual exploitation.
Safeguarding training compliance was monitored, facilitated and overseen by the trusts
safeguarding team. All staff at the services we visited had completed safeguarding training level
Referrals
Adults Children Total referrals
0 11 11
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 110
three which was mandatory for staff delivering services for children, young people and families.
Both female genital mutilation and child sexual exploitation awareness were included within the
safeguarding training. The trust had a specialist domestic violence and female genital mutilation
safeguarding nurse who could be contacted for specialist advice.
Safeguarding supervision was carried out by the safeguarding team, each locality had a specialist
safeguarding nurse who facilitated and monitored safeguarding supervision and compliance
levels. Safeguarding supervision consisted of both formal and informal supervision and was
carried out every six to eight weeks. All staff we spoke with during our inspection had received
safeguarding supervision within the previous six weeks.
During our inspection staff told us that they were able to contact their safeguarding specialist
nurse for advice at any time. This was encouraged by the teams and meant the appropriate
referral pathway was followed. Any contact made with the safeguarding team about an individual
was logged on the electronic patient record. There was a duty rota for cover when the locality
nurse was on annual leave or unavailable due to sickness.
All services received safeguarding information from external agencies through a secure electronic
email system. During our inspection we observed that services facilitated this in different ways for
example the health visiting teams had administration staff who monitored the email account whilst
the child health inclusion team had a rota to facilitate monitoring the incoming information to
ensure safeguarding information was not missed.
During our inspection we reviewed three safeguarding referral records and found that information
within them was legible, dated and timed. Risk assessments were included within the
safeguarding records and information was clearly documented including action plans and
priorities.
Cleanliness, infection control and hygiene
The trust had a standard (Universal) infection prevention and control policy which informed staff of
the safe management of sharps, procedure for dealing with bodily fluids, personal protective
equipment and decontamination of the environment. The policy was in date and accessible to staff
electronically. Infection prevention and control formed part of the trust mandatory training and was
undertaken annually. All staff we spoke with were compliant at the time of the inspection. Staff had
access to personal protective equipment such as gloves, alcohol hand gels and aprons.
The trust did not have a separate hand decontamination policy however, hand hygiene was
detailed within the main infection prevention and control policy and followed the World Health
Organisation ‘5 Moments’ guidance. During our inspection we found that hand hygiene audits
were not completed by any of the community teams, this meant that the service could not highlight
that hand hygiene procedures carried out by staff were effective in the prevention and control of
the spread of infection. The trusts infection prevention and control policy stated that hand hygiene
audits should be undertaken monthly
The service operated clinics and appointments from a variety of sites for which cleanliness was
overseen and maintained by the building leaseholder (not the trust), as such cleaning schedules
and audits were not available to view during our inspection. Both clinic sites visited during our
inspection were visibly clean and tidy. Information requested following our inspection showed the
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 111
trust regularly carried out self-assessment cleanliness audits on buildings not solely leased by
them to assure themselves of compliance with infection prevention and control. Following our
inspection, we reviewed a cleaning audit from a building which was maintained solely by the trust
and found that cleaning was carried out regularly in line with the infection prevention and control
policy, the compliance rate was 90%.
The trust had an infection prevention and control team however, the team only routinely audited
(monthly) for the special schools nursing team who operated from permanent base rooms within
six schools across the area. This was a concern because all other teams within the service were
not receiving advice or input from specialist infection prevention and control nurses highlighting
best practice and there were no champions within any of the teams across the service.
Environment and equipment
Premises used in the provision of care and treatment which were visited during our inspection
were tidy and well maintained. Clinic rooms had hard flooring in line with infection prevention and
control guidance for effective decontamination and wipeable patient seating. Staff told us that each
member of staff utilising the clinic room was responsible for ensuring the equipment and
environment were clean and fit for purpose however, this was not recorded.
Cleaning wipes were available for the decontamination and cleaning of equipment at all sites we
visited however, cleaning after the use of equipment was not currently being recorded or
documented. This meant that the service could not highlight that equipment was being
decontaminated and cleaned in line with the trusts policy for the management and
decontamination of medical devices. We were told by the clinical lead that one team within the
service was currently trialling the recording of the cleaning equipment after each use, however
staff told us during our inspection that this had been in place for two months but had not been
audited or feedback sought from staff with a view to rolling this out across the service.
We observed six sets of weighing scales at various sites and saw all were calibrated within the last
few months and fit for purpose. Staff told us that the calibration of equipment such as weighing
scales and audiometer headphones was recorded centrally and arrangements for re-calibration
arranged through the administration staff/clerks.
During our inspection we observed stock used by the service was in date, stored and labelled
correctly. Clinical waste was labelled and stored correctly within clinical settings and sharps were
managed in line with trust policy.
All offices we visited were securely locked with either a keypad or swipe card for access.
Cupboards containing personal documents and information were locked and keys kept in a
separate area.
Assessing and responding to patient risk
The majority of teams within the service managed areas of assessing and responding to risk
effectively. A proactive approach to anticipating and managing risks to patients was embedded
and recognised as the responsibility of all staff.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 112
Each team we visited held a weekly safety meeting to discuss caseloads, staffing and address any
concerns such as safeguarding alerts. During our inspection we attended a team safety meeting
and observed there was good identification of current issues and evident forward planning in
relation to those issues.
All patient electronic records had an alert system which informed staff of concerns such as
children on child protection plans, female genital mutilation alerts and language barrier alerts. Staff
were able to show us the alerts and how to access the information from them. The system could
also be accessed by various community healthcare services such as GP’s and walk in centres.
Information between external agencies was received and managed through a protected shared
email account.
There were robust plans in place when immunisation and vaccination sessions took place, and
this was carried out by a designated immunisation and vaccination team. The team had been set
up in September 2018 and staff told us this was due to increasing caseloads within the school
nursing service. The immunisation and vaccination team leader was able to give an example of a
recent immunisation session which had not gone particularly well due to a lack of cooperation from
the school. Following the session, the team discussed the incident and sought ways in which to
improve going forward. The team leader spoke with the school and arranged for two immunisation
champions to be selected for future immunisation sessions to aid the process.
A further example of assessing and responding to patient risk was obtained from the child health
inclusion team. This team assesses the health and wellbeing of asylum seekers within the first
three weeks of arrival into the U.K. Although the team were not commissioned to provide
immunisations and vaccinations they had sought governance approval from the trust to do so for
prioritised patients such as new born babies and children who have never received any
vaccinations, having identified a risk to these patients.
Health visiting teams used a variety of questionnaires to identify various themes throughout
contact stages such as assessing mums for possible signs of depression within the postnatal
period, identifying social interaction for children such as emotion, activity and social conduct. This
meant that the patient or mum could be referred to other services when appropriate.
School nursing had an effective system in place for triaging referrals using a standard operating
procedure which enabled them to classify referrals as “non-urgent, urgent and immediate”. This
meant that children with the most urgent needs were referred on or assessed in a timely manner.
There were however, areas of school nursing in which assessing and responding to patient risk
was not managed effectively. Part of the school nursing role was to deliver health and wellbeing
questionnaires to look for health needs in children. During our inspection staff told us that there
was no set time frame as to how quickly questionnaires should be triaged. Information supplied by
the trust following our inspection detailed a standard operating procedure which stated that initial
triage of questionnaires should be completed two weeks following the closure of the information
being uploaded onto the electronic system. This was a significant risk because children who are
potentially vulnerable who may need direct intervention and support for example due to mental
health or safeguarding could be left waiting for this. During our inspection we also found that there
were no clinical pathways to support school nurses for specific identified conditions such as self-
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 113
harm or mental health. The clinical leads told us that they were in the process of developing a
series of pathways to support school nursing.
Staffing
Between August 2017 and July 2018, the trust reported an overall vacancy rate of 27% in
community services for children, young people and families.
Staff group Total number of substantive staff Total % vacancies overall (excluding
seconded staff)
Clerical & Adm Clinical Suppr 1.4 -1%
Clerical & Admin Central Serv 0.9 6%
Nurse Health Visitor Community
Services 8.8 34%
Core service total 11.2 27%
Turnover
Between August 2017 and July 2018, the trust reported an overall turnover rate of 11.3% in
community services for children, young people and families.
Staff group Total number of
substantive staff
Total number of
substantive staff
leavers in the last 12
months
Total % of staff leavers
in the last 12 months
Allied health professionals 55.7 5.9 10.5%
Health care assistants 61.8 1.0 1.6%
Nursing & midwifery registered 137.9 20.9 15.2%
Other (including admin & clerical) 35.3 5.1 14.3%
Core service total 290.7 32.8 11.3%
Sickness
Between August 2017 and July 2018, the trust reported an overall sickness rate of 6% in
community services for children, young people and families.
Staff group Total number of
substantive staff
Total % permanent staff
sickness overall
Allied health professionals 55.7 3%
Health care assistants 61.8 8%
Nursing & midwifery registered 137.9 7%
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 114
Staff group Total number of
substantive staff
Total % permanent staff
sickness overall
Other (including admin & clerical) 55.7 6%
Core service total 290.7 6%
Nursing – Bank and Agency Qualified nurses
Between August 2017 and July 2018, Mersey Care NHS Foundation Trust reported an overall
bank and agency usage of 2472 hours for qualified nursing staff.
Total Number of Hours
available
Total Hours Filled by
Bank Staff
Total hours Filled by
Agency Staff
Total hours NOT filled
by Bank Staff
4526 216 2256 49
**Some of the data provided by the trust showed that more hours were filled than available, hence percentages are
not shown, just number of hours.
Nursing - Bank and Agency Healthcare Assistants
Between August 2017 and July 2018, Mersey Care NHS Foundation Trust reported no usage of
bank and agency staff for health care assistants.
Suspensions and supervisions
During the reporting period, this core service reported that there were no cases where staff have
been either suspended or placed under supervision.
Capacity and demand was assessed in all teams throughout each locality and caseloads were
monitored by team leaders to ensure even distribution of work throughout each service. A planning
tool was used to plan and manage demand, workload and resources. The service was in the
process of implementing a new electronic system to monitor caseloads which would allow for
easier monitoring of staff workload. Staffing and workload were discussed at monthly team
meetings and weekly staffing huddles for all teams, across all areas.
We spoke with a team lead for the health visiting South locality who reported good staffing
numbers within the team. This team had a member of staff who had previously left returning in
December which meant that there were no vacancies within the team. Staffing levels were an
issue within the North locality due to sickness however, the South team were able to cover
caseloads and appointments comfortably for this due to having full staffing levels.
The service was engaged with a national improvement programme through NHS Improvement to
support a reduction in sickness absence and undertake research into factors affecting sickness
and to monitor the impact of health and well-being interventions.
There were staffing issues across all school nursing teams and staff told us that there was a
national shortages of school nurses. The service was addressing this issue by developing staff by
them completing a public health training programme which meant that when qualified these staff
would be able to practice as school nurses which showed succession planning.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 115
There was a good skill mix in all teams we visited. There was a wide variety of both clinical and
non-clinical staff who supported the service including; health visitors, nursery nurses, community
nurses, public health school nurses, school nurses, support workers, school health practitioners,
assistant practitioners, healthcare assistants, specialist paediatric liaison nurses, specialist family
nurses and administration clerks.
All staffing issues including current vacancy rates and turnover across the three localities were in
the process of being implemented into the monthly integrated performance and quality report. As
such, we were unable to assess these figures across the three localities following our inspection
as this was still under development. Sickness levels across teams were detailed within the
integrated performance and quality report, we observed that sickness within health visiting in the
north was the highest at 9% which mirrored information given to us during our inspection. Action
plans had been put into place to support this.
Quality of records
The service used an electronic system for patient records. Staff could access the information they
needed to assess, plan and deliver care, this included agency and bank staff. The electronic
patient recording system could also be accessed by various external healthcare providers such as
GP’s, walk in centres and other community services.
Staff told us that the trust was going ”paper light” which involved the scanning of pre-electronic
records onto the system. Existing paper records were held securely in locked filing cabinets within
all office sites we visited during our inspection. Nursing notes which were completed on home
visits and during clinics were typed into the electronic system on the staff’s return to the office and
paper copies confidentially destroyed. Questionnaires were scanned onto the system and
attached to patient records by administration staff or team clerks and then confidentially destroyed.
The quality of documentation was consistently good across the service. We reviewed 15 sets of
records during our inspection, entries were legible, dated, timed and the system logged
electronically the name of the person inputting the information. Care plans, safeguarding and
various health assessments and/or questionnaires were clearly documented for health visiting,
special schools and school nursing. We did however observe two school nursing records were
advice had been given regarding specific conditions but not actually documented.
Staff told us that patient records were audited annually however, the clinical leads were unable to
access the results of the 2017/2018 audit and this information was requested following the
inspection. The results showed that there was good compliance in relation to areas such as
recording of patient NHS numbers and health promotion advice being discussed however,
compliance was poor in other areas for example the patients first language and if an interpreter
would be required.
There was clear evidence within the information of actions to improve the audit results and how
this was disseminated to staff. During our inspection, the clinical leads told us the audit was
currently being retaken to compare to the results from the previous year to measure improvement.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 116
Medicines
Medicines were appropriately stored and access was restricted to authorised staff. There were
appropriate arrangements in place for the destruction of unwanted or expired medicines. We saw
that medicines in cold storage were kept in a fridge however the fridge was unlocked at the time of
our inspection which meant that medicines may be accessed by unauthorised people. A daily
record of fridge temperatures was maintained to ensure that medicines were kept at the correct
temperature. The temperature record had been completed each day for the fridge which was used
by the immunisation and vaccination team. Staff were able to describe the process of reporting a
problem with either the fridge or the temperature measures.
There was a medicines management policy for both cold chain medicines and the reporting of
medicines related incidents. Both were in date and accessible to staff electronically. Staff were
able to describe the process for ordering medicines and reporting medicine related incidents.
Two teams within the service were able to administer medications by the use of Patient Group
Directives; the child health inclusion team and the immunisation and vaccination team. Patient
Group Directives are written instructions which allow specified healthcare professionals to supply
or administer a particular medicine in the absence of a written prescription from a doctor.
During our inspection we reviewed all Patient Group Directives for both teams and found them to
be signed, in date and easily accessible to staff both electronically and in paper format. The team
leader for the immunisation and vaccination team told us that staff were encouraged to take paper
copies of the Patient Group Directives out with them when attending immunisation and vaccination
sessions. When not in use we observed that the Patient Group Directives were stored in a locked
cabinet within each respective office.
The immunisation and vaccination team had access to advice and assistance from the trust’s
medicine management team. The medicine management team had responsibility for the ordering
and auditing of medicine stock for the team and completing audits of fridge temperatures which
were carried out quarterly. Staff told us that a medicines management audit had been undertaken
recently but the team leader had not received the results of this. We requested this information
following our inspection however, the trust did not provide this.
During our inspection we reviewed the medicines log for vaccinations being held in the fridge and
found that there was a discrepancy with one vaccine for which the count was incorrect by one vial.
There was a further discrepancy with the number of adrenaline grab bags which were used for
allergic reactions during immunisation sessions. Staff advised they would record both
discrepancies as incidents on the electronic system for review and investigation by the medicine
management team. All medicines held were in date with the batch numbers were clearly recorded.
Incident reporting, learning and improvement
Serious Incidents - STEIS
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include ‘never events’ (serious patient safety incidents that are wholly preventable).
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 117
In accordance with the Serious Incident Framework 2015, the trust reported two serious incidents
(SIs) in community services for children, young people and families, which met the reporting
criteria, set by NHS England between August 2017 and July 2018. They were both categorised as
‘Other’.
Incident Type Number of Incidents
Other 2
Core Service Total 2
Serious Incidents (SIRI) – Trust data
Between 1 August 2017 and 31 July 2018, trust staff in this core service reported two serious
incidents. Of these, none involved the unexpected death of a patient. The most common types of
serious incidents were ‘other’ (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
Other 2
Core Service Total 2
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 two ‘prevention of future death’ reports sent to the trust for a
response. A third report involved a patient who died whilst in the trust’s care, but the trust was not
directly asked for a response.. None of these related to this core service.
All staff had access to the trust-wide electronic incident reporting system. Staff were able to tell us
and demonstrate how they would report an incident using this system. Staff had a good
understanding of what would constitute a reportable incident and gave specific examples of when
they had completed an incident report.
All staff we spoke with were aware of duty of candour which is a regulatory duty that relates to
openness and transparency and requires 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. Most staff were able to tell us the who the duty of candour lead was for the
trust and we saw posters detailing what duty of candour was and the name of the lead in all office
bases we visited.
Managers reviewed all low-level incidents and we saw evidence that appropriate responsive
actions were taken as a result of incidents. Managers were able to give specific examples of
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 118
incidents reported and subsequent actions as a result of them. One example of this was the
reporting of a lack of car parking facilities which was resulting in staff being late for work due to
driving around to locate a suitable space. As a direct result of this the service had supplied staff
with laptops and introduced “agile working” which meant that staff were able to work from home or
alternative locations.
We saw evidence that the service investigated serious incidents thoroughly and monitored the
impact of recommendations for improvement through audit. Lessons were learned and
communicated through weekly and monthly staff meetings and email. Leaders were able to tell us
when duty of candour would be applied and robust arrangements were in place by way of twice
weekly “being open” meetings to review any moderate incidents within 72 hours and agree actions
which met with national guidance. Community health services for children, young people and
families had no incidents up to our inspection for which a formal duty of candour notice would be
applied.
The trust had developed its own programme ”just and learning” which was designed to promote
openness and willingness to report incidents without fear of retribution or victimisation. Information
supplied prior to our inspection informed us that there were 40 “just and learning” ambassadors
within the trust however, there were no ambassadors within the community children, young people
and families service and some staff had not heard of the programme.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 119
Is the service effective?
Evidence-based care and treatment
Staff at each service followed the Department of Health and Social Care Healthy Child
Programme. The Healthy Child Programme is an early intervention and prevention public health
programme of screening tests, immunisations, developmental reviews, information and guidance
to support parenting and healthy choices. The teams offered immunisation, vaccination, health
and development reviews, new birth screening and advice around health and wellbeing.
During our inspection we saw evidence that the service used questionnaires and pathways which
followed best practice and national guidance. An example of this was the family nurse partnership
who used an observational tool called DANCE (Dyadic Assessment of Naturalistic Caregiver
Experience) which enabled staff to assess parent and child interaction. Health visiting had an
infant feeding policy in place which was based on national guidance and staff were able to give us
detailed information about breastfeeding and the benefits to both mother and baby and how this
was used in practice for patients.
National Institute for Health and Care Excellence (NICE) guidance was used in the development of
questionnaires for both school nursing and health visiting. All patient group directives followed the
National Institute for Health and Care Excellence (NICE) guidance and staff were updated in any
changes to guidance for all teams by email or during team meetings.
Following our inspection, we requested the minutes from a selection of team meetings across the
service and were able to see evidence of the discussion of changes in practice as a result of
amendments to national guidance and best practice.
Patient outcomes
Audits – changes to working practices
The trust have participated in no clinical audits in relation to this core service as part of their
Clinical Audit Programme.
The service monitored the effectiveness of care and treatment and used the findings to improve
patient outcomes. We were given examples of how services supported the delivery of the healthy
child programme. Staff across the health visiting teams had trialled using a text message service
to remind families the night before an appointment was due in an attempt to increase the key
performance indicator target for one-year assessments which was noted to be low. As a direct
result of this health visiting teams had seen a slight increase in the number of attendances.
The immunisation and vaccination team was set up as a direct result of the monitoring of key
performance indicators which showed targets were not being met and thus the team was created
separately from school nursing in a bid to increase target performance. Although the team was
new staff told us they felt patient outcomes would improve as a direct result of the team being able
to monitor uptake rates and performance separately from the school nursing service.
The patient uptake rate for flu vaccinations was monitored by Public Health England with a
national target of 65%. The team were currently underperforming at 55%, we saw evidence of an
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 120
action plan and staff told us they had been actively engaged in providing ideas in how the target
could be improved.
School nursing were able to give an example of submitting data in relation to the national child
measurement programme which showed a high percentage of patients who had opted out of the
programme. As a result of this the service had changed the application forms to an electronic
format which aligned with national NHS priorities of becoming paperless, the resulting audit to
assess for improvement had not been undertaken at the time of our inspection, however, staff
were optimistic for improvement.
Competent staff
Clinical Supervision
Between 1 August 2017 and 31 July 2018, the average clinical supervision rate for the core
service was 5%, the trust did not have a target for clinical supervision.
Team
Clinical
Supervision
Target
Clinical Supervision
Delivered
Clinical
supervision rate
(%)
831 Z 3007 LCH Practice Nurse Development
(L7)
169 135 80%
830 Z 2047 LCH Vaccination and Immunisation
Team (L7)
134 2 1%
830 Z 3541 LCH AHP's North - Rehab at Home
(L7)
12 0 0%
830 Z 2599 LCH Specialist Students - North (L7) 20 0 0%
830 Z 2536 LCH Physiotherapy Adults - South
Liverpool (L7)
11 0 0%
350 L9 Podiatry - Sefton CS (Z4CH27) 39 0 0%
830 Z 3029 LCH LOOHS - Social Workers (L7) 18 0 0%
350 L9 Respiratory/Actrite (Sefton) (Z4CH44) 69 0 0%
830 Z 2531 LCH Adults Occupational Therapy -
North (L7)
27 0 0%
350 L9 Sefton Bank Staff Control (Z4CH80) 3 0 0%
830 Z 2541 LCH Podiatry - Team Leaders (L7) 6 0 0%
350 L9 Treatment Room South - Sefton CS
(Z4CH30)
26 0 0%
830 Z 3020 LCH Health Visitor Team Leaders -
South (L7)
6 0 0%
351 L9 Treatment Room South - Sefton CS
(Z4CH30)
36 0 0%
830 Z 3039 LCH Health Technology Managers
(L7)
6 0 0%
830 Z 0109 LCH Operational Senior 8 0 0%
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 121
Team
Clinical
Supervision
Target
Clinical Supervision
Delivered
Clinical
supervision rate
(%)
Management - Nurse-Led (L7)
350 L9 Dietetics - Sefton CS (Z4CH14) 19 0 0%
830 Z 0144 LCH Children in Care (L7) 9 0 0%
830 Z 2534 LCH Physiotherapy Adults - Central
(L7)
10 0 0%
830 Z 0145 LCH Safeguarding Adult's (L7) 15 0 0%
830 Z 2539 LCH Podiatry - North (L7) 28 0 0%
830 Z 0146 LCH Safeguarding Children (L7) 32 0 0%
830 Z 2545 LCH AHP's North Dietetics Team
Leaders (L7)
18 0 0%
830 Z 0147 LCH Targeted Services for Young
People (L7)
6 0 0%
830 Z 3016 LCH Social Inclusion - Children's
(L7)
12 0 0%
830 Z 2019 LCH Health Visitors Central Team 5
(L7)
37 0 0%
830 Z 3027 LCH LOOHS - ERT (L7) 61 0 0%
830 Z 2020 LCH Health Visitor Team Leaders -
Central (L7)
15 0 0%
830 Z 3033 LCH Skin Team (L7) 36 0 0%
830 Z 2021 LCH Health Visitors Central Team 1
(L7)
36 0 0%
830 Z 3042 LCH Health Visitors South Team 2
(L7)
243 0 0%
830 Z 2022 LCH Health Visitors Central Team 2
(L7)
41 0 0%
831 Z 2524 LCH School Nurses North Liverpool
Team 1 (L7)
31 0 0%
830 Z 2023 LCH Health Visitors Central Team 3
(L7)
28 0 0%
831 Z 3027 LCH LOOHS - ERT (L7) 16 0 0%
830 Z 2024 LCH Health Visitors Central Team 4
(L7)
22 0 0%
830 Z 2532 LCH Adults Occupational Therapy -
South Liverpool (L7)
6 0 0%
830 Z 2025 LCH School Nurses Team Leaders -
Central (L7)
6 0 0%
830 Z 2535 LCH Physiotherapy Adults - North
Liverpool (L7)
46 0 0%
830 Z 2026 LCH School Nursing Central Team
1 (L7)
42 0 0%
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 122
Team
Clinical
Supervision
Target
Clinical Supervision
Delivered
Clinical
supervision rate
(%)
830 Z 2538 LCH Podiatry - Central (L7) 29 0 0%
830 Z 2027 LCH School Nursing Central Team
2 (L7)
30 0 0%
830 Z 2540 LCH Podiatry - South Liverpool (L7) 29 0 0%
830 Z 2030 LCH Family Nurse Partnership -
Liverpool (L7)
21 0 0%
830 Z 2544 LCH AHP's North - Dietetics (L7) 35 0 0%
830 Z 2037 LCH Treatment Rooms - Central
(L7)
51 0 0%
830 Z 2559 LCH MM Distribution/Stores (L7) 3 0 0%
830 Z 2038 LCH Treatment Rooms - North (L7) 12 0 0%
830 Z 3007 LCH Practice Nurse Development
(L7)
18 0 0%
830 Z 2039 LCH Treatment Rooms - South
Liverpool (L7)
51 0 0%
830 Z 3019 LCH Educational Healthcare Plan
Liverpool (L7)
5 0 0%
830 Z 3021 LCH Health Visitors South Team 1
(L7)
42 0 0%
350 L9 Pharmacy Community - Sefton CS
(Z4CH25)
3 0 0%
830 Z 3023 LCH School Nurses South Liverpool
Team 1 (L7)
40 0 0%
830 Z 3026 LCH LOOHS - Community
Assessment Team (L7)
40 0 0%
830 Z 2099 LCH Specialist Students - Central
(L7)
4 0 0%
830 Z 3028 LCH LOOHS - Therapy Service (L7) 29 0 0%
830 Z 2503 LCH Operational Management -
North Liverpool (L7)
3 0 0%
830 Z 3030 LCH Bladder & Bowel Team (L7) 138 0 0%
830 Z 2520 LCH Health Visitor Team Leaders -
North (L7)
17 0 0%
830 Z 3038 LCH Telehealth (L7) 24 0 0%
830 Z 2521 LCH Health Visitors North Team 1
(L7)
48 0 0%
830 Z 3040 LCH Single Point of Contact (L7) 331 0 0%
830 Z 2522 LCH Health Visitors North Team 3
(L7)
78 0 0%
830 Z 3530 LCH Children's Liaison Team (L7) 16 0 0%
830 Z 2523 LCH School Nurses Team Leaders - 3 0 0%
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 123
Team
Clinical
Supervision
Target
Clinical Supervision
Delivered
Clinical
supervision rate
(%)
North (L7)
831 Z 2523 LCH School Nurses Team Leaders -
North (L7)
25 0 0%
830 Z 2524 LCH School Nurses North Liverpool
Team 1 (L7)
46 0 0%
831 Z 2531 LCH Adults Occupational Therapy -
North (L7)
18 0 0%
830 Z 2525 LCH Special Schools Liverpool (L7) 33 0 0%
831 Z 3016 LCH Social Inclusion - Children's
(L7)
9 0 0%
830 Z 2527 LCH AHP's North - Speech &
Language Therapy SALT (L7)
32 0 0%
350 L9 Diabetes - Sefton CS (Z4CH13) 13 0 0%
830 Z 2530 LCH Adults Occupational Therapy -
Central (L7)
7 0 0%
Core Service Total 2688 137 5%
Clinical supervision was regular and took place both formally and informally during handovers,
team discussions, peer reviews and appraisals. Sessions focussed on information sharing and
learning. Staff told us that they received clinical supervision on average every six weeks. Clinical
supervision is important because it enables staff to reflect upon their practice with skilled
supervisors and practitioners with a view to increasing knowledge, skills and highlighting
development needs to improve patient care, going forwards.
Clinical supervision rates were collated and were due to be reported within the monthly integrated
performance and quality report for each locality. The compliance with clinical supervision was
discussed at weekly divisional safety meetings. Following our inspection, we saw evidence from
the weekly divisional safety meetings minutes that clinical supervision was discussed and ways to
improve rates discussed, going forward.
Leaders told us during our inspection that whilst clinical supervision was not new, the reporting of
clinical supervision had not been formalised which had resulted in rates appearing low. A
standard form was now being used to record the information and this was being collated by the
performance and intelligence team. Clinical leaders were confident that rates would increase
because of this, going forward. We saw evidence of improvement in clinical supervision rates from
those stated above within the October monthly integrated performance and quality report for all
three localities.
Appraisals for permanent non-medical staff
Between August 2017 and July 2018, 83% of permanent non-medical staff within the community
services for children, young people and families core service had received an appraisal compared
to the trust target of 95%.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 124
Total number of permanent non-medical
staff requiring an appraisal
Total number of permanent non-
medical staff who have had an
appraisal
% appraisals
210 175 83%
Managers appraised staff’s work performance and supported professional development. During
our inspection, all staff we spoke with said they had received an appraisal within the past 12
months.
We saw written evidence of appraisal meetings for staff in school nursing, which included areas for
development and action plans for achieving goals which had been identified. In health visiting we
saw the schedule for staff appraisals for the coming year.
The clinical leads told us that the service was moving onto a new electronic system in April 2019
which would enable both clinical supervision and staff appraisals to be recorded and monitored
more efficiently than it was at present. The system would also enable staff to access their own
records and therefore monitor their own performance. Appraisal rate data was reported monthly as
part of the integrated performance and quality report for each locality.
All staff within the service were qualified to carry out their roles effectively. Each team had a good
mix of staff covering a range of services. Staff told us how their roles were being developed to
provide holistic care across the children’s, young people and families service. For example, the
special schools team had recruited a qualified public health nurse to enable the delivery of aspects
of the Healthy Child Programme alongside the medical care model which was already being
delivered.
The majority of staff told us they were supported in developing new skills and were excited about
the opportunities this offered. An example of this was a school nurse who told us she had attended
training offered by the National Prevention of Cruelty to Children (NPCC) in looking at identifying
neglect within health and social care. Health visiting staff told us they were encouraged to attend
training offered by the Institute of Health Visiting which incorporates ‘train the trainer’ training
within its programmes. This meant that once staff were trained they would then become trainers
themselves and were able to return and train other staff members. However, we were told that not
all staff felt supported and had raised concerns about training not being offered across all teams
and the cessation of staff development days.
All teams across the service had robust preceptorship programmes which aided new starters in
becoming familiar with their area of work and allowed for issues or concerns to be highlighted. All
preceptorship programmes across school nursing, special schools and health visiting spanned six
months and were overseen by a senior nurse or team leader. The family nurse partnership had a
specific proficiency programme which was overseen by the family nurse partnership supervisor.
Each new staff member received an appraisal after three months on the preceptorship programme
in which staff were encouraged to discuss worries or concerns. During our inspection we spoke
with three new staff members from across various teams who told us they felt supported in their
preceptorship.
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Multidisciplinary working and coordinated care pathways
Staff of different kinds worked together as a team to benefit service users. Health visitors, nurses
and other healthcare professionals supported each other to provide good care. We saw many
examples of excellent multidisciplinary working across teams during our inspection.
The service had a team of paediatric liaison nurses who worked from four acute hospital sites. The
team supervisor told us that the aim of the team was to bridge the gap between maternity and
health visiting and also accident and emergency departments and school nursing. Information was
shared and this ensured safeguarding concerns and opportunities were not missed. Health visiting
staff told us of the benefit of receiving information from the liaison nurses in planning assessments
and appointments to meet key performance indicator targets.
Both school nursing and health visiting teams were co-located and staff told us of the benefit of
this and how this had impacted positively on the quality and overall delivery of the service. For
example, health visitors could discuss the children on their caseload who were due to transfer to
school nursing.
Health visiting teams had begun working from the early help assessment hub which was operated
and run by the local safeguarding children board. The early help assessment is a service which
specifically looks at early identification of families who may require additional help and support.
Each month a different health visitor would work from within the hub which incorporated; a police
officer, social worker and support workers. Staff told us they felt this was a really positive
experience and had greatly aided in understanding how other services worked and in gaining face
to face advice. Team leaders told us an amendment was being made so that health visitors would
rotate on a three-month basis as feedback although positive for the project had stated that monthly
rotation was not allowing for development of professional relationships.
During our inspection we observed excellent working relationships between school nursing and
teachers. A multidisciplinary approach to the completion of school questionnaires was observed
and both professions had evident respect and appreciation for each other.
The child health inclusion team worked across disciplines and had established good working
relationships with local schools, dentists, doctors and social workers. This team had extended its
multidisciplinary working as it was one of eight regional centres for first contact asylum seekers.
The team lead attended national meetings for Public Health England and national network
meetings to discuss best practice and programme improvement.
There was an abundance of multidisciplinary meetings across teams within the service and it was
evident that the service had great enthusiasm for working across services both externally and
internally to improve the quality and delivery of the service.
Health promotion
Health promotion was deeply embedded within all teams and staff told us this was a fundamental
part of all areas of work within community services for children, young people and families.
Healthy eating and diet, exercise programmes during pregnancy, smoking cessation and sexual
health were some health promotion activities addressed. Staff were aware of services available in
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the community across teams and localities where they could refer patients and their families when
necessary.
We saw evidence of information leaflets pertaining to dental hygiene, emotional health and
wellbeing and smoking cessation. School nursing teams had products for helping in giving talks
relating to menstruation and sexual health. Health visiting teams were able to give advice on
breastfeeding and had access to a breastfeeding advice service. We observed the child health
inclusion team had access to toothbrushes and toothpastes which had been supplied by a charity
to give out to first contact asylum seekers. This service had also put an internal case forward to
secure funding for vitamin drops which had been given out previously but had since been
withdrawn.
The service had a healthy families team which was a service offered to any child identified as
being overweight. The whole family were invited to attend a six-week programme providing
education and advice regarding healthy eating and lifestyle. However, many staff we spoke with
during our inspection were unaware of the team or how to refer a patient onto them.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Deprivation of Liberty Safeguards
Mersey Care NHS Foundation Trust told us that 97 Deprivation of Liberty Safeguard (DoLS)
applications were made to the Local Authority between 1 August 2017 and 31 July 2018 of which
none were pertinent to community health services for children, young people and families.
Staff we spoke with said they had not had to apply for any Deprivation of Liberty Safeguards. All
staff said they would discuss any capacity issues with the trust safeguarding team who are easily
accessible via telephone and email.
Staff we spoke with were aware of the importance of mental capacity when carrying out
assessments and could explain their decision making when considering this. Both mental capacity
and deprivation of liberty training were included within the trusts mandatory training and the
compliance rate was 92%. Both the family nurse partnership and health visiting staff we spoke
with were able to tell us that if there were concerns in relation to maternal mental capacity they
could access an enhanced midwifery team for advice.
The service had a consent policy which was in date and accessible to staff electronically. All staff
we spoke with during our inspection had a good understanding of consent and Gillick
competencies and how these were applied. Staff were able to verbalise when a decline of consent
would be overridden if there was an issue in relation to a safeguarding concern.
As the services were pre-planned often consent had already been sought and recorded within the
electronic patient record. The immunisation and vaccinations team sent out consent letters to
parents before an immunisation session. We saw evidence that consent was documented clearly
and legibly during our inspection.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 127
Is the service caring?
Compassionate care
During our inspection we observed two school questionnaire completion sessions involving over
52 interactions between school nursing staff and children. There was an exceptional, therapeutic
approach to care delivery. We observed staff were highly skilled at adjusting their tone, language
and terminology to adapt to the child they were speaking with. We observed that staff knelt down
so that they were at the same level as the child and spoke reassuringly and compassionately
during all interactions.
We saw evidence of a family and friends test from a baby weigh-in clinic in which patients
described receiving an “excellent service” and that the “staff are incredibly caring and friendly and
put me at ease”.
During our inspection, we spoke with 53 members of staff across a variety of professional groups.
All those we spoke with showed compassion in their work and were clearly dedicated in their
profession.
Emotional support
Staff provided emotional support to patients to minimise their distress and we were given many
examples where this was evident.
One team member told us of a situation where a patient’s house had burnt down. The team had
worked with a local charity to provide vouchers for the family to buy clothing for both mum and her
children. The team also linked in with local food banks to ensure both mum and her children had
food. The team had since held fundraising events for the charity.
During one of the school questionnaire sessions, a child became upset and had started to ask a
lot of questions to the school nursing team. We observed the school nurse reassuringly ask the
child if he would like to speak in private, following this the child returned to the classroom happy.
There was an occasion when a child had disclosed to the service during the completion of a
questionnaire about concerns they had. The service worked with the child and their family together
with the school to ensure the family were safe.
We attended a home visit during our inspection and found the interaction and emotional support
given to the mum exceptional. The health visitor was reassuring and allowed the mum plenty of
time to discuss her worries and concerns. The mum was given advice on the changing dynamics
of family life after the birth of a baby. The trusted interaction between the health visitor and the
new mum was evident.
Understanding and involvement of patients and those close to them
Staff involved the children, young people and families and those close to them in decisions about
their care and treatment.
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All staff we observed had an excellent rapport with the children, young people, families and carers.
There were examples of complex issues the teams had to deal with and long term professional
relationships built with parents and families.
We observed staff during the school questionnaire sessions explaining to the children the reason
for the questionnaire and how the information would be used to plan sessions in their school and a
timeframe for this. We observed staff explaining in simple terminology what confidentiality and
ethnicity meant and why this was being asked. Children were clearly advised that they did not
have to take part if they didn’t want to. At the end of the explanation clarification was sought as to
if the children understood what was being said to them and they were offered an explanation
again, if they did not understand.
The health visitor during the home visit clearly explained to the patient the reason for the visit and
provided reassurance that whilst she may not be seen by the same health visitor for clinic
appointments, the health visitor would endeavour to attend all home visits herself.
It was evident from the school visit, home visit and from speaking with staff that the understanding
and involvement of patients and their families in their care was of paramount importance to them.
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Is the service responsive?
Planning and delivering services which meet people’s needs
The trust planned and provided service in a way which met the needs of the local people.
Changing needs of the community were monitored using a variety of sources including local
intelligence, GP information and schools.
Health visiting planned its visits and tailored the work according to the local population using
intelligence on areas of social deprivation and previous poor attendance to clinics. School nursing
used the questionnaires to plan its programme of work and develop services as needs were
collated and understood. The immunisation and vaccination team were in the process of
developing drop in clinics based on local intelligence to suggest where these would be most
beneficial and see the greatest uptake rate.
Prior to the acquisition of some of the children’s services from Liverpool Community Health NHS
Trust, the trust had not previously held any physical health services. As such, there was an
ongoing transformation programme for which there was a transformational clinical lead and
improvement plans were based on planning and delivering services based on local needs. At the
time of our inspection, the trust was gathering information relevant to each locality and in the
process of planning services going forward. There were clear plans in place.
Meeting the needs of people in vulnerable circumstances
The service took account of patient’s individual needs and we were given many examples of
support given to vulnerable children, young people and families.
Health visiting, school nursing and the family nurse partnership all held weekly safety meetings
were caseload allocation including vulnerable patients were discussed. The electronic patient
record was used to alert staff to anything which may be deemed as a vulnerable situation such as
safeguarding or looked after children alerts.
The child health inclusion team specifically dealt with vulnerable children, young people and their
families as the first contact for asylum seekers. As such this service had access to crisis
counselling, midwifery services and a GP on site at the clinic where the patients and their families
were seen.
The special schools team had access to a specialist complex needs nurse for advice and support
in relation to caring for children with complex needs including learning disabilities and physical
health disabilities.
The immunisation and vaccinations team had met with a local Imam to offer educational sessions
for local Muslim communities regarding immunisations. Further work was planned for educational
sessions for both the polish and travelling communities.
All services we spoke with were able to tell us about referral processes for mental health (both
child and maternal), speech and language therapists, early help intervention, counselling and
bereavement services.
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Each service had access to language line for people with English as a second language. They
were easily accessible by telephone and leaflets informing people of the service were available.
Staff told us that face to face interpreter bookings could also be made.
Access to the right care at the right time
Accessibility
The largest ethnic minority group within the trust catchment area is white other with 1.75% of the
population.
Ethnic minority group Percentage of catchment population (if known)
First largest White Other 1.75
Second largest Chinese 0.8
Third largest Other 0.7
Fourth largest Black African 0.7
During our inspection, we observed a variation in the way referrals were managed across the
teams and services. There were however, no reported incidents specifically related to the way in
which referrals were managed.
Staff told us during our inspection that referrals for health visiting were managed through one
central team electronically. Referrals were received from GP’s and from information shared by the
paediatric liaison nurses located within the acute hospitals. Each health visitor was attached to a
local GP practice, this meant that they saw patients who were within specific GP catchment
populations.
School nursing referrals were received electronically through a protected shared email account.
Each team had a staff member to cover the incoming referrals throughout the day. A triaging
process was in place which allowed referrals to be allocated and seen based on immediacy of
need.
The child health inclusion team received referrals in a set format each day from the home office.
Staff told us that it was incredibly difficult to meet the targets for the key performance indicators as
due to the nature of the patients the service was seeing. For example, a target to have an
antenatal contact at 28 weeks of pregnancy was often impossible for the team as often they were
seeing patients already in late stages of pregnancy.
The family partnership nurses received referrals from the GP, hospital and patients. All referrals
into the team were taken to the weekly meeting for discussion and allocation. The service had a
number of national targets set out by the Department of Health, data was inputted into a national
database monthly. The service had a dashboard from which information regarding current
compliance against national targets was monitored. Following our inspection, information supplied
by the trust showed that the service was performing in line with the national standards.
Both the family nurse partnership and all health visiting teams offered set clinic appointments or
home visits. The child health inclusion team offered clinic appointments on set days however, due
to the nature of the patients using the services they would often see patients who “turned up” at
the clinic without an appointment wherever possible. Health visiting offered baby weigh-in drop-in
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clinics which were run by nursery nurses and staff told us these were well attended. The health
visiting service did not offer any additional drop-in clinics and staff told us that these had been
removed in order to ensure compliance with ante-natal contact appointments.
The immunisation and vaccination team offered three drop-in clinics across the area at the time of
our inspection. They also facilitated mop-up sessions for any children who had been unable to
attend the school immunisation session which were run from the clinic where the team were
based.
All services and teams we visited told us of issues with patients not attending for clinic
appointments. This was addressed within each team during the safety meeting and monitored
regularly. Where a patient accessed other services or there were concerns around the family, the
relevant services were informed.
Learning from complaints and concerns
Complaints
Community services for children, young people and families received seven complaints between 1
August 2017 and 31 July 2018. The main complaints themes were privacy, dignity and wellbeing.
Total
Complaints Fully upheld Partially upheld Not upheld
Referred to
Ombudsman
Upheld by
Ombudsman
7 2 2 2 0 0
The service took complaints and concerns seriously, investigated them and learned lessons from
the results and shared these with staff at weekly safety and monthly team meetings, if appropriate.
Specific feedback from complaints, relating to the staff member involved was discussed on a one
to one basis. We were given a specific example of learning as a result of a complaint which
resulted in additional training for staff around managing challenging situations. Families we spoke
with were aware of how to submit a compliant
The team leaders told us that they invited complainants to discuss the complaint in the first
instance, to identify and resolve issues in a timely manner. There was a standard template for
completion of informal complaints and this was completed by the relevant team leader. The formal
complaint rate was low within the service and staff told us that they referred patients to the patient
advice and liaison service if they were unable to resolve concerns at the time they were raised.
Information relating to complaints was published in the monthly integrated performance and quality
report.
We reviewed two complaints which related to children, young people and families. There was
evidence that these complaints had been thoroughly investigated and the responses to the
complainant contained sufficient detail. The responses to these complaints were provided to the
complainants in a timely way in both cases both with details of how to refer the complaint to the
Parliamentary Health Service Ombudsman if the complainant remained unsatisfied.
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Compliments
The trust received 157 compliments during the last 12 months from 1 August 2017 and 31 July
2018. Three of these related to community services for children, young people and families, which
accounted for 2% of all compliments received by the trust as a whole.
The service encouraged staff to log compliments on the electronic system as well as complaints or
incidents. Staff told us that most compliments were received verbally and often they did not record
these as they felt they were “just doing their job”.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 133
Is the service well-led?
Leadership
The service had managers at all levels with the right skills and abilities to run a service providing
high-quality sustainable care.
The locality care managers and clinical leads had a range of experience and came from a variety
of professional backgrounds. This provided a diverse knowledge base which was utilised across
the three localities and gave the benefit of understanding the challenges and priorities for
sustaining the community children, young people and families service.
The team leaders had the experience and capability to understand their teams and staff we spoke
with across services and teams held their team leaders in the highest possible regard. They
described their immediate managers as approachable and supportive. Leadership beyond the
immediate level was not always apparent to staff and some staff members did not know who their
locality care manager or clinical lead was.
All staff we spoke with were aware of the chief executive but were not aware of any other
members of the senior management team or board.
Vision and strategy
The trust had a clear vision and set of values which were continuous improvement, accountability,
respect and enthusiasm. The service had a strategy for community children, young people and
families in the form of an improvement plan. The service had a transformation lead to support the
delivery of the improvement plan. The lead was working across the three localities to support both
care managers and clinical leads.
During our inspection clinical leads and care managers were able to tell us both the trusts strategy
and the improvement plans and strategy for the service. They were able to tell us the trusts vision
and how the community children, young people and families service was striving to achieve this.
Staff within the teams across the services we spoke with were able to quote the trusts vision of
“perfect care”. However, staff were unaware of either the trust or service strategy or how this was
going to be achieved for community children, young people and families.
Culture
All levels of management promoted a positive inclusive culture that supported and valued staff.
Staff told us they enjoyed working in within their respective teams and felt well-supported by their
colleagues and immediate line managers. All staff we spoke to had a positive attitude about
working for the service and were hopeful for improvements and improved stability that working for
a new trust would bring. All staff stated they had seen a marked improvement in both
communication and engagement following the acquisition of services by the trust.
We spoke to a variety of staff at the teams and services we visited. Those who had been in post
for some time had seen improved staff morale. We saw good working relationships between all
grades of nursing, team leads and ancillary staff within each service. However, staff within some
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ancillary services told us they often felt left out and gave specific examples of when they had not
been included within team planning and events.
Staff told us that professional development within the service was actively encouraged and
promoted. Staff were able to provide specific examples of requesting development and how this
had been facilitated.
The trust was working hard to promote a positive culture of openness, transparency and honesty
and staff told us they were encouraged to speak up and raise concerns. The majority of staff we
spoke with were able to tell us who the trust’s freedom to speak up guardian was and there were
posters which detailed the initiative and named the trust guardian which were visible within all
offices we visited.
Governance
Governance structures, processes and systems of accountability were clearly set out within the
service. Each team within the community services for children, young people and families held
weekly team huddles, actions from these meetings were recorded and we saw evidence of this
following our inspection. Actions from the team meetings fed into the weekly locality meeting for
which actions were also recorded and evidence of this was provided by the trust following our
inspection. Actions from the weekly locality meetings fed into the monthly quality assurance
committee meeting, at board level, for which evidence was provided prior to our inspection.
Community services for children, young people and families were delivered across three localities;
North Liverpool, Central Liverpool and South Liverpool. Each locality encompassed different
teams based on geographical location, teams included; health visiting, school nursing, special
schools, child health inclusion team, immunisation and vaccination team, healthy families team,
child health information services, family nurse partnership and paediatric liaison service.
Each team had a supervisor or team lead who were responsible for the daily management of each
team and reported directly to the locality care manager however, operational vacancies existed in
all localities for a manager in between the team leader level and care manager level which the
trust told us they had recruited for and were in the process of putting into place. The care
managers reported directly to the operational associate directors alongside the locality clinical
leads. The associate directors reported to the chief operating officer who then reported to the
board.
Clinical leads and care managers were able to tell us how information was fed up and down into
the operational team however, staff were not and some were unaware of who or what constituted
for the senior operational management team or what the governance structure looked like beyond
their immediate line managers.
Management of risk, issues and performance
There were effective processes in place to identify, monitor and address current and future risks.
The monthly integrated performance and quality reported highlighted current key risks within each
locality and detailed what measures were in place to control the risk and the action plan going
forward. All risks where held on an electronic divisional risk register and we discussed key risks
with the management team, risks were managed well and both locality care managers and clinical
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leads were able to explain which risks were pertinent to their particular area and describe where
they were up to in terms of progress. We saw that risks were being continuously monitored and
updated, an example of this was the risk to the special schools’ team in which they were unable to
provide the healthy child programme due to not having any nurses with a specialist community
public health nursing qualification. This risk had been eliminated by the recruitment of a specialist
community public health nurse who had commenced in post in October. This was part of a series
of risks associated with the special schools’ team and evidence provided by the trust following our
inspection showed there were clearly defined timescales and actions to eliminate all risks
highlighted and that plans were in place to do this.
The service had begun undertaking individual team self-assessment inspections which followed
the Care Quality Commissions five key questions methodology. Each team was in the process of
receiving the self-assessment inspection and this was being conducted by the quality assurance
team. The reports highlighted areas of achievement, areas of concern, areas for improvement,
risks and actions required for each team. During our inspection we were told by the clinical leads
that these reports would be carried out annually and any team with actions to be completed would
be reviewed after three months. This process enabled the service to monitor compliance with the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The clinical leads for
each respective locality had oversight of the reports and told us that they would be able to monitor
trends, themes and also share best practice across localities going forwards. These reports were
discussed at monthly divisional meetings.
The service had appointed a children’s transformational lead to oversee the redesign of the
service and support staff during the process. A Liverpool community services sub-committee had
been established to help improve and gain assurances on the quality of the care provided for all of
the community services during the redesign. We reviewed the minutes from the sub-committee
meeting minutes and found risks, action plans and the improvement plan were scrutinised in great
detail with clear timeframes for completion of tasks and risks going forwards. There was evidence
that tasks were completed within specified timeframes for example the ongoing rebranding of
patient leaflets to show the Mersey Care Foundation Trust logo was almost completed and this
had a timeframe of December 2018.
The service had effective systems for monitoring and managing performance. Team performance
was overseen by individual team leaders. Each team was required to submit data and report
against key performance indicators on a monthly basis. Staff told us they received updates on
where their team was in terms of performance via their monthly team meetings. Following our
inspection, we saw evidence within the meeting minutes of the discussion of performance against
the key performance indicators.
Staff were informed of the teams’ performance at monthly team meetings. We reviewed team
meeting minutes following our inspection and saw evidence of this. Locality performance was
reported within the monthly integrated performance and quality report and discussed at monthly
divisional meetings. We reviewed divisional meeting minutes following our inspection and saw
evidence of this. Directorate management reviewed quality, safety and operational performance
data at the monthly operational management board, this fed directly into the quality assurance
committee, which was at board level. All staff we spoke with during our inspection were able to tell
us in detail where their team/division were up to in terms of performance. The service performed
consistently well across all three localities in relation to all aspects of the healthy child programme
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with the exception of breastfeeding prevalence for the North locality. The breastfeeding prevalence
for the North locality was consistently below the target of 30% with an average over a twelve-
month period of 19.9%. Staff told were able to verbalise why the rate was consistently low for this
locality and what measures were in place to try to improve the figures such as being able to
access specialist advice on breastfeeding for patients through partner organisations.
The service collated information such as the number of children accessing the service and
developmental checks at different ages. Monthly performance data was published within the
integrated performance and quality report, measured against the previous month for comparison
and an overall level for the year to date given. This meant the service could see where targets
were not being met and identify areas for improvement.
Information management
The service collected, analysed, managed and used information well to support all its activities,
using secure electronic systems with security safeguards. There were systems in place to ensure
the confidentiality of identifiable data, records and data management systems in line with data
security standards. Both staff and management told us that privacy audits were carried out
monthly for each team by the team leader, this ensured only staff who should be accessing
information, were accessing information.
The online records system was effective for use in information gathering for audit and reporting
purposes. For example, the immunisation and vaccination team were able to pull uptake rates for
the influenza vaccination straight from the electronic system which could then be fed into the
Public Health England database. The different information systems used within the service were
used to collate and inform reports and intelligence for the team leaders and the locality leads, such
as the monthly integrated performance and quality report.
Staff within the department told us that they had access to the information that was needed for
them to undertake their roles effectively, this included bank staff and staff assisting from other
teams or localities. We observed that connectivity within office settings was good and staff told us
that when there was a problem with electronic systems these were rectified quickly and efficiently.
However, staff told us that often there were connectivity issues when working from patient’s
homes or site visits. Three out of four of the acute sites where the paediatric liaison nurses worked
from, did not have access to input information onto the electronic patient record. These nurses
could only access the system in the ‘read only’ function. We observed that this issue was on the
divisional risk register and an action plan was in place with specified time scales in which to
resolve this issue.
Engagement
The trust engaged well with staff and local organisations to plan and manage appropriate services
and collaborated with partner organisations effectively. However, public and patient engagement
was lacking.
As the service did not operate from permanent sites which were solely owned or leased by the
trust, staff told us the only method of receiving feedback from patients or the public was by
physically giving patients family and friends feedback forms. Staff had been unable to do this as
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the logo on the family and friends test information had not been amended to show name of the
new trust.
School nursing staff told us they engaged with children by holding focus groups within schools
which helped in the development of questionnaires. Direct feedback as a result of this had helped
school nursing staff to change one of the questions within the questionnaire which they felt was
more appropriate and would yield more detailed results.
The child health inclusion team had taken part in a feedback consultation review carried out by the
engagement team for the trust. Nine families were interviewed to gauge how they felt they were
treated by the team during their clinic appointments and reviews. We reviewed the consultation
and found all responses to the team were positive and there were many examples of the
commitment and care this team provided.
The trust were working hard to engage with staff and staff told us about communications received
weekly from the Chief Executive, a scheme in which staff could send questions or comments to
the Chief Executive and requests could be made for ‘birthday breakfasts’. The trust held bi-annual
roadshows for all staff which team leaders told us they actively encouraged staff to attend.
There were many good examples of how both the trust and team leaders were striving to promote
health and wellbeing for staff. The service was carrying out monthly ‘pulse checks’ at all team
meetings to assess staff morale and look for any improvements which could be made. A ‘buddy’
system for those returning from long term sick was being trialled by one health visiting teams to
support staff with workload and pressures on their return to work.
The child health inclusion team told us they had received a full day of resilience training in
collaboration with an external counselling and wellbeing organisation. In health visiting one staff
member told us during the summer they had taken part in power walks and rounders during lunch
to promote wellbeing and boost staff morale.
Learning, continuous improvement and innovation
There was a clear focus on continuous learning and improvement. The service was committed to
improving services by learning from when things go well and when they go wrong. We were given
many examples of when areas of work had been scrutinised and improvements suggested. For
example, school nursing were in the process of developing an electronic questionnaire and the
immunisation and vaccination team were developing an electronic consent form. Both these areas
of work were time consuming and difficult when information needed to be shared. It was proposed
that electronic versions would aid in the management of each respective area.
Improvement and innovation within the service was driven by leaders and senior management.
We were given many examples of ideas for improvement, some of which were underway and
some which were yet to be agreed. For example, the deployment of a health visitor within the early
help assessment hubs to assist in multidisciplinary working and increase staff knowledge. A forum
had been arranged for December 2018 to discuss the implementation of the 0-19 service model
which forms part of the Department of Health’s Five Year Forward View to co-ordinate the delivery
of public health for children aged 0-19 by integrating health visiting and school nursing teams.
Mersey Care NHS Foundation Trust evidence appendix: community health services for children, young people and families Page 138
Staff were encouraged to think about ways in which the service could improve the quality of the
care given and were keen to learn from other services at other trusts. For example, health visiting
were working with commissioners and team leaders from health visiting services across the North
West in the development of a peri-natal mental health pathway. School nursing were working
collaboratively with sexual health teams to increase staff knowledge base and develop additional
training for staff.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 139
End of life care
Facts and data about this service
Information about the sites, which offer end of life care services at this trust, is shown below:
Location site name Team/ward/satellite name Patient group
Number of clinics per month
Geographical area served
Innovation Park, Edge Lane,
Liverpool, L7 9NJ Palliative care team Mixed N/A Liverpool
Litherland Town Hall, Hatton Hill Road, Liverpool,
L21 9JN
Palliative care team Mixed N/A South Sefton
End of life services are provided by two palliative care teams which are based in Liverpool and
South Sefton. Mersey Care NHS Foundation Trust acquired the services that are provided in
South Sefton in June 2017. The trust subsequently acquired services that are provided in
Liverpool in April 2018. This meant that at the time of inspection, both palliative care teams were in
the process of making sure that a standardized service was provided across both areas.
End of life services in the community are led by GPs, and are supported by the palliative care
teams, community district nursing teams as well as allied health professionals such as
occupational therapists. Referrals to the palliative care teams are made when advice or support is
required to deliver safe and effective care.
Between November 2017 and October 2018, community services reported 4,648 deaths. Records
indicated that during the same period, the palliative care teams in both Liverpool and South Sefton
had received a total of 2,081 referrals (45% of occasions).
During the inspection, we spoke to staff of different grades, including district nurses, members of
the palliative care team and senior managers. We attended a multidisciplinary team meeting that
was held at a local hospice. We attended six visits to patient’s home addresses with district
nursing staff as well as members of the palliative care team, and spoke to ten patients and
relatives on the telephone, discussing the care that they had received.
We took time to review six patient records during home visits that we attended, as well as
reviewing retrospective patient records of patients who had passed away. Additionally, we
reviewed information that was provided by the trust both before and after the inspection.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 140
Is the service safe?
Mandatory and Statutory Training
The trust had an induction, statutory and mandatory training policy that was available to all staff on
the intranet. Mandatory training had been delivered through both face to face sessions and e-
learning. Staff who we spoke with were aware of their responsibilities to complete this in a timely
manner.
Training was monitored by the learning and development department at a trust wide level. In
addition, local records had been kept for the Liverpool palliative care team. This was because they
had employed an educator who had maintained oversight of this. However, the South Sefton team
did not have an educator to undertake this role.
Mandatory training modules differed between the Liverpool and South Sefton palliative are teams.
This was because both services had been acquired at different times, meaning that South Sefton
completed modules that had been developed by Mersey Care NHS Foundation Trust, while the
Liverpool team completed modules that had been developed by the organisation that they were
previously managed by.
The trust set a target of 90%90% for completion of mandatory training and their overall training
compliance was 88% against this target.
A breakdown of compliance for mandatory courses as of July 2018July 2018 for all staff in end of
life care services is shown below.
South Sefton palliative care team:
Training courses Grand Total %
Mandatory training - Conflict resolution (every 3 years) 83%
Mandatory training - Equality, diversity and human rights (every 3 years)
100%
Mandatory training - Fire safety (every 3 years) 100%
Mandatory training - Health and safety (every 3 years) 100%
Mandatory training - Infection Control (every 3 years) 83%
Mandatory training - Moving and handling (every 3 years) 67%
Mandatory training - Data security awareness – Level 1 (every year)
50%
Mandatory training - Information governance 0%
Role specific mandatory training – Basic life support (every year)
83%
Role specific mandatory training – Basic PREVENT awareness (once only)
100%
Role specific mandatory training – Mental Capacity Act / Mental Health Act and Deprivation of Liberty safeguards (every 3
33%
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 141
Training courses Grand Total %
years)
Role specific mandatory training – Safe and effective use of medicines (every 3 years)
33%
Role specific mandatory training – Controlled drugs and high risk medicines (every 3 years)
50%
Role specific mandatory training – Medicines calculations (once only)
33%
Role specific mandatory training – Moving and handling people (every year)
83%
Role specific mandatory training – MUST adapted nutritional screening (once only)
0%
Grand Total 62%
Liverpool palliative care team:
Training courses Grand Total %
Equality, diversity and human rights (every 3 years) 100%
Fire safety (every 3 years) 100%
Harassment and bullying awareness (once only) 100%
Health and safety (every 3 years) 100%
Information governance (every year) 91%
PREVENT (every 3 years) 100%
Health record keeping (every 3 years) 100%
PREVENT training for clinicians (once only) 100%
Conflict resolution (every 3 years) 100%
Consent (every 3 years) 100%
Infection control – level 2 (every year) 100%
Mental Capacity Act (every 3 years) 100%
Moving and handling for people handlers (every 3 years) 91%
Resuscitation (every year) 100%
Investigation of incidents using an RCA (once only) 90%
Medicines management awareness (every 3 years) 100%
Grand Total 98%
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 142
Safeguarding
There was a safeguarding policy for adults and children that was available on the intranet. Staff
who we spoke with knew how to access this. However, we found that this was out of date and
should have been last reviewed in 2016.
The trust had a safeguarding team who were available between Monday and Friday, during
normal working hours. Referrals to external safeguarding services were made out of hours. Staff
who we spoke with informed us that they knew how to contact them for advice if needed.
Staff who we spoke with gave us examples of what constituted a safeguarding concern. Examples
given included neglect, physical abuse and emotional abuse. One member of staff gave us an
example of a recent scenario when they had made a safeguarding referral for a patient.
Most staff had an awareness of female genital mutilation. This was important as since October
2015 it is mandatory for regulated health and social care professionals to report known cases of
female genital mutilation in persons under the age of 18 to the police.
In addition, staff also had an awareness of child sexual exploitation as well as PREVENT (a
counter terrorism strategy that is aimed to stop people becoming terrorists or supporting
terrorism).
Staff understood their responsibilities to report safeguarding concerns and knew how to do this.
Contact numbers were available on the intranet for different safeguarding teams across Liverpool
and South Sefton.
Safeguarding concerns were recorded on the electronic records system when needed. This was
important as it reduced the risk of safeguarding concerns not being communicated between
members of staff. In addition, safeguarding concerns had been included in the daily safety huddle
that all staff attended at the start of every shift.
Liverpool Palliative Care Team:
Training courses Grand Total %
Safeguarding Adults Level 2 – (Every 3 years) 100%
Safeguarding Children Level 2 – (Every 3 years) 100%
South Sefton Palliative Care Team:
Training courses Grand Total %
Mandatory Training - Safeguarding Adults - Level 1 (Every 3 Years)
100%
Mandatory Training - Safeguarding Children - Level 1 (Every 3 Years)
100%
Role Specific Mandated Training - Safeguarding Adults Level 2 -Trust Model (Every 3 Years)
100%
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 143
Training courses Grand Total %
Role Specific Mandated Training - Safeguarding Children Level 2 - Trust Model (Every 3 Years)
100%
Role Specific Mandated Training - Safeguarding Adults Level 3 - Trust Model (Every 3 Years)
100%
Role Specific Mandated Training - Safeguarding Children Level 3 - Trust Model (Every 3 Years)
100%
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.
End of life care services made four safeguarding referrals between 1 August 2017 and 31 July
2018, of which four concerned adults and none concerned children.
Cleanliness, infection control and hygiene
The trust had an infection and prevention control policy which was available for staff to access on
the intranet.
Between April and November 2018, the service had not reported any incidents of patients
developing meticillin-resistant staphylococcus aureus, methicillin-sensitive staphylococcus aureus
or colostrum difficile while being cared for in the community.
We found that patients who were at risk of infection had been identified during daily safety huddles
that took place at each district nursing base. This was important as it allowed information to be
communicated between all staff and made staff aware of potential risks that were faced prior to
undertaking a home visit.
All district nurses and members of the palliative care team carried hand gel. We observed that
staff decontaminated their hands using this after each patient contact. This reduced the potential
risk of infection being spread.
Referrals
Adults Children Total referrals
4 0 4
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 144
Staff also had access to personal protective equipment, including clinical gloves and aprons. Staff
were aware of their responsibilities to use these when needed.
Environment and equipment
All equipment used by the palliative care team was maintained by an external provider. The trust
had recently introduced a system to monitor the location of equipment as well as compliance with
servicing and portable appliance testing when needed. However, records indicated that this was in
the process of being updated. This meant that the service did not yet have a full oversight of all
equipment that was being used.
We reviewed compliance with the servicing of syringe drivers that were used on a regular basis.
Although records indicated that 93% of these that were in the Liverpool area had been serviced in
the last 12 months, only 67% had been serviced in line with the manufacturers guidance in the
South Sefton area. This was important as it meant that there was an increased risk that equipment
would become faulty during use.
The trust had a policy for the use for syringe drivers. This was important as they were used on a
regular basis. However, the service had not planned to monitor compliance with the policy. This
meant that there was an increased risk that improvements would not always be made when
needed.
The palliative care and district nursing teams informed us that they could request equipment when
required and were aware of the process to do this. Equipment could be accessed straight away if
needed. Staff who we spoke with told us that there was sufficient equipment available to manage
patients at the end of life.
The service had planned for sharps to be disposed of after use. All members of the district nursing
teams carried boxes to dispose of sharps when they had been used. District nurses who we spoke
with were aware of the procedure to dispose of these safely.
Assessing and responding to patient risk
A team of palliative care nurses were available during normal working hours, between Monday
and Friday in both the Liverpool and South Sefton areas. During these times, members of the
palliative care team attended home visits with the district nurses. District nurses were available to
provide care and treatment to patients 24 hours a day, seven days a week.
There was no formal arrangement in place to support out of hours district nurses if they required
advice about topics such as the management of a patient who was at the end of life. However,
staff informed that if they had concerns, they would contact a GP to seek further advice.
The service did not have a formal agreement to access a specialist consultant in palliative care for
advice. However, members of the palliative care team informed us that they would speak to a
consultant who was based at a local hospice if needed.
The palliative care team regularly reviewed all patients who were known to them. This was
important as it meant that patients were prioritised and management plans were put in place in a
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 145
timely manner, which was particularly important at weekends as there was only one member of
the palliative care team on duty.
Safety huddles were held at each district nurse team base at the start of every shift. This allowed
staff to prioritise patients within their caseload and for the management team to ensure that staff
knew about priority patients. The safety huddle covered topics such as infection control, do not
attempt cardiopulmonary resuscitation as well as if a patient was on an end of life pathway.
There was also access to an emergency response team. Staff knew how to contact them if
immediate support was required. Referrals were made for several different reasons, including to
prevent an inappropriate hospital admission while a patient was waiting for a social services
referral to be made or for community health care funding for a support package to be agreed.
The trust had a deteriorating patient policy which was available to all staff on the intranet. Staff
who we spoke with were aware of this and knew how to access it. However, we found that this
should have been last reviewed in April 2017.
The service had not always used a system to identify patients who were at risk of deterioration.
This was because there had not always been a requirement for the national early warning score
system to be used in all areas. A national early warning score is based on a patient’s vital signs
such as pulse rate, blood pressure and temperature. It also provides guidance for staff to follow if
a patient’s vital signs are outside of normal parameters.
However, despite no standardised system staff were required to monitor patient’s vital signs as
part of a home visit. We attended six home visits during the inspection, finding that these had been
completed thoroughly on all but one occasion.
In addition, we found that documentation from previous visits had been removed from patient’s
records and placed in patient files which were located at the district nurse bases. Staff informed us
that they checked the patient’s files before they attended a home visit so that they could compare
vital signs from previous visits.
The management team had recognised the need for a standardised approach across all areas,
and were in the process of implementing a service wide system to support staff in monitoring
deteriorating patients.
Staff were also required to complete a variety of risk assessments for all patients. This included
risk assessments for falls and pressure ulcers. We found that these had been completed on five
out of six occasions when required.
However, on one occasion, we reviewed the records of a patient who had been deemed at high
risk of falls, finding that there was no documented evidence of what action had been taken to keep
the patient safe. In addition, the falls risk assessment that was used for all patients did not reflect
current practice. This was because the risk assessment stated that a referral had to be made to a
team that no longer existed.
Staffing
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 146
The Liverpool palliative care team employed six band seven nurses and five band six nurses. The
South Sefton palliative care team employed four band seven nurses as well as two band six
nurses. Both the Liverpool and South Sefton palliative care teams had been established to have a
team leader. Members of the management team informed us that while South Sefton had a
substantive team leader, two members of part time staff were currently undertaking this position in
Liverpool on an interim basis.
There were sufficient numbers of staff available during weekdays. However, staff informed us that
they had sometimes struggled to provide an effective service at weekends. This was because the
service had planned to only have one member of staff on duty, meaning that staff had not been
able to undertake home visits with members of the district nursing team and had to provide
support over the phone.
Rotas for Liverpool and South Sefton between June 2018 and November 2018 indicated that the
planned number of palliative care nurses had been achieved on all occasions, Members of the
management team informed us that there were plans to review staffing levels to ensure that there
were sufficient numbers of palliative care nurses to match the needs of the number of patients who
had been referred to the service, particularly at the weekends.
Records indicated that staffing caseloads for both Liverpool and South Sefton had been
manageable between August 2017 and July 2018. Caseloads in Liverpool had ranged between
seven and nine patients per member of staff and caseloads in South Sefton had ranged between
eight and 14 patients per member of staff during the same period.
The service employed a part time GP who led end of life services across both the Liverpool and
South Sefton areas. There were no other members of medical staff employed by the service to
provide end of life care.
Members of the management team informed us that there were several staffing vacancies across
the district nursing teams in both the Liverpool and South Sefton areas. There had been a small
number of occasions when this had impacted on patients receiving end of life care.
For example, on one occasion, a patient who had been discharged from hospital during the night
had not been seen due to staffing shortages in the night team. In addition, relatives had raised
concerns that a member of staff had not been available to discontinue a syringe driver after their
relative had passed away.
Vacancies
Between August 2017 and July 2018, the trust reported an overall vacancy rate of -10% (over
establishment) in end of life care services.
Staff group Total number of substantive staff Total % vacancies overall (excluding
seconded staff)
Clerical & Admin 1.5 -23%
Nurse Other Community Services 18.9 -8%
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 147
Core service total 20.4 -10%
Turnover
Between August 2017 and July 2018, the trust reported an overall turnover rate of 16% in end of
life care services.
Staff group Total number of substantive staff
Total number of substantive staff
leavers in the last 12 months
Total % of staff leavers in the last 12 months
Nursing & midwifery registered 8.8 10 11%
Other (including admin & clerical) 0.4 0.4 100%
Core service total 1.4 9.3 16%
Sickness
Between August 2017 and July 2018, the trust reported an overall sickness rate of 10% for end of
life care services.
Staff group Total number of
substantive staff
Total % permanent staff
sickness overall
Nursing & midwifery registered 8.8 8%
Other (including admin & clerical) 0.4 30%
Core service total 1.4 10%
Suspensions and Supervisions
There was no data pertinent to end of life care services.
Quality of records
The service used a paper based and an electronic records system. All district nursing records
were paper based and were completed following each patient visit. We found that paper based
records were removed regularly from records at a patient’s home address and placed in a folder
which were secured securely at each district nursing base. This meant that district nurses had to
review patient records before attending a patient visit who required end of life care.
Patient records were also kept electronically which included records made by members of the
palliative care team. All staff had access to the electronic system and could review the records
from patient visits.
GP consultations and visits had also been recorded on the electronic system. Providing that a
patient had given permission for their electronic records to be shared, all staff were able to access
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 148
these when needed. This system allowed care between different teams to be shared so that care
for patients at the end of life was co-ordinated effectively.
We reviewed six sets of patient records during patient visits, finding that patient records were
legible, dated and signed. In addition, any examination or advice given had been clearly
documented.
The palliative care teams in both the Liverpool and South Sefton areas had introduced a paper
based individualised care plan for staff to use when patients were in the last days of their life. This
covered a range of topics such as the administration of anticipatory medicines as well as care after
death and verification of death.
We found that this document had not always been completed fully when needed. We reviewed 15
sets of records for patients who had passed away, finding that eight had not been fully completed.
This included if medical devices had been removed, if controlled drugs had been destroyed in line
with policy or who a death had been verified by.
We had concerns that members of the management team did not always have oversight of areas
that required improvements to be made. This was because members of the management team
informed us that this information may have been sometimes been included in other parts of the
patient records and as a result, had not always been captured in either clinical or patient record
audits.
Medicines
The trust had a medicines management policy which was available to staff on the intranet. Staff
we spoke with were aware of this and knew how to locate it. This was supported by a small
number of standard operating procedures, including a procedure for the destruction of controlled
drugs.
However, we had concerns that controlled drugs had not always been destroyed after a patient
had passed away. This was because on sampling eight retrospective records for patients who had
passed away, we found that there was no evidence that controlled drugs had been destroyed on
two occasions. This meant there was an increased risk to safety as the controlled drugs had not
been accounted for and there was a risk that they could be reused by people who they were not
intended for.
The trust had undertaken a care of the dying audit in June 2018. Records indicated that
compliance with destroying controlled drugs in line with trust policy was only 62%.
In addition, the trust did not have a process to support staff on occasions when controlled drugs
had been removed by a third party, such as the coroner or the police. This meant that there was
no documented evidence of what had happened to the controlled drugs.
We raised these concerns with the trust following the inspection who informed us that a safety
alert had been issued to remind staff about destroying controlled drugs. In addition, the trust
informed us that staff had been asked to incident report occasions when a third party had taken
the controlled drugs so that there was a clear audit trail of how they had been managed. However,
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 149
there was no evidence provided after the inspection and at the time of writing the report that the
trust’s policies and procedures had been amended to reflect this.
We attended six visits to patient’s homes, finding that staff had clearly checked and documented
administration of patient’s controlled drugs correctly on all occasions. This had been done in line
with trust policy. However, we found that on two occasions, patient’s own medicines had not been
clearly documented.
Anticipatory medicines were prescribed by a patient’s GP. Alternatively, there were several
members of the palliative care team who were nurse prescribers. This meant that they could
prescribe anticipatory medicines in a timelier manner. The end of life care strategy that was
published by the Department of Health in 2008 states that it is important to prescribe anticipatory
medicines as early as possible. This is important so that staff can treat common symptoms, such
as nausea and vomiting as well as pain.
The service had introduced a pre-populated anticipatory medicines prescription chart which listed
several different medicines along with the maximum dose. Staff were required to record the
administration of anticipatory medicines on this chart. In addition, staff were required to review
anticipatory medicines every 28 days, which was in line with national guidance.
We sampled six retrospective records for patients who had required anticipatory medicines, finding
that there was documented evidence that they had been prescribed and administered in a timely
manner on all but one occasion. Staff who we spoke with were aware that patient’s own medicines
should be discontinued where possible, which was in line with national guidance and was done in
association with a GP.
Staff were supported to administer anticipatory medicines by documentation which was included in
each patient’s individualised care plan. This provided a step by step process of how to manage
several different conditions. In addition, the anticipatory medicines prescription charts indicated
maximum doses of each drug, indicating when a further medical review should be sought.
The service used syringe drivers to administer medicines such as pain relief. However, we had
concerns that the service was not always able to provide a member of staff who had been trained
to use a syringe driver safely when needed. This was because training compliance varied between
the Liverpool and South Sefton localities as well as different district nursing teams.
Records indicated that overall compliance was only 57% in South Sefton, ranging between 0%
(BGT district nursing base) and 89% (Crosby district nursing base). In addition, records also
indicated that overall compliance in the Liverpool area was 70%, with compliance ranging from 0%
(City Centre district nursing base) and 100% (Croxteth district nursing base).
However, we did note that there was 100% compliance with syringe driver training in the out of
hours district nursing team. This was important as they were responsible for covering both the
South Sefton and Liverpool areas between 5.30pm and 8.30am, seven days a week.
Following the inspection, the trust informed us that they aimed to improve overall compliance to
95% by March 2019.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 150
An advice leaflet was given to patients and relatives about the use of strong opioids, such as
morphine (a controlled drug used for pain relief). This provided advice about topics such as side
effects, when to get in touch with a doctor as well as providing information about the different
types of opioids that were available and what they were used for.
Safety performance
Safety Thermometer (September 2017 to September 2018)
The NHS Safety Thermometer allows teams to measure harm and the proportion of patients that
are ‘harm free’ during their working day. For example, at shift handover or during ward rounds.
This is not limited to hospital; patients can experience harm at any point in a care pathway and the
NHS Safety Thermometer helps teams in a wide range of settings, from acute wards to a patient’s
own home, to measure, assess, learn and improve the safety of the care they provide. Safety
Thermometer data should also not be used for attribution of causation as the tool is patient
focussed.
Caveat: the information relates to community services overall.
New Pressure Ulcers
The trust reported 70 new pressure ulcers between September 2017 and September 2018.
The most number of new pressure ulcers was reported in August 2018 with 12 (1.44% prevalence
rate). However, the highest prevalence rate occurred in May 2018 with 2.55% (five new pressure
ulcers).
Many pressure ulcers are acquired by patients who were at the end of life. This is due to several
reasons, including reduced mobility as well as difficulties with nutrition and hydration.
However, it was unclear how many pressure ulcers had been acquired by patients at the end of
life. This was because information provided by the service following the inspection was unclear. In
addition, safety dashboards were not used for end of life services to highlight the total number of
patient harms that had occurred.
Members of the palliative care and the district nursing team had recognised this as an issue. As a
result, several awareness and training events had been organised for staff from both the Liverpool
and South Sefton areas.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 151
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
1.53 0.40 0.41 0.51 2.55 1.74 1.33 0.68 1.38 0.73 0.81 1.44 1.29
No 3 1 1 1 5 4 4 6 11 6 6 12 10
Catheter & UTI
The trust reported three catheter & UTI between September 2017 and September 2018.
The most number of catheter & UTI’s were reported between April and July 2018 with one each.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 152
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.11 0.00 0.12 0.13 0.00 0.00
No 0 0 0 0 0 0 0 1 0 1 1 0 0
Falls with Harm
The trust reported 67 falls with harm between September 2017 and September 2018.
The most number of falls with harm was reported in June 2018 with 17 (2.07% prevalence rate).
However, the highest prevalence rate occurred in September 2017 with 3.06% (six falls with
harm).
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
3.06 1.59 0.00 0.00 1.53 0.43 0.00 1.25 0.88 2.07 1.48 0.12 0.77
No 6 4 0 0 3 1 0 11 7 17 11 1 6
Harm Free Care
The trust reported 6227 cases of harm free care between September 2017 and September 2018.
The most number of harm free care instances was reported in April 2018 with 847 (96.47%
prevalence rate). However, the highest prevalence rate occurred in December 2017 with 98.98%
(184 instances of harm free care).
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 153
Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18 Aug 18 Sep 18
Prevalence %
94.90 97.62 97.65 98.98 93.88 96.52 97.67 96.47 95.00 95.00 96.24 96.88 95.74
No 186 246 239 194 184 222 294 847 770 779 716 808 742
Incident reporting, learning and improvement
The trust had an incident reporting policy which was available to staff on the intranet. All clinical
and non-clinical incidents were recorded using an electronic incident reporting system. Staff who
we spoke with were aware of this policy and knew how to access the reporting system.
Staff who we spoke with could give us examples of types of incidents that they would report. This
included pressure ulcers, medication errors or anything that resulted in patient harm.
During the last 12 months, a total of 229 (Liverpool) and 120 (South Sefton) clinical and non-
clinical incidents had been reported concerning patients who were at the end of life, including
patients who were both known and not known to the palliative care team.
There was documented evidence that incidents that had been reported had been investigated and
that actions had been implemented to minimise the risk of a similar incident reoccurring as much
as practicably possible.
Members of the palliative care team informed us that they attended weekly ‘being open’ meetings
which were attended by staff from across community services. This allowed staff to share
examples of learning across different staff groups.
Minutes from the end of life steering group, which were held every two months, indicated that
incidents had been discussed and actions had been taken to make improvements when needed.
However, the service was unable to provide any themes or trends of incidents that had been
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 154
reported. This meant that it was unclear if the service had monitored this or always aware where
improvements needed to be made to help lower the risk of further incidents occurring.
Although the service had a system to review all unexpected deaths that had occurred within
community services, we had concerns that learning had not been facilitated by reviewing any
expected deaths that had occurred. This was important as it meant that there was a risk that
potential opportunities for learning had been missed.
However, we did note that the trust had recognised this as an area for improvement, and had
implemented a process for staff to report all expected deaths using the electronic incident
reporting system. Staff who we spoke with were aware that this had been introduced a week prior
to the inspection.
We reviewed minutes from mortality groups that had been held between July 2018 and the time of
inspection. Records indicated that these had been held every two months. Although there was
evidence that all unexpected deaths had been discussed, and in some cases learning had been
identified, there was no evidence of actions being implemented to make improvements. In
addition, it was unclear how learning from mortality reviews had been disseminated to all staff
when required.
We were not assured that Duty of Candour had been applied when needed. This was because
when we reviewed all incidents that had resulted in a moderate level of harm or above, we found
that not all incidents were included on a tracker that was used to identify the progress of each
stage of the Duty of Candour.
This is a legal duty on hospital trusts to inform and apologise to patients if there have been
mistakes in their care that have led to significant harm. The duty of candour aims to help patients
receive accurate truthful information from health providers.
Serious Incidents - STEIS
Trusts are required to report serious incidents to Strategic Executive Information System (STEIS).
These include ‘never events’ (serious patient safety incidents that are wholly preventable).
In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents
(SIs) in end of life care services, which met the reporting criteria set by NHS England between
August 2017 and July 2018.
Serious Incidents – SIRI (trust Data)
Between 1 August 2017 and 31 July 2018, trust staff in this core service reported no serious
incidents.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 155
Is the service effective?
Evidence-based care and treatment
The service followed the most up to date guidance when implementing policies and procedures,
including the Supporting Care Improving Outcomes guidance (National Institute for Clinical
Excellence, 2004), End of Life Strategy (Department of Health, 2015) as well as the Care of Dying
Adults in the Last days of life (National Institute for Clinical Excellence, 2017).
The service had responded to the Department of Health’s End of Life Strategy (2015) by
introducing advanced care planning. This is an approach used when the medical team are
uncertain if a patient will recover despite treatment being provided. It supports patients and
relatives to continue with treatment, but also facilitates discussion about their wishes for the future
if the treatment is unsuccessful.
The responsibility for advanced care planning was shared between the service and local GPs. The
service had introduced advanced care planning documents for staff to use when having
discussions with patients and relatives. However, we found that not all district nursing staff were
aware of these forms, or their responsibility to complete them.
In addition, the service had not made any arrangements to monitor the application of this. This
meant that it was unclear if advanced care planning was being completed consistently.
The palliative care team had responded to the review of the Liverpool care pathway in 2013 by
implementing an individual patient communication record which provided clear guidance for staff
when managing a patient at the end of life.
This document met the priorities of care of the dying person which had been set out by the
leadership alliance for the care of dying people. The key priorities are recognising and
communicating that a patient is dying, patients and those close to them are involved in all
discussions about their care, the needs of family members and others are considered when
providing care and an individual plan is implemented which considers food and drink, symptom
control, as well as psychological and spiritual support.
However, we noted that the individualised care plan had only been implemented in September
2018 as a standard document across both the Liverpool and South Sefton areas. This meant that
the service had not yet been able to assess the effectiveness of the document as the specialist
palliative care team were in the process of embedding this into the end of life education
programme that was being delivered to all district nursing staff.
Nutrition and hydration
The trust used a universal malnutrition scoring tool. This was used to identify patients who were at
risk of malnutrition. Compliance with this was monitored through internal audits and key
performance indicators.
We found that this had been completed for all patients whose records we reviewed. In addition, we
found that a referral had been made to a dietitian when needed. For example, on one occasion, a
patient had struggled to swallow and a referral had been made in a timely manner.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 156
In response to the Liverpool Care Pathway being removed, a communication record had been
implemented to support staff when treating a patient at the end of life. Part of this record
considered the need for clinically assisted hydration which was used when patients were no longer
able to eat and drink normally.
The trust had a procedure to support staff to administer subcutaneous fluids when required. This is
where fluids can be administered by an injection into a patient’s skin to make sure that they remain
hydrated.
Records indicated that between November 2017 and November 2018, although 47 referrals had
been made for patients in the Liverpool area, only nine referrals had been made for patients at the
end of life in South Sefton. However, it was unclear if all patients had received a referral when
needed as this had not been measured.
We had concerns that nutrition and hydration had not always been discussed with patients and
families when needed. This was because results of an audit that had been completed in June
2018 indicated that this had only been discussed on 23% of occasions. The service had
recognised that improvements had been required, and had responded by including this topic as
part of the palliative care education package for all staff.
Pain relief
Both GPs and members of the palliative care team could prescribe pain relief for patients when
required. Several members of the palliative care team were nurse prescribers, which meant that
they could prescribe pain relief immediately when needed.
However, members of the night district nursing team informed us that they had not been trained as
nurse prescribers, meaning that they had to refer patients to a GP if they required pain relief to be
prescribed or needed further support out of hours.
The palliative care team also provided support and advice about the administration of pain relief
for patients at the end of life. In addition, the palliative care team provided pain management
support to all other patients in the community.
Staff from the district nursing team informed us that they used a pain scale of 1-3 to assess a
patient’s level of pain. Staff also informed us that an abbey pain tool was used on occasions when
needed. This is a tool that is used to help patients who are unable to communicate clearly to
express the amount of pain that they are in.
Appropriate medication for pain management was available for staff to use and anticipatory
prescribing was managed well. We reviewed a total of 17 records and found that patients who had
complained of pain had been given pain relief when needed.
However, pain scores had not always been documented clearly. This meant that it was unclear
how the effectiveness of the pain relief that had been administered had been measured.
An audit that had been completed in June 2018 indicated that 85% of patients had been pain free
at the time of death. This meant that pain relief had been prescribed and administered effectively
in these cases.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 157
Patients and relatives that we spoke with confirmed that pain had been managed well.
Patient outcomes
The service had collected data to assess the efficacy of the treatment that they provided,
identifying areas that needed further improvement. Members of the palliative care team had been
actively involved in this process and were able to identify areas of both positive and negative
performance.
However, we had concerns that an audit that was completed in June 2018 had not captured
information from all parts of community services. This was because records indicated that all
records that had been reviewed had been for patients in the Liverpool area. This meant that it was
unclear how the service had monitored compliance with the provision of end of life care in the
South Sefton area.
Records indicated that results from a care of the dying audit (Liverpool and South Sefton) that had
been completed in June 2018 had varied.
Question % Compliance
1. Has the patient been referred to specialist palliative care? 38%
2. Was there evidence of specialist palliative care team involvement? 38%
3. Have patients and families been given information leaflets? 38%
4. Are the patients details complete? 85%
5. Are actual problems / symptoms documented? 54%
6. Has consent been obtained? 15%
7. Is the preferred method of communication completed? 15%
8. Has the preferred place of care been discussed? 85%
9. Has the preferred place of care been reviewed? 85%
10. Was recognition of dying discussed with the patient, family or carers? 85%
11. Did a discussion with the GP take place? 100%
12. Was the patient pain free at the time of death? 85%
13. Was the patient free of other symptoms at the time of death? 77%
14. Was the date and time of death recorded? 92%
15. Was the patient or family understanding of the care plan ascertained? 62%
16. Has the preferred place of death been achieved? 100%
17. Was a bereavement visit offered? 45%
18. Was a bereavement visit accepted? 20%
19. Did discussions take place with the families or carers about nutrition and hydration?
23%
20. Is there documented evidence that controlled drugs have been denatured in the patient’s home or returned to a community pharmacy?
62%
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 158
The service had acted against the findings of this audit. For example, the education programme
that was delivered to all members of the district nursing team had been strengthened and an
individualised care plan had been introduced to support staff when providing end of life care to all
patients.
In addition, the service had planned to re-audit this in January 2019, as well as measuring the
effectiveness of the individualised care plan that had been introduced.
Competent staff
Appraisals for permanent non-medical staff
As of July 2018July 2018, 94%94% of permanent non-medical staff within the end of life care core
service had received an appraisal compared to the trust target of 86%86%. Appraisals were
important as they allowed staff to discuss positive and negative aspects of their performance, so
that further improvements could be made.
Clinical Supervision
Between 1 August 2017 and 31 July 2018, the average clinical supervision rate for the core
service was 0%. The trust did not have a target.
Team
Clinical
Supervision
Target
Clinical
Supervision
Delivered
Clinical
supervision
rate (%)
Liverpool Palliative Care Team 35 0 0%
South Sefton Palliative Care Team 18 0 0%
Core Service Total 53 0 0%
The trust had recently introduced an electronic system for clinical supervision to be recorded when
this had been completed. However, this system was not being used effectively at the time of the
inspection.
In addition, the service had not made formal arrangements for staff to receive clinical supervision
on a regular basis. Clinical supervision is important as it provides an opportunity for staff to
discuss patients who are on their case load and seek further support and advice if needed.
However, members of the palliative care staff informed us that there was informal access to a
clinical psychologist if they had any areas of concern that they wanted to raise. In addition, staff
informed us that they had regular conversations with consultants who specialised in palliative care
as well as GPs as part of the multidisciplinary team meetings that they attended on a regular
basis.
Members of the palliative care team were given opportunity to develop their knowledge and skills
so that they could provide more effective care and treatment. For example, most palliative care
nurses had completed a nurse prescribing course. In addition, one member of staff informed us
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 159
that they had been supported to complete a formal qualification in education as a main part of their
role was to deliver education about end of life care to other district nursing staff.
The palliative care team were committed to providing education about end of life care to all nursing
staff. This was available through both e-learning as well as face to face teaching.
We noted that the palliative care team in Liverpool had been funded to have an educator who was
responsible for co-ordinating training throughout the area, as well as developing education
programmes for staff. However, staff in the South Sefton palliative care team raised concerns that
they did not have a similar role, meaning that it was sometimes difficult to achieve everything that
they wanted due to operational demand.
Other key skills in end of life care were also delivered, including topics such as assessment and
care planning, pain and symptom control, advanced care planning and care of the patient in the
last days of life. However, we noted that the education programmes delivered by the Liverpool and
South Sefton team were different. This meant that there was a risk that the care delivered across
both areas would be different.
Records indicated that end of life care training had been delivered to 81% of staff in the Liverpool
area and 75% of staff in the South Sefton area. The management team informed us that they
aimed to have delivered training to 95% of staff in both the Liverpool and South Sefton areas by
the end of December 2018.
Verification of expected death training had been delivered to 66 members of nursing staff across
the district nursing teams. This included 46 members of day staff and 20 out of hours staff.
Multidisciplinary working and coordinated care pathways
The palliative care team were involved in several multidisciplinary team meetings, working
collaboratively with staff throughout the community. The palliative care team told us that providing
care and treatment for patients at the end of life was everybody’s responsibility. District nursing
staff throughout the service spoke highly of the palliative care team and found them to be
accessible and supportive.
Members of the palliative care teams worked closely with district nurses. For example, the
palliative care nurses visited staff bases on a regular basis. This was important as it allowed
members of the palliative care team to have discussions with district nurses about their caseload
on a regular basis as well as providing an opportunity to share information when needed.
However, it was not always clear when district nursing staff should refer a patient to the palliative
care team. This was because although there was an end of life policy, there was no clear criteria
for a referral to be made and meant that there was an increased risk that patients would not
always be referred to the palliative care team when needed.
District nurses attended gold standard framework meetings, which were held by GPs across both
the Liverpool and South Sefton areas. These meetings were important as they supported staff to
coordinate patients care and effectively. However, we were informed that the application of the
gold standard framework meetings was sometimes inconsistent. This was because some GPs
held the meetings every two weeks, and others held them every quarter.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 160
Members of the palliative care team attended meetings and worked closely with local hospices in
both the Liverpool and South Sefton areas on a weekly basis. This provided an opportunity to
discuss patients who were known to the hospices. We attended one of these meetings, finding it to
be well attended by staff from the hospice, allied health professionals, such as physiotherapists as
well as cancer nurses.
There was access to a variety of district nursing teams, including occupational therapy, dietetics,
physiotherapy as well as speech and language therapy who were available between Monday and
Friday, during normal working hours. Staff who we spoke with were aware of these teams and
knew how to make a referral when needed.
However, one patient informed us that there had been a delay in receiving a visit from the
continence team which meant that they had to buy products themselves in the meantime. We
noted that this was because each member of staff in the continence team had a high caseload,
meaning that they had not always been able to assess patients in a timely manner.
Staff informed us that information had not always been shared effectively between hospitals and
the district nursing team when a patient had been discharged home. This meant that there was an
increased risk that the most up to date patient information had not always been available.
However, members of the palliative care team in the South Sefton area had worked with a local
trust to put together a ‘safe transfer’ checklist so that staff knew what was required to undertake a
safe transfer.
Health promotion
Staff across the community service encouraged patients to make healthy lifestyle changes and
promoted ways for patients to manage their own health. This included referrals to smoking
cessation services and wellbeing services.
We observed occasions when staff had recognised that relatives had needed support so that they
were able to continue to care for patients at home. This included making referrals to external
services that could provide support at night time, enabling relatives to get some rest. However,
staff informed us that there had sometimes been delays in accessing these services.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
The trust had a consent to capacity and treatment policy which was in date and was available for
staff to access on the intranet. Some staff were aware of this and knew how to access it.
Staff who we spoke with were not always clear about the need to document when they had
obtained consent from a patient. We reviewed six sets of records, finding that consent had not
been documented on two occasions. In addition, an audit that had been undertaken in June 2018
indicated that consent had been documented correctly on 15% of occasions.
Staff informed us that decisions about mental capacity were made by a GP or a member of
medical staff on occasions when a patient had been admitted to hospital.
However, staff were not always aware about the principles of mental capacity and when a full
mental capacity should be undertaken. For example, during a home visit that we attended, we
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 161
observed that a patient had reduced mental capacity to decide about their own care and
treatment. Although it had been noted from a previous visit that the patient had capacity, the
patient’s condition had changed but a referral was not made to a GP so that an assessment could
be undertaken.
We reviewed four do not attempt cardiopulmonary resuscitation orders, finding that these had not
been discussed with the patient on two occasions. On one of these occasions, the do not attempt
cardiopulmonary resuscitation order had not been discussed with the patient as they had
fluctuating capacity at the time the decision had been made (this is when a patient’s capacity is
reduced for a short period of time due to several reasons, including an acute episode of illness).
Records indicated that although the patient had regained capacity, this had still not been reviewed
with the patient. This meant that there was a risk that care and treatment would not reflect the
patient’s wishes.
Although do not attempt cardiopulmonary resuscitation orders were implemented and discussed
with patients and relatives by GPs or medical staff, the service had not monitored compliance with
the correct completion of do not attempt cardiopulmonary resuscitation orders in community
settings. This was important as there was a risk that areas of poor compliance would not be
identified, particularly as staff did not always understand their responsibility to challenge a decision
that had been made when needed.
We did note that an audit of compliance on ward 35 (a community inpatient ward) had been
completed in October 2018 measuring the correct completion of do not attempt cardiopulmonary
resuscitation orders. However, the sample size of this was small as it only captured three patient
records.
Deprivation of Liberty Safeguards
Mersey Care NHS Foundation Trust told us that 97 Deprivation of Liberty Safeguard (DoLs)
applications were made to the Local Authority between 1 August 2017 and 31 July 2018. None of
these were pertinent to end of life care services.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 162
Is the service caring?
Compassionate care
The palliative care and district nursing teams were committed to providing high quality,
compassionate care. Palliative care team members were proud of the type of service that they
provided and were keen to maintain high standards of care at all times.
We saw examples of positive interactions between staff and patients who were at the end of life.
Conversations were had in a sensitive and respectful manner. Patients and relatives that we
spoke to were keen to tell us that their own experience had been similar.
We spoke to 10 patients and relatives. Comments included ’we are extremely happy with the care
that we are getting’ and ‘we are more than happy, we can’t fault it and that staff are very helpful’.
The chaplain had planned to measure patient experience as this was not currently being done.
Staff informed us of several situations when they felt that staff had gone ‘the extra mile’ to care for
patients and relatives. For example, on one occasion staff had committed to looking after a
patient’s dog during their admission to hospital. This meant that the dog was still at the patient’s
home address when they had discharged and staff informed us how much of a difference that this
had made in the days before the patient had passed away.
On another occasion, staff informed us about an incident when they had struggled to secure
continued healthcare funding for a patient who did not have many possessions. All staff helped to
raise money so that they could buy the patient several basic items which enabled them to stay at
their home address.
Staff could tell us how they cared for the deceased, ensuring that dignity was maintained after
death. However, there was sometimes limited evidence documenting what actions had been taken
after a patient had passed away. For example, staff had not always documented if medical
devices such as cannulas (a plastic tube which is inserted into a vein to administer medication)
had been removed.
There had been a small number of concerns raised by relatives that district nurses had not
attended a home address in a timely manner to care for a patient who had passed away. Members
of the management team informed us that these incidents had been because of operational
demand.
Emotional support
The emotional requirements of patients were considered as part of the individual communication
record that was used when it had been recognised that a patient was at the end of life. We
reviewed a sample of records and found that there had been a regular reassessment of patient’s
needs completed which included nutrition, hydration, pain relief, personal hygiene and anxiety on
all occasions.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 163
Staff gave us examples of when they had supported patients and relatives through difficult
situations. For example, we were informed about one occasion when a patient had become
increasingly agitated. Staff had ensured that the patient had remained at home by supporting extra
visits which supported the patient’s relatives as well as the patient.
Staff informed us that psychology services could be accessed through local hospices or GPs to
support patients and relatives when needed.
However, records indicated that bereavement support had only been available to a small number
of families after a patient had passed away. A care of the dying audit that had been undertaken in
June 2018 indicated that only 45% of families had been offered bereavement support as well as a
bereavement visit following a patient’s death. In addition, only 20% of the families had accepted a
bereavement visit.
The trust employed a chaplain. However, staff were unable to easily access this service. This was
because access to the chaplain by community services had not been agreed since the services in
Liverpool and South Sefton had been acquired. Staff liaised with patient’s own churches and
organisations to meet the patient’s individual spiritual needs. In addition. On occasions, advice
from local hospices had been sought by referring patients to the service when needed.
Understanding and involvement of patients and those close to them
Palliative care team members and other staff communicated with patients and relatives in a way in
which they understood. Patients and relatives that we spoke to confirmed this to be the case.
Records that we reviewed showed that patients and relatives were involved in their own care and
treatment. Treatment options that were available were discussed and patients were given the
choice of how they wanted their care to proceed.
At times when it was uncertain if patients would recover despite treatment being provided,
conversations were had so that patients had a choice, for example, what their preferred place of
care would be in the event of further deterioration. These discussions were supported using
standardised documentation such as individualised care plans.
Advice leaflets were available for staff to give to relatives which answered frequently asked
questions and gave advice about important topics such as the dying process and what to expect,
medication as well as support and contact details for several different organisations.
Other information was also available which provided practical advice to relatives about what
actions to take when a patient had passed away. This included an overview of how a death is
verified as well as who to contact.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 164
Is the service responsive?
Planning and delivering services which meet people’s needs
The service worked closely with GPs and other multidisciplinary teams to identify patients who had
a life limiting illness and were in the last 12 months of life as early as possible. This was important
as it allowed time for staff to communicate and plan care and treatment with patients and their
relatives.
Members of staff from the palliative care team informed us that they had introduced training to all
staff so that they were able to verify the expected death of a patient. This was introduced as GPs
had sometimes taken a long time to attend a home address after a patient had passed away.
Although a high number of district nurses had received training to verify a patient’s death, some
staff informed us that they did not feel confident to do this. In addition, nursing staff were not
always available to attend a patient’s home immediately after they had passed away. We reviewed
11 patient records for patients who had passed away, finding that a GP had verified a patient’s
death on all but one occasion, which meant that this system of nurses verifying a patient’s death
was not yet fully effective.
Advanced care planning was discussed as part of gold standard framework meetings that were
coordinated by GPs in both the Liverpool and South Sefton areas. Advanced care planning is
important as it gave patients the opportunity to discuss how they would like their care to look as
their illness progressed.
However, it was unclear about whose responsibility it was to complete advanced care plans.
Although we saw some evidence on electronic records that this had been considered, it was
unclear about what the responsibilities of district nurses were in this process. The service had
developed advanced care planning documents, but we did not see any evidence of these having
been completed in any patient records that we reviewed.
We did note that advanced care planning had been added to the end of life care education
programme that was delivered to all staff.
Meeting the needs of people in vulnerable circumstances
The management team had introduced a care after death section as part of a patient’s
individualised care plan. This included important information such as if the patient’s GP had been
informed of the patient’s death as well as if verbal and written advice about next steps had been
given to the patient’s relatives or carers.
However, we found that this had not been completed on nine out of 11 occasions. This meant that
it was unclear if staff had followed the care after death standard operating procedure fully, and
more importantly, it was unclear if support had been provided to relatives when needed.
The service had introduced advice leaflets to give to relatives after a patient had passed away.
This was important as it provided information about the next steps, including the removal of
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 165
equipment and medicines from their home as well as practical advice about what to expect from
funeral directors and how to collect a death certificate.
Staff had not received training on the management of patients in line with cultural preferences or
differences. However, staff informed us that they worked in collaboration with family members and
relatives so that they could meet the needs of patients. Chaplaincy services were accessed
externally when required as staff informed us that arrangements to access the chaplain who was
employed by the trust had not yet been agreed.
Specialist services, such as psychological support and bereavement services were accessed
through local hospices. Staff knew what services were available and how to access them.
Members of the palliative care team informed us that they had encountered problems in accessing
services for patients who had mental health problems. We were informed that although patients
received an initial assessment, follow up appointments had not always been undertaken in a
timely manner. This meant that it was unclear if the needs of patients who had mental health
problems had always been met.
There was access to a language line which provided translation services for patients and relatives.
The trust had undertaken an audit on the use of this system and records indicated that between
April and July 2018, 93% of face to face requests had been fulfilled when needed. There was also
24 hours a day, seven days a week access to sign language interpreters.
The trust had introduced dementia awareness training which was available to all staff. However,
records from July 2018 indicated that only 17% of palliative care staff had completed this.
Access to the right care at the right time
Between November 2017 and October 2018, the trust had reported 4,648 deaths. Records
indicated that during the same period, the palliative care teams in both Liverpool and South Sefton
had received a total of 2,081 referrals (45% of occasions).
The palliative care team planned to triage all referrals within 24 hours and to clinically review all
patients within 72 hours. In addition, the palliative care team planned to triage all urgent referrals
within four hours However, the service had not monitored these targets. This meant that it was
unclear if the palliative care team had triaged patients in a timely manner.
Members of the management team informed us that there had been occasions when urgent
referrals had not been triaged in a timely manner. This was because staff had labelled the referral
as non-urgent on the electronic records system.
Referrals to the specialist palliative care team were made by several healthcare professionals,
including district nurses and GP’s. We reviewed five initial assessment forms that had been
received, finding that they had been managed in a timely manner. Initial assessments included
diagnosis, psychological and spiritual assessment, complex social needs as well as medication
and preferred place of care.
We did note that staff who we spoke with informed us that they had found the palliative care team
to be responsive and that they had not had any problems when they had needed to seek advice.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 166
There was a team of district nurses who provided cover at night time. This included supporting
patients who were at the end of life. The night team had access to syringe drivers if a patient
deteriorated, meaning that they could administer anticipatory medicines if required.
However, members of staff informed us that they were not always able to deliver treatment in a
timely manner as they had to cover a large geographical area. There had been a small number of
incidents reported when there had been a delay in treatment or a visit had not been facilitated by a
member of the out of hours team when needed.
An audit had been undertaken in June 2018, which identified that 85% of patients had achieved
their preferred place of care. However, we noted that this audit only covered the Liverpool area.
This meant that it was unclear if this had been achieved for patients in the South Sefton area.
Records indicated that between April and November 2018, the service had supported
approximately 200 urgent discharges for patients who were at the end of life in the Liverpool
locality. Urgent discharges had been supported by the community assessment team who liaised
with staff from a hospital as well as members of the palliative care team when needed. However, it
was unclear how many urgent discharges had been facilitated in the South Sefton locality as this
information had not been recorded.
Staff informed us that there had been difficulties in accessing appropriate places of care on
occasions when a patient had deteriorated and could not remain at home safely. For example, in
the Liverpool area, access to funded beds in local hospices were no longer available. This meant
that some patients were managed in beds that did not always suit their needs or preferences. For
example, on occasions, only nursing home beds had been available.
The district nursing and specialist palliative care teams could make referrals to an external charity
which provided a night sitting service which was used to support relatives who needed support.
This service was also available to visit to support patients with personal care. However, this was
only available in the Liverpool area, and was not offered in the South Sefton area.
In addition, district nursing staff informed us that patients sometimes had to wait for up to 12
weeks to access this. Also, this service was only available for up to 12 weeks. Staff informed us
that there was no time in their caseloads to fit these patients in when the care had finished and
therefore patients could wait months to be seen. We raised this with management at the time of
inspection who informed us that this had not been monitored.
Records indicated that there had not always been timely access to occupational therapy services.
Although that there had been an increase in the number of referrals for patients at the end of life,
the occupational therapy team had not always had sufficient staff to meet the needs of patients.
Records indicated that between April 2018 to November 2018, patients had waited an average of
2 weeks to be seen by a member of the team. Although staff informed us that they aimed to see
patients within a week of referral, it was unclear if there was a formal standard for this.
An audit of avoidable hospital admissions for the South Sefton area had recently been completed.
This audit reviewed the arrangements that had been in place on occasions when hospital
admission had been potentially avoidable. Records indicated that 13 out of 20 patients did not
have a care package, 17 out of 20 patients did not have an advanced care plan and 11 out of 20
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 167
patients had not been prescribed anticipatory medicines. However, the audit report had not
identified if any of these factors had resulted in avoidable admissions.
Accessibility
The largest ethnic minority group within the trust catchment area is White other with 1.75% of the
population.
Ethnic minority group
Percentage of catchment population (if known)
First largest White Other 1.75
Second largest Chinese 0.8
Third largest Other 0.7
Fourth largest Black African 0.7
Waiting times
There is no information pertaining to end of life care services.
The trust has identified services as measured on ‘referral to initial assessment’ and ‘assessment to
treatment’. However, there is no data pertaining to end of life care services.
Learning from complaints and concerns
The trust had an up to date complaints policy which was available to all staff on the intranet. The
policy highlighted that an initial response to a complaint had to be made within three working days
and that a full response was required within 25 working days for straight forward cases and 40
working days for more complex cases.
There was a trust wide complaints team who were responsible for co-ordinating any complaints or
concerns that had been received from patients or relatives.
Complaints
End of life care received four complaints between 1 August 2017 and 31 July 2018.
Total Complaints
Fully upheld Partially upheld Not upheld Referred to
Ombudsman Upheld by
Ombudsman
4 1 2 1 0 0
During the inspection, we reviewed all four complaints that had been made, finding that there had
been two occasions when the response time of 40 working days had not been met. The service
had taken 49 and 62 working days respectively to resolve the complaints. Holding letters had been
sent to inform the complainant that there would be a delay in responding to the complaint, which
was in line with trust policy.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 168
In addition, records indicated that the service had received seven concerns from relatives about
the end of life care that had been provided. These had not escalated to a full complaint as they
had been managed locally by a member of the management team. However, it was unclear on
reviewing these what action had been taken to feed any learning back to staff.
For example, one concern had been raised in October 2018, raising concerns that poor
documentation by a member of the district nursing team had delayed the coroner in issuing a
death certificate. There was no documented evidence of what action had been taken to learn from
this concern.
Compliments
The trust received 157 compliments during the last 12 months from 1 August 2017 and 31 July
2018. Nine of these related to end of life care, which accounted for 6% of all compliments received
by the trust.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 169
Is the service well-led?
Leadership
The community nursing division, including both palliative care teams had a clear leadership
structure. Community services were run using a locality based model, which meant that all
services in an area had been run by a designated leadership team. Each locality had an associate
director, a clinical lead, a care manager and a governance manager.
Because of this model, both palliative care teams were run under different localities. This was
important as up until the time of inspection, both teams had operated differently. In addition, the
trust had acquired the South Sefton palliative care service in June 2017. The Liverpool palliative
care team had only been acquired in April 2018.
Both staff from the district nursing and the palliative care teams informed us that the locality
leadership teams had not always been visible. However, staff also informed us that the care
managers and clinical leads had become more visible in recent months.
It was unclear if the trust had identified a member of the executive or non-executive team to have
responsibility for overseeing the delivery of end of life care. Although, the trust informed us
following the inspection that there was an executive lead, we did not see any documented
evidence of this being the case on reviewing executive’s portfolios. In addition, staff who were
responsible for delivering end of life care were not aware that there was an executive lead for the
service.
The trust had also employed a part time GP who was the clinical lead for end of life services. They
chaired both the end of life steering group which was held bi-monthly as well as the clinical
effectiveness sub-committee which was held for all district nursing community services. We noted
that between June 2017 and April 2018, the South Sefton palliative care team had not had a
clinical lead. Staff informed us that during this time, end of life services were nurse and GP led.
In addition, both palliative care teams had a team leader, who were responsible for coordinating
the provision of end of life care services on a day to day basis.
Vision and strategy
The trust had an overall vision, which was ‘our services, our people, our resources and our future’.
This was supported by an operational plan for 2018/2019. However, the plan only included the
South Sefton area. Key priorities for this period included to reduce the number of community
acquired pressure ulcers to zero as well as to reduce staff sickness to 6%.
The service’s main objectives were to actively promote best evidence end of life care, optimize
pain control for patients at the end of life, effectively manage patient symptoms at the end of life,
support patients to die in their preferred place of care, support carers and relatives within the
bereavement stage and to educate other clinicians.
Although both localities did not have a formal vision or strategy for end of life services, members of
the palliative care teams were able to tell us what their main priorities were. We were informed that
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 170
these had been aligned to the strategy for both the North West palliative care network and local
care commissioning groups. However, at the time of the inspection it was unclear how these would
be achieved as the service were in the process of developing an implementation plan so that
these priorities could be actioned.
The trust had undertaken a full-service review of the provision of end of life services in the South
Sefton area in May 2018. This had been completed by the palliative care team leader and had
been submitted to the trust board for review. However, this had not yet been undertaken for the
Liverpool area.
We noted that prior to a service review being undertaken, the service had developed an action
plan to make improvements to the provision of end of life services. We reviewed this, finding that
15 out of 26 actions had been completed. However, two actions did not have timescales for
completion. This meant that there was an increased risk that improvements would not be made in
a timely manner.
The service review had identified several recommendations to make further improvements to the
provision of end of life services. This included gaining wider access to bereavement support
services, develop formalised medical support, to develop workforce plans to match the increased
number of referrals and bed shortages in the South Sefton area.
However we noted that during this inspection, an action plan to make the improvements that had
been identified in the service review six months earlier had not yet been created. This meant that it
was unclear how and when the improvements would be made.
Culture
The palliative care team were very proud of the work that they had done. They were focused on
providing the best possible care and meeting the needs of the people that used the service.
We found there to be an open and honest culture within the service. Members of the palliative care
team informed us that they felt supported in reporting incidents. The palliative care team were
keen to learn and make further improvements when required.
District nursing staff spoke highly of the palliative care teams in both Liverpool and South Sefton.
They informed us that they had always been accessible and supportive.
However, some staff who we spoke with informed us that they had not always been able to trust
senior managers throughout the service and felt that there was still a blame culture. Some staff felt
that they had not always felt confident to raise issues when they arose. Although staff recognised
that there had been some improvements, they felt that further improvements were still required.
The trust had a freedom to speak up guardian. However, most staff who we spoke with were
unaware of this and did not know how to contact them if needed. A freedom to speak up guardian
is a designated member of the executive team who staff can contact anonymously about issues
that they have. This is particularly important for staff who do not feel that they can raise concerns
with a manager directly.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 171
The executive team had recognised the need for further improvements and were in the process of
aligning all community services to the trust’s way of working. For example, the trust had
encouraged joint working between senior managers from each locality. This had been aimed at
both improving working relationships as well as sharing best practice and learning.
The trust had a lone working policy which was available to all staff on the intranet. Staff who we
spoke with were aware of this and knew how to access it. We observed staff using lone worker
devices correctly before entering each patient’s home address. In addition, all staff had access to
a panic alarm in case of an emergency and knew how to use this if needed.
However, members of the management team informed us that not all of these worked when
needed. This meant that there was a risk that staff would not always be able to seek immediate
help in the case of an emergency.
Governance
The service had a governance structure which allowed information to be shared between palliative
care services, some members of the senior management team as well as external stakeholders
and providers. However, we had concerns that members of the senior leadership team did not
always have an oversight of end of life services.
An end of life steering group meeting was held every two months and was attended by members
of the Liverpool and South Sefton palliative care teams. The meeting was chaired by the GP lead
for end of life services.
We reviewed minutes from the last three end of life steering group meeting minutes, finding that
there had been a small number of actions that required escalating to the divisional clinical
effectiveness group. Records indicated that all issues that had been identified at this meeting had
been discussed and actioned appropriately.
Both meetings had action logs which documented an owner who had responsibility for completing
actions as well as a timescale for completion. There was documented evidence that an updated
action log had been discussed at every meeting so that agreed actions were monitored for
completion.
However, it was unclear how issues that had been identified about end of life services in the
clinical effectiveness group meetings had been escalated to the senior leadership team for the
community division. This was because there was no documented evidence that end of live
services had been discussed as part of divisional governance meetings, meaning that there was
an increased risk that the senior leadership team would not always be aware of issues that were
faced when delivering end of life services.
The terms of reference for senior leadership team meetings indicated that although different staff
from across community services were required to attend this meeting, a representative from the
palliative care team had not been identified as a member of the meeting. In addition, on reviewing
the agendas and associated papers for the last four senior leadership team meetings that had
been held, there was no evidence that end of life care had been discussed.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 172
Monthly palliative care team meetings had been planned in the Liverpool and South Sefton
localities. Between May and November 2018, records indicated that only four out of seven planned
meetings had taken place. Staff informed us that this was due to operational demand. Team
meetings are important as it provides an opportunity for staff to share learning, discuss any issues
that they may have as well as escalating areas of risk when needed.
Records that were provided following the inspection indicated that some palliative care team
meetings had taken place. However, minutes from these meetings did not always have
documented actions on occasions when issues had been identified. This meant that it was unclear
of how improvements would be made and how the completion of actions would be monitored.
The trust had an overall business continuity plan which was in date. This was important as it
provided guidance for staff on what actions to take in the event of increased operational demand.
Team leaders had completed a business continuity plan in November 2018 (prior to our
inspection) relating to patients who were at the end of life in both the Liverpool and South Sefton
areas. However, we noted that business continuity training had not been provided to staff.
Management of risk, issues and performance
The trust had an incident reporting and risk management strategy which was available to all staff
on the intranet. Members of the management team were aware of this and knew how to access it.
Members of the palliative care team were aware of how to escalate risks that were faced by the
service so that actions could be put in place to reduce the risk as much as practicably possible.
Palliative care team leaders informed us that all risks would be escalated to a care manager in
either the Liverpool or South Sefton localities.
We had concerns that not all risks for end of life services had been identified, which meant that
there was an increased risk that appropriate controls were not in place to manage these
effectively. This was because that on reviewing the risk register, we found that there had not been
any risks listed which were specific to end of life services.
Members of the management team informed us that some risks that had been included on the risk
management system for district nursing services had an impact on the effective provision of end of
life services. For example, although staffing and skill mix had been included, there were no actions
in place to manage the impact of this on end of life services.
In addition, we identified some risks during the inspection that had not been included on the risk
management system. This included the failure of staff to follow the trusts policies and procedures
in making sure that controlled drugs had been destroyed in line with legislation. Members of the
management or executive team were unaware of this risk until we formally raised our concerns
following the inspection.
The palliative care teams had some systems in place to make sure that they had oversight of any
issues that were faced in the delivery of end of life services so that improvements could be made
when needed. For example, members of the management team informed us that all reported
incidents had been reviewed during end of life steering group meetings. We reviewed minutes
from these meetings, finding that incidents had been discussed and that actions had been
implemented to reduce the risk of similar incidents happening again.
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 173
In addition, the palliative care team in both Liverpool and South Sefton had implemented some
audits to measure compliance against best practice guidance as well as trust policies and
procedures. An audit meeting had been held every two months to discuss any audits that staff had
proposed to undertake, which included local audits and others that were led by external
organisations such as the North West palliative care network. However, we were not assured that
these had been done in a way which provided oversight of all end of life services.
For example, a care of the dying audit that had been undertaken in June 2018 had only included a
records sample from the Liverpool area. This meant that the care that had been provided in the
South Sefton area had not been monitored and it was unclear if all areas for improvement had
been identified.
At the time of inspection, the service had only planned to review all unexpected deaths. Minutes of
meetings indicated that these had been discussed when completed. However, we had concerns
that learning from all deaths had not taken place as expected deaths had not been reported on the
incident reporting system and none of these had been reviewed to identify potential learning.
The senior management team informed us that the trust had recognised this as an area for
improvement and that they had planned to review all expected deaths going forward. Members of
the palliative care team informed us that they had been asked to be involved in these meetings on
a regular basis.
Information management
Information dashboards were used to monitor some community services and we found that this
information was reviewed by staff at different levels. However, members of the palliative care team
informed us that they had not always recorded information in a way that had been effective in
providing an oversight of the provision of end of life care. For example, key performance targets
such as how long it had taken a member of the palliative care team to triage a patient had not
been measured. This meant that there was an increased risk that members of the senior
management team did not always have oversight of all issues that were faced by end of life
services.
Members of the palliative care team informed us that they had made plans to introduce an end of
life care dashboard so that all information could be monitored more effectively.
However, we did note that some information had been used in a way to make improvements to the
service. For example, information from incidents that had been reported and results from audits
that had been completed had been used to make further improvements to end of life services.
The service used paper records and an electronic management information system for patient
records. There was a sharing agreement in place for access to patient information from external
healthcare providers such as GP’ who used the system for patient records and information. Staff
had access via login details and passwords.
Engagement
Mersey Care NHS Foundation Trust evidence appendix: end of life care Page 174
All community staff had been given the opportunity to take part in the annual friends and family
test survey. However, the results were not specific to end of life services. In addition, we were
informed that a low number of staff across community services had taken part in this.
The service did not have a system which allowed patients and relatives to provide feedback about
the care that they had received. This meant that there was an increased risk that areas for
improvement had not always been identified. However, the service had identified this shortfall and
the management team had made plans for this to be done in the future.
We did note that members of the management teams at different levels had developed ways in
which to communicate with all staff throughout the trust in several ways. This included emails,
newsletters as well as a webpage which allowed staff to ask the chief executive questions.
Learning, continuous improvement and innovation
The trust had undertaken several service reviews across the community division so that
improvements could be made. Records indicated that although a service review of the South
Sefton palliative care team had been undertaken, actions from this had not yet been implemented.
In addition, a service review of the Liverpool palliative care team had not been undertaken. It was
unclear if the trust had planned for this to be done.
The executive team had recognised that the South Sefton and Liverpool palliative care teams had
worked separately up until April 2018. We were informed that although there had been occasions
when both palliative care teams had worked together, plans had been made to standardise the
service fully. However, it was unclear when this would be achieved.
Members of the palliative care teams in both Liverpool and South Sefton were committed to
making improvements to the provision of end of life services and attended several internal and
external meetings so that improvements could be made to the service locally.
For example, the service had worked with external providers to make some improvements when
needed. For example, members of the palliative care team had worked with local hospitals to
develop a safe discharge pathway for patients who were at the end of their life.
Accreditations
NHS Trusts can participate in several accreditation schemes whereby the services they provide
are reviewed and a decision is made if 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 to continue to be accredited.
The trust prided a list of services, which have been awarded an accreditation together with the
relevant dates of accreditation. However, there was no information pertinent to end of life care
services.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 175
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)
Baird House Community Hub
CMHT - Arundel
/ CMHT
Windsor House
100 Mixed
Northwood House CMHT - Kirkby 16 Mixed
Moss House CMHT - Moss
House 64 Mixed
Norris Green CMHT - North
Liverpool 84 Mixed
Park Lodge CMHT - Park
Lodge 68 Mixed
SSNC CMHT - South
Sefton (SSNC) 140 Mixed
Hesketh Centre CMHT – North
Sefton 87 Mixed
Morley Road
DISH
(Supported
Living Services)
Crosby
Not provided Not provided
Rathbone Eating Disorder
Daily Therapy Session
1:1 and Groups as
required
Mixed
Royal Hospital
Hospital Mental
Health Liaison
Team - RLUH
N/A Mixed
Baird Innovation Park HOT Team 8 Mixed
3 separate locations Talk
Liverpool
7 New Hall - L10 1LD
151 Dale Street - L2 2AH
St Andrews Business Centre
91 St Marys Road L19 2NL
IAPT (Talk) 791 Mixed
Haigh Road Psychotherapy N/A Mixed
Clock View
Single Point of
Access-
Clockview
N/A Mixed
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 176
Location site name Team name Number of clinics Patient group (male,
female, mixed)
Hesketh Centre
Single Point of
Access-
Hesketh
N/A Mixed
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 177
Is the service safe?
Safe and clean environment
Staff did regular risk assessments and audits of the environment. All of the locations we visited
were clean and had good furnishings. Interview rooms were fitted with alarms. The clinic rooms
were clean and had the necessary equipment needed to carry out physical examinations. We saw
that equipment had been checked regularly.
Each location had a cleaning schedule and cleaning records were up to date. Staff adhered to
infection control principles including handwashing. There were robust infection control audits and
policies in place.
Safe staffing
Park Lodge and North Sefton CMHTs had enough staff, who knew the patients and had received
basic training to keep people safe from avoidable harm. However, at Moss House there were three
vacancies for mental health practitioners and three staff that were absent due to sickness. This
had resulted in increased workloads for the remaining staff. Recruitment was taking place and
managers had agreed to remove Moss House staff from weekend duties for a period of two
months to allow for increased cover during core hours.
There were enough medical staff at each location. The service used locums to cover vacancies.
The trust acknowledged that the use of locums had been a particular issue at Moss House. All
patients had access to psychiatry and patients were seen within 24 hours in an emergency.
Managers assessed the size of individual staff caseloads regularly and helped staff to manage
them. Staff told us that their caseloads were manageable and included patients on stepped up
care.
The table below gives an overview of trust staffing levels. It provides data on substantive staff
numbers, vacancies and sickness, and use of bank and agency staff. This data was provided to us
by the trust in August 2018 and covers the period 1 August 2017 to 31 July 2018.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 July 2018 690.9 N/A
Total number of substantive staff leavers 1 August 2017–31 July 2018
73.5 N/A
Average WTE* leavers over 12 months (%) 1 August 2017–31 July 2018
11% N/A
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 178
Substantive staff figures Trust target
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31 July 2018 -1.3 N/A
Total vacancies overall (%) At 31 July 2018 -3% 5%
Total permanent staff sickness overall (%)
Most recent month (At 31 July 2018)
6% N/A
1 August 2017–31 July 2018
5% N/A
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 July 2018 30.3 N/A
Establishment levels nursing assistants (WTE*) At 31 July 2018 2.2 N/A
Number of vacancies, qualified nurses (WTE*) At 31 July 2018 1.1 N/A
Number of vacancies nursing assistants (WTE*) At 31 July 2018 -1.2 N/A
Qualified nurse vacancy rate At 31 July 2018 4% 5%
Nursing assistant vacancy rate At 31 July 2018 -55% 5%
Bank and agency use
Hours bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 August 2017-31 July
2018 6410 N/A
Hours filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses) 1 August 2017-31 July
2018 956 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses) 1 August 2017-31 July
2018 3195 N/A
Hours filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 August 2017-31 July
2018 4043 N/A
Hours filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 August 2017-31 July
2018 22 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants) 1 August 2017-31 July
2018 196 N/A
*Whole-time Equivalent / minus figures mean they are oversubscribed
This core service reported an overall vacancy rate of 4% for registered nurses at 31 July 2018.
This core service reported an overall vacancy rate of -55% for registered nursing assistants.
This core service has reported a vacancy rate for all staff of -3% as of 31 July 2018.
Registered nurses Health care assistants Overall staff figures
Team
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 179
Eating Disorders 0 0 0 0 0 0 -1.2 9.5 -13%
Kirkby CMHT 1.3 7.7 17% 0 0 0 1.3 9.3 14%
Moss CMHT -1.0 12.6 -8% 0 0 0 -1.0 12.6 -8%
North Liverpool CMHT 0.8 10 8% -1.2 2.2 55% -0.4 12.2 -3%
Core service total 1.1 30.3 4% -1.2 2.2 55% -1.3 43.6 -3%
Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%
NB: All figures displayed are whole-time equivalents
Between 1 August 2017 and 31 July 2018, bank staff filled 6410 hours to cover sickness, absence
or vacancy for qualified nurses.
In the same period, agency staff covered 956 hours for qualified nurses. Three thousand, one
hundred and ninety-five hours were unable to be filled by either bank or agency staff.
Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Baird House
Community
Hub 1304 1178 956 326
Moss CMHT 2053 379 0 163
CMHT - North
Liverpool 5931 657 0 847
Kirkby CMHT 1092 875 0 114
CMHT - South
Sefton (SSNC) 5812 623 0 344
CMHT -
Arundel /
CMHT
Windsor
House 3357 1033 0 587
Post
Diagnostics Nr 326 616 0 0
Psychotherap
y 1466 175 0 163
Community
MH Team
North Sefton 1781 24 0 163
Single Point of
Access 0 408 0 0
Single Point of
Access 0 191 0 0
Spa/Patient
Flow 3161 164 0 489
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 180
Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Exec Nursing 815 88 0 0
Core service
total 27097 6410 956 3195
Trust Total 242318 125599 64603 31532
Between 1 August 2017 and 31 July 2018, bank staff to cover sickness, absence or vacancy for
nursing assistants filled 4043 hours.
In the same period, agency staff covered 22 hours. 196 hours were unable to be filled by either
bank or agency staff.
Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Liv Health And
Wellbeing 358 318 0 196
CMHT - North
Liverpool 1304 24 0 0
CMHT - South
Sefton (SSNC) 1716 16 0 0
DISH (Brook
Road West) 0 382 0 0
DISH
(Cavendish
Road)
0 361 0 0
DISH
(Glenwylynn
Road)
0 332 0 0
DISH (Regent
Road, Crosby) 0 126 0 0
DISH
(Moorgate
Avenue)
0 522 0 0
DISH (64
Wadham
Road)
0 259 11 0
DISH (210
Wadham
Road)
0 738 0 0
Single Point of
Access 0 127 0 0
Single Point of
Access 0 841 12 0
Core service
total 3378 4043 22 195
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 181
Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Trust Total 210729 442987 204924 29961
This core service had 73.5 (11%) staff leavers between 1 August 2017 and 31 July 2018.
Team Substantive
staff
Substantive staff
Leavers
Average % staff leavers
350 L9 Liverpool Junior LD (Z1FR20) 0.0 1.0 200%
350 L9 210 Wadham Road (Z1BN85) 3.0 2.0 63%
350 L9 Brook Road West (Z1BN50) 4.0 2.0 55%
350 L9 Cheshire Probation (SCF630) 1.2 0.5 45%
350 L9 S&K Acute Care (Z1VA11) 3.4 1.0 39%
350 L9 Local Psychology (Z2AB03) 4.6 1.8 37%
350 L9 64 Wadham Road (Z1BN75) 4.0 1.0 26%
350 L9 Addictions Management (Z1LK50) 0.1 0.2 24%
350 L9 Alt Ward (Z1AB71) 24.7 4.0 15%
350 L9 Southport Acute Care Team (Z1NW09) 18.0 2.0 14%
350 L9 Moss CMHT (Z1AH29) 15.1 2.0 14%
350 L9 Albert Ward (Z1AB11) 28.1 3.8 14%
350 L9 Psychotherapy (Z1EH90) 24.5 3.0 13%
350 L9 Talk Liverpool (Z2AB40) 99.0 11.8 12%
350 L9 Norris Green Community Hub (Z1AH30) 42.0 5.0 12%
350 L9 CMHT North Liverpool & Kirkby (Z1AD18)
12.4 1.4 11%
350 L9 Liverpool EI South/Central (Z1NW11) 27.8 3.0 10%
350 L9 South Sefton Neighbourhood (Z1AH38) 47.1 4.4 10%
350 L9 Community Psychology S&K (Z2AB25) 16.2 1.5 10%
350 L9 Community Psychology Liverpool (Z2AB30)
11.1 1.0 9%
350 L9 Brunswick Ward (Z1AE11) 28.8 2.0 7%
350 L9 Eating Disorders (Z1EH95) 8.3 0.5 6%
350 L9 Early Intervention (Z1NW14) 17.8 0.8 5%
350 L9 Rathbone Rehab Centre (Z1BG11) 31.2 1.0 3%
350 L9 Medical Aintree Older People (Z1AA04) 2.0 0.0 0%
350 L9 Liverpool EI Senior Medical Staff(Z1DR15)
1.0 0.0 0%
350 L9 Early Intervention Sefton Meds (Z1DR16)
1.9 0.0 0%
350 L9 Criminal Justice Liaison Team (Z1AF95) 39.1 0.0 0%
350 L9 Perinatal Liverpool (Z1VA01) 7.0 0.0 0%
350 L9 Rathbone Dir.Support (Z1BG90) 0.0 0.0 0%
350 L9 Kirkby CMHT (Z1AH34) 10.6 0.0 0%
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 182
Team Substantive
staff
Substantive staff
Leavers
Average % staff leavers
350 L9 Community Mh Team Ns (Z1NW07) 17.7 0.0 0%
350 L9 North Liverpool Neighbourhood (Z1AH33)
2.0 0.0 0%
350 L9 Dish Infrastructure (Z1BN45) 3.0 0.0 0%
350 L9 Community Clinic Team (Z1AD10) 3.0 0.0 0%
350 L9 Cavendish Road (Z1BN55) 4.0 0.0 0%
350 L9 Glenwyllin Road (Z1BN60) 4.0 0.0 0%
350 L9 Moorgate Avenue (Z1BN70) 3.0 0.0 0%
350 L9 Regent Road Crosby (Z1BN65) 4.0 0.0 0%
350 L9 MBT ASPD (SCF580) 1.0 0.0 0%
350 L9 Police Project (SCF927) 1.0 0.0 0%
350 L9 Merseyside Probation Team (SCF631) 1.0 0.0 0%
350 L9 Stafford House PIPE (SCF632) 0.8 0.0 0%
Core service total 578.5 56.7 10%
Trust Total 2658.6 294.5 13%
The sickness rate for this core service was 5% between 1 August 2017 and 31 July 2018. The
most recent month’s data [31 July 2018] showed a sickness rate of 6%.
Team Total % staff
sickness
(at latest month)
Ave % permanent staff sickness (over the
past year)
350 L9 Rathbone Dir.Support (Z1BG90) 0% 32%
350 L9 210 Wadham Road (Z1BN85) 38% 21%
350 L9 Brook Road West (Z1BN50) 0% 20%
350 L9 64 Wadham Road (Z1BN75) 0% 11%
350 L9 Community Mh Team Ns (Z1NW07) 7% 11%
350 L9 Albert Ward (Z1AB11) 15% 9%
350 L9 Kirkby CMHT (Z1AH34) 36% 9%
350 L9 Moss CMHT (Z1AH29) 0% 8%
350 L9 Community Clinic Team (Z1AD10) 0% 7%
350 L9 Alt Ward (Z1AB71) 13% 7%
350 L9 Talk Liverpool (Z2AB40) 6% 6%
350 L9 CMHT Nrth Liverpool & Kirkby (Z1AD18)
3% 5%
350 L9 Norris Green Community Hub (Z1AH30)
10% 5%
350 L9 Early Intervention (Z1NW14) 5% 5%
350 L9 Rathbone Rehab Centre (Z1BG11) 4% 5%
350 L9 Brunswick Ward (Z1AE11) 10% 4%
350 L9 Southport Acute Care Team (Z1NW09)
2% 4%
350 L9 South Sefton Neighbourhood (Z1AH38)
4% 4%
350 L9 Local Psychology (Z2AB03) 0% 4%
350 L9 Liverpool EI South/Central 9% 3%
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 183
Team Total % staff
sickness
(at latest month)
Ave % permanent staff sickness (over the
past year)
(Z1NW11)
350 L9 Criminal Justice Liaison Team (Z1AF95)
3% 3%
350 L9 Regent Road Crosby (Z1BN65) 0% 2%
350 L9 Community Psychology Liverpool (Z2AB30)
0% 2%
350 L9 Cheshire Probation (SCF630) 16% 2%
350 L9 Cavendish Road (Z1BN55) 0% 1%
350 L9 Moorgate Avenue (Z1BN70) 0% 1%
350 L9 Psychotherapy (Z1EH90) 0% 1%
350 L9 S&K Acute Care (Z1VA11) 5% 1%
350 L9 Early Intervention Sefton Meds (Z1DR16)
9% 1%
350 L9 Perinatal Liverpool (Z1VA01) 0% 1%
350 L9 Eating Disorders (Z1EH95) 0% 1%
350 L9 Community Psychology S&K (Z2AB25)
0% 1%
350 L9 Dish Infrastructure (Z1BN45) 0% 0%
350 L9 Glenwyllin Road (Z1BN60) 0% 0%
350 L9 North Liverpool Neighbourhood (Z1AH33)
0% 0%
350 L9 Liverpool EI Senior Medical Staff(Z1DR15)
0% 0%
350 L9 Addictions Management (Z1LK50) 0% 0%
350 L9 Addictions Senior Medical Staff (Z1LK10)
0% 0%
350 L9 Merseyside Probation Team (SCF631)
0% 0%
350 L9 Stafford House PIPE (SCF632) 0% 0%
Core service total 6% 5%
Trust Total 8% 8%
Medical staff
There is no data pertaining to this core service.
We requested data regarding the establishment and vacancy rate of medical staff for the service.
Data relating to Park Lodge and North Sefton was not received. The service was covering
vacancies with locums. We did not see any impact on the service being provided as a result.
Mandatory training
The service provided mandatory training in key skills to staff. However, staff compliance with role
specific mandatory training was below target.
The compliance for mandatory and statutory training courses at 31 May 2018 was 87%. Of the
training courses listed 26 failed to achieve the trust target and of those, 11 failed to score above
75%.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 184
The trust reported their training compliance data on an ongoing monthly basis. Statutory training
was reported as part of the monthly board report dashboard produced by Workforce and a
separate dashboard was provided by the Learning and Development team for all other courses
classified by CQC as role essential.
The training compliance reported for this core service during this inspection was the same as the
87% reported in the last year’s compliance.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service % Trust target % Trustwide mandatory/ statutory training total %
Role Specific Mandated Training -
Medicines Calculations (Every 3 Years) 100% 90% 63%
Mandatory Training - Safeguarding Adults
- Level 1 (Every 3 Years) 99% 95% 95%
Mandatory Training - Safeguarding
Children - Level 1 (Every 3 Years) 98% 95% 95%
Mandatory Training - Equality, Diversity
and Human Rights (Every 3 Years) 96% 95% 91%
Mandatory Training - Health & Safety
(Every 3 Years) 96% 95% 92%
Role Specific Mandated Training - Basic
Prevent Awareness (1 Time) 96% 90% 93%
Mandatory Training - Conflict Resolution
(Every 3 Years) 95% 95% 92%
Mandatory Training - Fire Safety (Every 3
Years) 95% 95% 92%
Mandatory Training - Infection Control
(Every 3 Years) 95% 95% 92%
Continuous Professional Development -
Adverse Incidents (Every 3 Years) 94% 95% 92%
Mandatory Training - Moving & Handling
(Every 3 Years) 94% 95% 90%
Role Specific Mandated Training -
Controlled Drugs & High Risk Medicines 94% 90% 67%
Continuous Professional Development -
Complaints (Every 3 Years) 92% 95% 94%
Role Specific Mandated Training -
Safeguarding Adults Level 2 -Trust Model
(Every 3 Years)
90% 90% 87%
Role Specific Mandated Training -
Safeguarding Children Level 2 - Trust
Model (Every 3 Years)
90% 90% 87%
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 185
Training course This core service % Trust target % Trustwide mandatory/ statutory training total %
Continuous Professional Development -
Smoking Cessation (1 Time) 89% 95% 89%
Continuous Professional Development -
Fraud Awareness (Every 3 Years) 88% 95% 89%
Continuous Professional Development -
Suicide Prevention & Safety Planning
(Every 3 Years)
88% 95% 90%
Continuous Professional Development -
Dementia Awareness (1 Time) 78% 95% 78%
Role Specific Mandated Training - Mental
Capacity Act - Level 1 (Every 3 Years) 77% 90% 88%
Role Specific Mandated Training - Mental
Health Act - Level 1 (Every 3 Years) 77% 90% 90%
Role Specific Mandated Training -
Safeguarding Children Level 3 - Trust
Model (Every 3 Years)
76% 90% 76%
Role Specific Mandated Training -
Safeguarding Adults Level 3 - Trust Model
(Every 3 Years)
75% 95% 76%
Role Specific Mandated Training -
Personal Safety (Every Year) 75% 90% 80%
Role Specific Mandated Training -
Deprivation of Liberties - Level 1 (Every 3
Years)
74% 90% 89%
Role Specific Mandated Training -
Intermediate Life Support (Every Year) 69% 90% 72%
Role Specific Mandated Training - Safe
and Effective Use of Medicines (Every 3
Years)
62% 90% 63%
Role Specific Mandated Training -
Personal Safety Breakaway - Level 1
(Every 2 Years)
61% 90% 50%
Role Specific Mandated Training - Basic
Life Support (Every Year) 60% 95% 70%
Role Specific Mandated Training - Rapid
Tranquilisation Training 53% 90% 61%
Mandatory Training (IG) - Data Security
Awareness - Level 1 (Every Year) 51% 95% 50%
Role Specific Mandated Training -
MHA/DoL's Level 2 (Every 3 Years) 50% 90% 53%
Role Specific Mandated Training -
Witness to Medication (Every 3 Years) 30% 90% 48%
Role Specific Mandated Training -
Personal Safety Breakaway - Level 1
(Every Year)
21% 90% 74%
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 186
Training course This core service % Trust target % Trustwide mandatory/ statutory training total %
Continuous Professional Development -
Moving and Handling of Inanimate
Objects
0% 95% 56%
Core Service Total % 87% 87%
The trust’s target for mandatory training was 95%. During inspection we received updated
mandatory training figures. The figures showed that staff compliance with mandatory training was
91% and above for all mandatory training except for data security awareness training which was
below trust target at 50% compliance at Moss House. Park Lodge was 91% compliant and North
Sefton were 100% compliant for data security awareness training.
The trust’s target for role specific mandatory training was 90%. During inspection we received
updated role specific mandatory training data which showed that there had been improvements at
two of the services we visited. However, Moss House failed to meet a number of course targets.
Compliance rates for role specific training at Moss House ranged between 23% and 78% except
for safeguarding adults and children (level two) which had 93% compliance. This meant that the
trust could not be assured that all staff were able to safely manage conflict with patients or able to
apply the Mental Health Act and Mental Capacity Act.
North Sefton met the trust target for all role specific mandatory training.
Park Lodge compliance was above 75% for all role specific mandatory training except personal
safety breakaway training, which was 36%.
Assessing and managing risk to patients and staff
Assessment and management of patient risk
Staff completed and updated risk assessments for each patient and used these to understand and
manage risks individually. Staff used the trust’s standard assessment tool. Risk assessments were
recorded on the trust’s new electronic treatment and care recording system.
Staff discussed crisis plans with patients and documented it in their care and treatment plans. The
records we looked at had robust risk management plans in place, which included early warning
signs, practitioner intervention, medication, useful telephone numbers and accommodation.
Risks were raised and discussed at the multidisciplinary meetings we attended.
The service had a robust lone working policy that staff referred to when needed. Staff we spoke
with were able to describe the lone working procedures.
Safeguarding
Staff understood how to protect patients from abuse and the service worked well with other
agencies to do so. The service had a safeguarding policy and staff were provided with training on
how to recognise and report abuse and they knew how to apply it.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 187
Safeguarding was a standing agenda item at multidisciplinary meetings.
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 29 safeguarding referrals between 1 August 2017 and 31 July 2018, of
which 15 concerned adults and 14 children.
The most adult referrals made in the period were in October 2017 with three.
There were two peaks identified in child referrals across the period in August 2017 (three) and
September (three).
Mersey Care NHS Trust submitted details of four external case reviews commenced or published
in the last 12 months, however none that relate to this core service.
Staff access to essential information
Staff kept detailed records of patients’ care and treatment plans including risk assessments.
Records were clear, up-to-date and person centred. However, the service was going through a
migration of one electronic system to another. Not all staff had access to all relevant patient
information in a timely manner. New staff only had access to the old system by getting another
staff member with access to log into it and get the information they needed. This meant that there
were delays in accessing patient information they required to be able to deliver patient care.
The new system had become live from 1 June 2018.The service had originally set 31 October
2018 as the transfer completion date for care plans and risk assessments but at the time of
inspection North Sefton was the only location out of the three that had managed to complete the
transfer. The trust informed us that a new completion date had been set for 30 November 2018.
Training in the use of the new system had been provided for staff since January 2018 but we saw
that staff were struggling to navigate the new system efficiently.
Referrals
Adults Children Total referrals
14 15 29
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 188
Medicines management
Staff followed best practice when storing, dispensing, and recording. Staff regularly reviewed the
effects of medications on individual patient physical health. Emergency and controlled medication
was not stored on the premises.
Track record on safety
Moss House had reported two serious incidents between 1 August 2017 and 31 July 2018, Park
Lodge had reported three and North Sefton reported one serious incident. Staff we spoke with
understood what needed to be reported and how to do it.
Providers must report all serious incidents to the Strategic Executive Information System (STEIS)
within two working days of an incident being identified.
Between 1 August 2017 and 31 July 2018 there were 32 STEIS incidents reported by this core
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. One of the unexpected
deaths were instances of ‘Apparent/actual/suspected self-inflicted harm meeting SI criteria’.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the
available preventative measures are in place. This core service reported no never events during
this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months.
The number of the most severe incidents recorded by the trust incident reporting system was
broadly comparable with STEIS.
Number of incidents reported
Type of incident reported on STEIS
Ap
pare
nt/
actu
al/su
sp
ecte
d s
elf
-
infl
icte
d h
arm
meeti
ng
SI
cri
teri
a
Co
nfi
den
tial in
form
ati
on
leak/i
nfo
rmati
on
go
ve
rna
nce
bre
ach
meeti
ng
SI c
rite
ria
Dis
rup
tiv
e/ ag
gre
ss
ive
/ vio
len
t
beh
avio
ur
meeti
ng
SI c
rite
ria
Su
bsta
nce
mis
us
e w
hilst
inp
ati
en
t m
eeti
ng
SI c
rite
ria
To
tal
AMH Community - Norris Green Hub 1 1
AMH Community Sefton 1 1
AMH Community Windsor House CMHT 1 1
Arundel House CMHT 1 1
Community AMH Service 1 1
CRHT Community 1 1
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 189
Number of incidents reported
Early Intervention Team 1 1
Early Intervention Team Sefton and Kirkby 1 1 2
FIRT 1 1 2
FIRT Community Services 1 1
Forensic Integrated Resource Team - Community Services 1 1
Forensic Integrated Resource team (FIRT) 1 1
Forensic Integrated Resource Team Community Services 1 1
Forensic Integrated Resource Team FIRT Community Services 2 2
Hesketh Centre 1 1
Homeless Outreach Team 1 1
Moss House 1 1
Moss House CMHT 1 1
North Liverpool CMHT 1 1
Park CMHT 1 1
Park Lodge 2 2
Scott Clinic – FIRT 1 1
Scott Clinic MSU 1 1
South Sefton CMHT Adult 2 2
South Sefton CMHT Adult (SSNC) 1 1
North Sefton 1 1
Total 21 1 4 6 32
Reporting incidents and learning from when things go wrong
The service managed patient safety incidents well. Staff recognised incidents and reported them
appropriately. Managers investigated incidents and shared lessons learned with the whole team
and the wider service. The service provided staff with incident newsletters monthly. The Oxford
model (a tool used to provide focus and consistency) was used to take forward lessons learnt from
serious untoward incidents or complaints, and share the learning with staff and partner
organisations to help prevent them reoccurring.
The trust had a policy in relation to duty of candour.
Local division safety huddle meeting minutes confirmed that staff discussed incidents, complaints
and compliments. During the meetings, they looked at themes and shared good practice.
Staff received quality practice alerts, which included important health and safety information that
could impact on working procedures or be potential workplace hazards.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 190
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 two ‘prevention of future death’ reports sent to the trust for a
response. A third report involved a patient who died whilst in the trust’s care, but the trust was not
directly asked for a response. One of the prevention of future deaths reports related to this core
service, details of which can be found below.
Regulation 28: Report to prevent future deaths
The coroner issued a report in June 2018 in conclusion of an inquest were a patient took their own
life.
The Coroner’s concerns were:
A more co-ordinated approach from the mental health services is required when a patient is
being transferred from one NHS trust to another. In this case is the patient had still been on a
Care Programme Approach (CPA) there would have been a direct referral from service to
service rather than through the GP but because he was taken off the programme, the referral
was made through the GP. This has delayed the intervention and the prevented effective
information exchange on a patient who was already subject to secondary care services. In
effect, this resulted in the patient having no intervention for a number of months.
The following learning / recommendations were given by the trust:
Mersey Care NHS Foundation Trust (MCFT) and the other trust that was involved both agreed to
separately review their policies whilst ensuring that staff are clear on the processes that should be
adopted when transferring patients from one organisation to another.
The trust had since amended their policy to include the recommendations from the regulation 28
report. They have also shared their new policy with the other trust.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 191
Is the service effective?
Assessment of needs and planning of care
Staff assessed the physical and mental health of all patients on admission. They developed
individual care plans and updated them when needed. We viewed 19 comprehensive patient care
and treatment records.
Best practice in treatment and care
Patients were not always receiving the treatment they needed. There were long waiting times for
psychological intervention with a clinical psychologist, and staff were not providing psychological
interventions. Maximum wait times for psychological assessment were between 16 and 37 weeks
and for psychological intervention were between 60 and 66 weeks across the three locations.
Veterans and patients on stepped up care were given priority appointments for assessment for
treatment and intervention. The trust was aware of the waiting times and were taking steps to
address them by training staff in psychological interventions However, the length of the wait times
was highlighted in our previous inspection report published in October 2015. This meant that the
trust had not taken effective action to reduce waiting times during the three years prior to the
current inspection.
The service provided smoking cessation at North Sefton team and held groups to support patients.
They held depot clinics and monitored patients on lithium and clozapine, co working with GPs to
ensure patients received the checks and monitoring required. Staff used ‘Health of the Nation
Outcome Scales’ to measure the health and social functioning of people with severe mental
illness, and the Liverpool University Neuroleptic Side-Effect Rating Scales (LUNSERS) to track
side-effects of antipsychotics.
The service had good links with local authorities and work together to determine support packages
for patients such as home carers.
Staff participated in clinical audit, benchmarking and quality improvement initiatives. The service
had linked up with another trust to look at stepped up care benchmarking.
This core service participated in 22 clinical audits as part of their clinical audit programme 2017 –
2018.
Audit name Audit scope Audit type Date
completed Key actions following the audit
Physical
Health
Schizophrenia
Audit
(Community) -
2018/19
Local
Division Clinical 17/07/2018
Community Action Plan: 1. Community
Physical Health Dashboard to be
completed by the end of September to
inform us of our performance ahead of the
future audit and improve the performance
for consistency across the board. 2. Repeat
the internal audit whilst awaiting the
performance dashboard as a measure to
our ongoing performance for Q23. 3.Target
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 192
Audit name Audit scope Audit type Date
completed Key actions following the audit
the key teams that have produced fewer
results and work out local actions to
improve their outcomes 4. Continue to
support teams to understand the
importance of the physical health and
promote the completion of the APHC which
is also supported by the Community
Physical health nurses and Assistant
Practitioners.5. The local division will
continue to support the priority of this
agenda at all levels
CPA/Non CPA
Care Planning
Q2 (July 2017
to September
2017)
Local
Division Clinical 03/10/2017
These results have been discussed within
the teams and remedial action plans in
development.
Dual
Diagnosis
Audit Report
Q2
Local
Division Clinical
Action taken last year was to identify a Dual
Diagnosis Lead. The actions taken to date
are: Cascading the audit and its findings to
ward managers. The provision of support to
ward teams from psychology and
psychology assistants. Identifying the
clinical training requirements to support
ward staff with dual diagnosis.
CPA/Non CPA
Care Planning
Q3 (October
2017 to
December
2017)
Local
Division Clinical 06/02/2018
CPA Action Plan:
1. Share the findings of the audit with all
respective Community managers and
Clinical Leads. 2. Develop a Supervision
case audit template for Team Managers to
use with Care-Co-ordinators. 3. Community
caseload review to include CPA caseload.
4. Re-Audit the CPA Standards to monitor
progress
Health
Records Audit
Secure,
Local,SpLD
and LCH
Sefton
Locality
Clinical 14/12/2017
Each Division has a breakdown of data
relating to their own area. The emphasis for
action and improvement is
countersignature of entries by staff that
cannot authorise a clinical note. There is a
review of the electronic patient records
systems in use to review how automation
can improve compliance.
Dual
Diagnosis
Audit Report
Q3
Local
Division Clinical 11/01/2018
1. Cascade audit and its findings to ward
managers within the Local Division paying
specific attention to Standard 3. 2.
Psychology and assistants to support
wards via staff and service user education
and support group MDT's. 3. Identify any
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 193
Audit name Audit scope Audit type Date
completed Key actions following the audit
clinical training requirements to support
ward staff with dual diagnosis.
Consent to
Medical
Treatment
Audit
Local
Division Clinical 28/02/2018
The following actions have been taken:
• Update referring consultants on the
importance of ensuring all parts of the ECT
paperwork are complete
• Review ECT paperwork to ensure that
unnecessary data in not being requested
• Ensure that RiO system properly records
the consent process for ECT
MARAC Audit
Report
Local
Division Clinical 09/04/2018
Audit Findings have been shared with the
Safeguarding Team and relevant
Safeguarding committees. Action Plan
completed: No actions required for
Standard 2 as alerts would only be placed
on patients who are currently open to
Mersey Care and where applicable. Not all
cases heard at MARAC are given any
MARAC actions.
National
Clinical Audit
of Psychosis
Local,
Secure and
SpLD
Divisions
Clinical 13/04/2018
Recommendation 1 (by the Royal College
of Psychiatrists)
Ensure that all people with psychosis:
have at least an annual assessment of
cardiovascular risk (using the current
version of Q-Risk) receive appropriate
interventions informed by the results of this
assessment have the results of this
assessment and the details of interventions
offered recorded in their case record.
Recommendation 2
Ensure that all people with psychosis are
offered CBTp and family interventions, by:
deploying sufficient numbers of trained
staff who can deliver these intervention
making sure that staff and clinical teams
are aware of how and when to refer people
for these treatments. Recommendation 3
Ensure that all people with psychosis: are
given written or online information about
the antipsychotic medication they are
prescribed are involved in the prescribing
decision, including having a documented
discussion about benefits and adverse
effects of the medication. Recommendation
4
Ensure that all people with psychosis who
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 194
Audit name Audit scope Audit type Date
completed Key actions following the audit
are unable to attend mainstream education,
training or work, are offered alternative
educational or occupational activities
according to their individual needs; and that
interventions offered are documented in
their care plan. Recommendation 5
An Annual Summary of Care should be
recorded for each patient in the digital care
record. This should: include information on
medication history, therapies offered and
physical health monitoring/interventions be
updated annually be shared with the patient
and their primary care
team. Recommendation 6
NHS Digital, NWIS, Commissioners, Trusts
and Health Boards should work together to
put in place key indicators for which data
can easily be collected, perhaps using an
Annual Summary of Care (see
Recommendation 5,above). This work
should be informed by the NCAP results
and the experience of the NCAP team.
National EIT
Audit
Local
Division Clinical 04/05/2018
The Royal College of Psychiatrists advise
that to be rated 'top performing' overall, a
team will be rated: Top Performing' in the
effective treatment domain and the timely
access domain. 'Performing well' or higher
in the well-managed service domain.
Dual
Diagnosis
Audit Report
Q4
Local
Division Clinical 18/05/2018
1. Monitor BiT to identify service users with
a dual diagnosis to highlight to ward
managers as to where a dual diagnosis
care plan hasn’t been formulated
2. To ensure dual diagnosis care planning
is included in the 1:1 named nurse
proforma being developed
3. Support and advice will be offered with
regards to those with dual diagnosis needs
CPA/Non CPA
Care Planning
Q4 (January
2018 to March
2018)
Local
Division Clinical 23/05/2018
These results have been discussed within
the teams and Action Plan has been
formulated: CPA: 1. Share the findings of
the CPA Audit with all respective
Community Team Managers and Clinical
leads.
2. Present the Action Plan to the
Community Managers at the Joint
Community manager’s forum.
3. Within the Structure of supervision carry
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 195
Audit name Audit scope Audit type Date
completed Key actions following the audit
out a documentation review and audit of at
least 1 patient record against the CPA
standards for each practitioner.
4. Through Pace and supervision ensure all
Community Practitioners are aware of the
CPA audit standards in respect of Clinical
Documentation.
5. Re-audit the CPA standards to monitor
progress
Non CPA:1. Share the audit findings with
the Clinical Leads and ensure that they are
circulated across the Community
Consultant Workforce.
2. Circulate the Audit standards to all
Community team members.
3. Re-audit against the agreed standards to
monitor progress
4. Monitor the local impact of RIO on
clinical recording.
Datix
Incidents
Audit Report
Local
Division Clinical 18/06/2018
These results have been discussed within
the teams and remedial action plans in
development
DNA Audit
Report
Local
Division Clinical 06/07/2018
These results have been discussed within
the teams and remedial action plans in
development.
Audit of 7
Days Follow
Up by North
Liverpool
CMHT
following
Inpatient
Admission
Local
Division Clinical 08/09/2017
The CMHT has performed well in this audit
and should be commended for the
promptness with which patients were
followed up. It would be interesting to audit
all 105 discharges from the CMHT to see if
anyone was not followed up and what the
reasons were. Pan to re-audit in 12 months'
time.
Physical
Health
Assessment
in patients
with Severe
Mental Illness
Local
Division Clinical 04/10/2017
Documentation is only first step increasing
use of Lester tool. How can we reduce
people's risks? Weight management
interventions. Close monitoring of
antipsychotics & switch. Very brief smoking
interventions. Closer collaboration with
primary care. Access to EMIS records for
clinical and audit purposes.
Antipsychotic
polypharmacy
re-audit
Local
Division Clinical 06/12/2017
Cases where total dose is over 100% of
BNF approved maximum should be closely
reviewed with each individual patient.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 196
Audit name Audit scope Audit type Date
completed Key actions following the audit
There needs to be clear discussion
identifying risks associated with
polypharmacy or a standardised form with
specific risks highlighted. To make sure all
patients with HDAT have their consent
form, risk assessment and monitoring sheet
filled in and documented in ePEX. Patients
on antipsychotic polypharmacy to be
reviewed regularly in terms of reducing
their does or stopping one of their
antipsychotic medications if needed.
Frequency of review is recommended to
depend on each patient however, we
wonder whether this should be
standardised? Re-audit with more focus on
quality of documentation.
An audit to
assess the
impact of an
SMS
Appointment
Reminder
Service on
'DNA' rates
across
CMHTs in
Mersey Care
NHS
Foundation
Trust
Local
Division Clinical 21/03/2018
Reasons for failure to receive reminders
should be investigated. Is there a way to
improve mobile phone records of patients?
Could the wording of the reminder affect
how patients feel about attending?
Clinic Letters
Audit
Local
Division Clinical 05/06/2018
Ensure PBR care cluster is quoted with
diagnosis when writing Non-CPA statement
of care letters. Briefing session for all junior
doctors on the guidelines of what to include
in clinic letters and get taught PBR
clustering. Always ensure a patient risk is
stated. Sufficient for it to be quoted either in
the body of the letter or the MSE.
Qualifying risk, such as not suicidal, is also
sufficient and can be of more value. Try to
ensure letters are dictated before the end
of the day. In addition, to check and alter
letters on ePEX as opposed to printing and
being altered by hand. To re-audit in 4-6
months’ time on a larger scale and consider
including physical health and Lester tool.
Invite other teams to do the same audit to
compare how the different CMHTs are
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 197
Audit name Audit scope Audit type Date
completed Key actions following the audit
doing. When staff changeover takes place -
Dr leaves a written handover of outstanding
letters with their consultant and secretary.
Audit of Post
Discharge
Follow-Up by
Southport
CMHT
Local
Division Clinical 05/06/2018
The CMHT has performed well in this audit
and should be commended for the
promptness with which patients were
followed up. It would be interesting to audit
all discharges from the CMHT and check
further compliance. Re-audit in 12 months.
A
retrospective
audit of
electronic
recording of
metabolic
parameters of
patients on
clozapine
Local
Division Clinical 26/06/2018
The staff involved in the health and well-
being clinics, care co-ordinators and other
clinicians involved in care of these patients
will receive feedback of the audit findings. It
was possible to break the findings down
into specific clinics but it was chosen not to
do this and instead use this as a snap shot
of practice for now so that particular teams
do not feel marginalised or criticised. To
address the problem, it was agreed that the
standardised form be reviewed for
measurement of parameters of metabolic
syndrome used in all patients on clozapine
in the service. These forms were to be
completed in each patient's electronic
medical notes. A Re-audit will capture
performance with any improvement or
decline in recording of data. In future, this
will look at individual HWB clinics
benchmarked against other services
nationally, and the total national sample.
Education of staff in clinics regarding the
individual parameters and why these are
important. Distribute a questionnaire
amongst HWB staff to highlight knowledge
gaps i.e. why are you taking obs? What do
you do with abnormal obs? Why is GASS
important?etc. Straightforward educational
and practical interventions can lead to
significant improvements in practice, and
should serve to continue to improve
practice in this area. Modern matron will
organise Educational sessions for teams
across the clinics. It was also considered
that a similar system for monitoring be
implemented in due course for all patients
on second-generation antipsychotics.
Schizophrenia Local Clinical 29/08/2017 Development a new community physical
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 198
Audit name Audit scope Audit type Date
completed Key actions following the audit
- Local
Division
Community
CPA Physical
Healthcare
Division health pathway with improved specialist
staff to support access and record keeping
systems and an intranet portal developed
to support the physical health pathway.
Skilled staff to deliver care
Managers made sure they had staff with a range of skills needed to provide high quality care.
They supported staff with appraisals, supervision, opportunities to update and further develop their
skills.
The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, the overall appraisal
rates for non-medical staff within this core service was 79%.
Twenty-one of the 40 teams were failing to achieve the trust’s appraisal target with Moss CMHT
reporting the lowest with 29%.
Team name
Total number
of permanent
non-medical
staff requiring
an appraisal
Total number of
permanent non-
medical staff who
have had an
appraisal
%
appraisal
s
350 L9 Local Psychology (Z2AB03) 5 5 100%
350 L9 Physical Health (AEB225) 5 5 100%
350 L9 Merseyside Probation Team (SCF631) 1 1 100%
350 L9 Catering Rathbone (Z2BD40) 5 5 100%
350 L9 Southport Acute Care Team (Z1NW09) 19 19 100%
350 L9 Cheshire Probation (SCF630) 2 2 100%
350 L9 Local Senior Management (Z1NW65) 4 4 100%
350 L9 Community Psychology S&K (Z2AB25) 16 16 100%
350 L9 North Liverpool Neighbourhood (Z1AH33) 2 2 100%
350 L9 Early Intervention (Z1NW14) 16 16 100%
350 L9 Smoking Cessation (AEB217) 1 1 100%
350 L9 Infection Control (AEB450) 3 3 100%
350 L9 Stafford House PIPE (SCF632) 1 1 100%
350 L9 Liverpool Neighbourhood 2 (Z1NW77) 1 1 100%
350 L9 Kirkby CMHT (Z1AH34) 11 11 100%
350 L9 South Sefton Neighbourhood (Z1AH38) 45 44 98%
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 199
Team name
Total number
of permanent
non-medical
staff requiring
an appraisal
Total number of
permanent non-
medical staff who
have had an
appraisal
%
appraisal
s
350 L9 Baird House Community Hub (Z1AH28) 41 40 98%
350 L9 Park Lodge(Z1AH30) 39 37 95%
350 L9 FMA's Southport (Z2CN65) 19 18 95%
350 L9 CMHT North Liverpool & Kirkby (Z1AD18) 12 11 92%
350 L9 Eating Disorders (Z1EH95) 11 10 91%
350 L9 Ambitions Sefton (Z1LK60) 70 63 90%
350 L9 Community Mental Health Team Ns (Z1NW07) 18 16 89%
350 L9 Alt Ward (Z1AB71) 24 21 88%
350 L9 Talk Liverpool (Z2AB40) 102 89 87%
350 L9 Community Psychology Liverpool (Z2AB30) 14 12 86%
350 L9 Brunswick Ward (Z1AE11) 29 24 83%
350 L9 Albert Ward (Z1AB11) 22 17 77%
350 L9 Psychotherapy (Z1EH90) 25 19 76%
350 L9 Liv Neighbourhood 1 (Z1NW75) 4 3 75%
350 L9 Social Inclusion & Participation Team (Z3DN13) 37 27 73%
350 L9 FMA's Norris Green (Z1SH15) 3 2 67%
350 L9 Catering Transport (Z2BD75) 2 1 50%
350 L9 Clinical Audit (AHB855) 2 1 50%
350 L9 Local Division Admin (Z1AD02) 130 61 47%
350 L9 Nurse Directorate Management (AEB200) 13 6 46%
350 L9 Mersey Care Community Assessment Team - Sefton
CS (Z4CH15) 10 4 40%
350 L9 S&K Neighbourhood 1 (Z1NW76) 3 1 33%
350 L9 S&K Acute Care (Z1VA11) 3 1 33%
350 L9 Moss House (Z1AH29) 14 4 29%
350 L9 Deputy Medical Director (AEA202) 2 0 0%
350 L9 Community Clinic Team (Z1AD10) 3 0 0%
350 L9 Infection Control - Sefton CS (Z4CH46) 1 0 0%
Core service total 790 624 79%
Trust wide 5565 4780 86%
The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, there was no data
pertaining to medical staff.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 200
Between 1 August 2017 and 31 July 2018, the average rate across all 66 teams in this core
service was 50% of the trust’s target.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different
ways, it’s important to understand the data they provide.
Team name
Clinical supervision
sessions required
Clinical
supervision
delivered
Clinical
supervision rate
(%)
350 L9 S&K Neighbourhood 1 (Z1NW76) 10 11 110%
350 L9 Stafford House PIPE (SCF632) 3 3 100%
351 L9 Brook Place (Z1HJ10) 21 21 100%
350 L9 Early Intervention (Z1NW14) 39 39 100%
350 L9 South Sefton Neighbourhood (Z1AH38)
98 98 100%
351 L9 Community Mental Health Team Ns (Z1NW07)
15 15 100%
350 L9 Merseyside Probation Team (SCF631) 3 3 100%
350 L9 MBT ASPD (SCF580) 3 3 100%
350 L9 Brook Place (Z1HJ10) 41 40 98%
350 L9 Criminal Justice Liaison Team (Z1AF95)
75 73 97%
351 L9 South Sefton Neighbourhood (Z1AH38)
35 34 97%
350 L9 Eating Disorders (Z1EH95) 26 25 96%
350 L9 Dish Infrastructure (Z1BN45) 83 78 94%
350 L9 Southport Acute Care Team (Z1NW09)
49 46 94%
351 L9 Criminal Justice Liaison Team (Z1AF95)
38 35 92%
350 L9 Community Mental Health Team Ns (Z1NW07)
36 33 92%
350 L9 Brunswick Ward (Z1AE11) 29 26 90%
350 L9 Baird House Community Hub (Z1AH28)
100 89 89%
350 L9 Local Senior Management (Z1NW65) 17 15 88%
350 L9 Kirkby CMHT (Z1AH34) 15 13 87%
350 L9 Cheshire Probation (SCF630) 7 6 86%
350 L9 Local Services CQUIN (Z1NW90) 45 38 84%
350 L9 Liv Neighbourhood 1 (Z1NW75) 12 10 83%
350 L9 Psychotherapy (Z1EH90) 77 60 78%
350 L9 Albert Ward (Z1AB11) 26 20 77%
350 L9 Moss CMHT (Z1AH29) 37 28 76%
350 L9 Rathbone Rehab Centre (Z1BG11) 28 21 75%
350 L9 Liverpool Neighbourhood 2 (Z1NW77) 3 2 67%
Unknown 549 356 65%
350 L9 Community Psychology Liverpool (Z2AB30)
34 22 65%
350 L9 Access (Z1NW13) 42 26 62%
350 L9 Community Clinic Team (Z1AD10) 5 3 60%
350 L9 Community Psychology S&K (Z2AB25)
51 28 55%
350 L9 Liverpool EI South/Central (Z1NW11) 56 28 50%
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 201
Team name Clinical supervision
sessions required
Clinical
supervision
delivered
Clinical
supervision rate
(%)
350 L9 Capital Project Managers (APA500) 2 1 50%
350 L9 Local Psychology (Z2AB03) 8 4 50%
351 L9 Kirkby CMHT (Z1AH34) 12 6 50%
350 L9 Local Risk & Governance (Z1NW08) 4 2 50%
350 L9 Alt Ward (Z1AB71) 27 13 48%
350 L9 Norris Green Community Hub (Z1AH30)
93 43 46%
350 L9 CMHT North Liverpool & Kirkby (Z1AD18)
33 14 42%
350 L9 Discharge to Access (Z1NW45) 5 2 40%
350 L9 S&K Acute Care (Z1VA11) 8 3 38%
350 L9 Infection Control (AEB450) 8 3 38%
350 L9 Perinatal Liverpool (Z1VA01) 21 7 33%
350 L9 Physical Health (AEB225) 9 3 33%
350 L9 North Liverpool Neighbourhood (Z1AH33)
6 2 33%
350 L9 Police Project (SCF927) 4 1 25%
350 L9 Nurse Directorate Management (AEB200)
27 2 7%
350 L9 Health & Wellbeing (ALB400) 42 3 7%
350 L9 Bank AHP & Social Work (AEB489) 68 3 4%
350 L9 Bank Nurses (AEB480) 296 8 3%
351 L9 Sefton Bank Staff Control (Z4CH80) 846 14 2%
350 L9 Infection Control - Sefton CS (Z4CH46)
2 0 0%
350 L9 Mersey Care Community Assessment Team - Sefton CS (Z4CH15)
30 0 0%
350 L9 Learning & Development (AHP500) 9 0 0%
350 L9 Legal Services (Z2GN10) 9 0 0%
350 L9 Deputy Medical Director (AEA202) 6 0 0%
350 L9 Acc LD Nursing Programme (AHP515) 3 0 0%
350 L9 Liverpool Community Development Service (Z2AB60)
12 0 0%
Core service total 3298 1482 45%
Trust Total 15334 4947 32%
However, during inspection we checked the appraisal and supervision figures and identified that
improvements had been made. Moss House community mental health team had improved with
71% compliance. Park Lodge and North Sefton were 100% compliant.
Staff told us supervision was happening every four weeks but they also received unplanned
supervision through daily tasks such as at multi-disciplinary meetings, team meetings and peer
supervision. Psychologists told us they had a weekly schedule for supervision.
Information received from the trust informed us that supervision rates at the time of inspection
were 94% compliance for Park Lodge, 76% for Moss House and North Sefton was 100 %
compliant.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 202
Multidisciplinary 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. Staff held regular and effective
multidisciplinary meetings, attended by doctors, nurses, social workers, mental health
practitioners, advanced practitioners, occupational therapists, support staff and psychologists. At
the meetings, staff shared information about patients on stepped up care.
Patient records and observations confirmed effective working relationships with other relevant
teams within the organisation, for example, A&E liaison and inpatient wards. The teams had
effective working relationships with teams outside the organisation (for example, GPs, police and
voluntary organisations).
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental
Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.
Staff were trained in and had a good understanding of the Mental Health Act and the Code of
Practice. Approved Mental Health Professionals were co-located within the teams we visited.
Staff had easy access to administrative support and legal advice on implementation of the Mental
Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
The trust had relevant policies and procedures and staff had easy access to them.
Over the three teams, there were 46 patients subject to community treatment orders. A community
treatment order provides a framework for the management of patient care in the community and
gives the responsible clinician the power to recall a patient back to hospital for treatment if
necessary (Mental Health Act Code of Practice 29.6).
Staff explained to patients their rights under the Mental Health Act in relation to the community
treatment orders and repeated these as required. Staff recorded that they had reviewed the
community treatment orders and the Mental Health Act administrator sent the teams reminders of
when this was needed. The Mental Health Act administrator reminded staff when they needed to
be reviewed and informed staff of when the extension was due. Park Lodge also maintained their
own records additional to the Mental Health Act administrator.
Approved Mental Health Professional reports were not always accessible on the trust’s
computerised system unless a patient had recently been an inpatient on the acute wards. The
Local Authority kept records within their own recording system.
The Mental Health Act administrator did regular audits to ensure the Mental Health Act was
applied correctly.
As of 31 May 2018, 77% of the workforce had received training in the Mental Health Act. The trust
stated that this training is mandatory for all core services for inpatient and all community staff and
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 203
renewed every three years. At the time of inspection Moss House had a completion rate of 67%,
Park Lodge 91% and North Sefton 100% for Mental Health Act training.
Good practice in applying the Mental Capacity Act
Staff supported patients to make decisions on their care for themselves. They understood the trust
policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly.
Staff had a good understanding of the Mental Capacity Act and the provider had a policy that staff
were aware of.
Patient records confirmed that staff gave patients every possible assistance to make a specific
decision for themselves before they assumed that the patient lacked the mental capacity to make
it. For patients who might have impaired mental capacity, staff assessed and recorded capacity to
consent appropriately. They did this on a decision-specific basis regarding significant decisions.
As of 31 May 2018, 77% of the workforce had received training in the Mental Capacity Act. The
trust stated that this training is mandatory for all core services for inpatient and all community staff
and renewed every three years. At the time of inspection, Moss House had a completion rate of
67%, Park Lodge 91% and North Sefton 100% for Mental Capacity Act training.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 204
Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity,
and supported their individual needs. Patients told us they felt supported and could speak to their
care coordinator about anything. We observed positive staff attitudes when interacting with
patients and meetings took place in private meeting rooms.
Patients were discussed respectfully at multidisciplinary meetings and patient information was
stored confidentially.
Involvement in care
Staff involved patients and those close to them in decisions about their care, treatment and
changes to the service.
Involvement of patients
Patients we spoke to told us they felt included in decisions about their care and treatment.
North Sefton had a women’s only group, run by a patient. It had been set up because of patients
feeling that other activities and groups were more male focussed.
Staff enabled patients to give feedback on the service using surveys. Outcomes of the surveys
were displayed in waiting rooms.
Patients, families and carers were encouraged to take part in events run by the trust. Staff directed
them to the trust website for further information.
Involvement of families and carers
The service encouraged families and carers to be involved in patients’ care and treatment (with
patients’ consent). Carers told us they felt involved.
A triangle of care assessment tool was used to monitor working relationships between patient,
mental health professionals and carers.
Patient advice and liaison service was available for patients, carers and families to assist in
resolving concerns or to provide positive feedback.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 205
Is the service responsive?
Access and waiting times
People could access the service closest to their home when they needed it. There were no waiting
lists for patient access to community mental health services, assessments and psychiatry.
The trust has identified the below services in the table as measured on ‘referral to initial
assessment’ and ‘assessment to treatment’.
The core service met the referral to assessment target in all but four of the targets listed. Access
team reported 64 days for the time from referral to initial assessment; this is one of the highest out
of all the teams. In addition, Sedgwick PL followed with 38 days, ADHD team with 35 days and
Single Point of Access Liverpool-Sefton with 34 days.
The core service met the assessment to treatment target in all of the targets listed (where
applicable).
Name of team Service Type
Days from referral to initial assessment
Days from referral to treatment
Target Is this target
national or
local?
Actual (median)
Target Is this target
national or
local?
Actual (median)
A&E Sefton Mental Illness Acute
30 Days Local 0
Access Team Mental Illness Acute
30 Days Local 64
ACT - N.Sefton Mental Illness Acute
30 Days Local 10
Adult Liaison Aintree Mental Illness Acute
30 Days Local 1
Adult Liaison S'port Mental Illness Acute
30 Days Local 1
Arundel NH Mental Illness Acute
30 Days Local 0
Assess/Immediate Car Mental Illness Acute
30 Days Local 32
CJL Scheme Mental Illness Acute
30 Days Local 0
EIS C&S Liverpool Mental Illness Acute
30 Days Local 14 18 Weeks National 14 Days
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 206
Name of team Service Type
Days from referral to initial assessment
Days from referral to treatment
Target Is this target
national or
local?
Actual (median)
Target Is this target
national or
local?
Actual (median)
EIS Kirkby Mental Illness Acute
30 Days Local 3 18 Weeks National 10 Days
EIS North Sefton Mental Illness Acute
30 Days Local 5 18 Weeks National 12 Days
EIS South Sefton Mental Illness Acute
30 Days Local 6.5 18 Weeks National 11.5 Days
EMI Liaison Aintree Mental Illness Acute
30 Days Local 1
Homelessness O'reach Mental Illness Acute
30 Days Local 9
Liverpool Liaison Mental Illness Acute
30 Days Local 0
PCMHLT Mental Illness Acute
30 Days Local 1
PD Case Mgt Team Mental Illness Acute
30 Days Local 7
Perinatal MH Team Mental Illness Acute
30 Days Local 11
PICU Mental Illness Acute
30 Days Local 7
Sedgwick (PL) Mental Illness Acute
30 Days Local 38
Tabani Mental Illness Acute
30 Days Local 5.5
Triage Car Mental Illness Acute
30 Days Local 0
ADHD Team Adult Mental Illness
30 Days Local 35
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 207
Name of team Service Type
Days from referral to initial assessment
Days from referral to treatment
Target Is this target
national or
local?
Actual (median)
Target Is this target
national or
local?
Actual (median)
Adult Community Arundel
Adult Mental Illness
30 Days Local 6
19
Adult Community Kirkby
Adult Mental Illness
30 Days Local 3
12.5
Adult Community Moss House
Adult Mental Illness
30 Days Local 3.5
5
Adult Community Norris Green
Adult Mental Illness
30 Days Local 8
12
Adult Community North Sefton
Adult Mental Illness
30 Days Local 2
8
Adult Community Park Lodge
Adult Mental Illness
30 Days Local 6.5
11.5
Adult Community South Sefton
Adult Mental Illness
30 Days Local 3
5.5
Adult Community Windsor
Adult Mental Illness
30 Days Local 4
7
Aspergers Service Liverpool
Adult Mental Illness
30 Days Local 24
43.5
Aspergers Service Sefton
Adult Mental Illness
30 Days Local 28
42
Bed Management Team Adult Mental Illness
30 Days Local 1
Criminal Justice Liaison Team
Adult Mental Illness
30 Days Local 0
1
DISH Adult Mental Illness
30 Days Local 14
21.5
Early Intervention Liverpool
Adult Mental Illness
30 Days Local 20
25
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 208
Name of team Service Type
Days from referral to initial assessment
Days from referral to treatment
Target Is this target
national or
local?
Actual (median)
Target Is this target
national or
local?
Actual (median)
Early Intervention North Sefton
Adult Mental Illness
30 Days Local 7
12
Early Intervention South Sefton-Kirkby
Adult Mental Illness
30 Days Local 13
13
Health & Wellbeing Broadoak
Adult Mental Illness
30 Days Local 28
28
Health & Wellbeing Clockview
Adult Mental Illness
30 Days Local 1.5
14
Health & Wellbeing ECT Adult Mental Illness
30 Days Local 0
0
Health & Wellbeing Hesketh
Adult Mental Illness
30 Days Local 5
29
Homeless Outreach Team
Adult Mental Illness
30 Days Local 6.5
22.5
Personality Disorder HUB
Adult Mental Illness
30 Days Local 14
23.5
Single Point of Access Liverpool-Sefton
Adult Mental Illness
30 Days Local 34
31
Single Point of Access North Sefton
Adult Mental Illness
30 Days Local 11
26.5
Triage Car Adult Mental Illness
30 Days Local 0
7
Personality Disorder HUB
Adult Mental Illness
30 Days Local 14
23.5
FOS Team (urgent) Community
7 days
10 days
Fos Team (Non-urgent) Community
25 days
31 days
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 209
The facilities promote comfort, dignity and privacy
The design, layout, and furnishings of the service supported treatment, privacy and dignity at
North Sefton.
Meeting rooms were clean, had good furnishings and promoted privacy and dignity. However, at
Park Lodge conversations could be overheard from the clinic room by other staff and one meeting
room was out of use due to infestation.
Patients’ engagement with the wider community
Staff supported patients with activities outside the service, such as work, education and family
relationships. Patients were directed to other services when required. Information leaflets and
notice boards in waiting rooms gave detail of other services and groups available such as walking,
creative writing, film, comedy and cycling groups.
The service referred patients, carers and families to the ‘life rooms’. The ‘life rooms’ was a trust
service that provided patients with advice on returning to work, money management, housing and
community services. The ‘life rooms’ held physical health and mental wellbeing sessions and
provided patients with access to pathway advisors, information technology and education advice
and support.
Meeting the needs of all people who use the service
The service was not accessible to all who needed it. We found concerns regarding wheelchair
access to Park Lodge and Moss house including the toilet facility at Moss House not being fit for
purpose for wheelchair users. Managers and staff agreed with our concerns when we raised them
and have put immediate measures in place to rectify some of the access concerns. The trust was
developing a business case to remedy the physical environment for wheelchair users.
The trust accepted that the building at Park Lodge was not fit for purpose. It was already on the
trust risk register. The trust confirmed they were taking steps to rectify it.
Staff helped patients with communication, advocacy and cultural support. Each location was close
to local transport links and support and advice leaflets were available in a range of languages.
Carers told us they felt frustrated about the use of locums and lack of continuity.
Listening to and learning from concerns and complaints
The service treated concerns and complaints seriously, investigated them and learned lessons
from the results, and shared these with all staff through email, supervision, team meetings,
multidisciplinary meetings and weekly safety meetings. Patients we spoke with told us they knew
how to complain.
This core service received 67 complaints between 1 August 2017 and 31 July 2018. Thirteen
(19%) of these were upheld, 14 (21%) were partially upheld and 18 (27%) were not upheld. None
were referred to the Ombudsman.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 210
Team Name
Fu
lly u
ph
eld
No
t u
ph
eld
Oth
er
(ple
as
e d
es
cri
be in
co
mm
en
ts c
olu
mn
)
Part
ially u
ph
eld
Un
der
inv
esti
gati
on
Wit
hd
raw
n
To
tal co
mp
lain
ts
Moss House CMHT 3 3 2 2 2
12
Southport CMHT
3 3 4 2
12
South Sefton CMHT Adult (SSNC) 3 2
1 3
9
ACCESS Team 1 1 1 2
5
North Liverpool CMHT
3
2
5
Park CMHT
1 1 1 2
5
Kirkby CMHT (Adult)
2
1
3
Arundel House CMHT
1
1
2
Early Intervention Team Sefton and Kirkby
2
2
Psychotherapy Service 1
1
2
South Sefton CMHT OP (SSNC) 2
2
Windsor House CMHT
1
1 2
Ambition Bootle 1
1
CMHT Crosby and Maghull
1
1
Early Interventions Team
1
1
Eating Disorders Services
1
1
N/A 1
1
North Liverpool OP CMHT 1
1
Grand Total 13 18 9 14 12 1 67
This core service received no compliments during the last 12 months from 1 August 2017 and 31
July 2018. However, during inspection we saw compliments that had been received in the form of
thank you and CQC comment cards.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 211
Is the service well led?
Leadership
Managers were visible in the service and were approachable for patients and staff.
The trust operated a ‘free up Friday’, where service managers invited senior managers to visit a
location and work a shift. Staff confirmed that senior managers had attended the locations within
the service.
Managers at all levels in the trust had the right skills, knowledge and abilities to perform their roles.
The managers demonstrated a good understanding of the service they managed and could
explain how the teams worked.
Staff told us that they knew who their divisional managers were and that they visited regularly.
A leadership programme was being used to support staff with development opportunities. Staff
confirmed they had accessed it.
Vision and strategy
The trust 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 trust vision and values were on display in communal areas of the locations and staff we spoke
to knew what they were.
Staff professional development objectives incorporated the trust’s vision and values.
Culture
Managers across the trust promoted a positive culture that supported and valued staff, creating a
sense of common purpose based on shared values.
Staff told us they felt respected and valued.
Staff had access to physical health and wellbeing support through the trust’s occupational health
service.
During the reporting period (1 August 2017 and 31 July 2018), there were no cases where staff
have been either suspended, placed under supervision or were moved to a different team.
Governance
The service had robust policies and procedures in place to promote safety including lone working,
infection prevention and control, reporting of incidents and learning from incidents. We saw that
patients were treated well and staff had built professional relationships with them. The service had
a clear framework that staff used at team meetings to ensure specific topics were being discussed
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 212
and promote consistency. It included safeguarding, serious incidents, lessons learnt, monthly
patient experience results, staffing levels, divisional priorities, complaints and compliments.
Staff understood arrangements for working with other teams both within the trust and externally, to
meet the needs of patients.
The trust provided a document detailing their 34 highest profile risks. Each of these has a current
risk score of 15 or higher. None related to this core service.
Management of risk, issues and performance
The trust had effective systems for identifying risks, planning to eliminate or reduce them, and
coping with both the expected and unexpected. Managers contributed to the trust’s risk register
and their concerns matched those on the risk register. For example, the building at Park Lodge
was on the trust risk register. Information was accessible and identified areas for improvement and
actions.
Surveillance meetings were taking place weekly to discuss and highlight concerns across the
division. Staff made notifications to external bodies when needed which included safeguarding
alerts to local authorities.
Information management
The trust collected, analysed, managed and used information to support all its activities, using
secure systems with security safeguards.
The service took part in 22 clinical audits including national audits which were in line with best
practice.
All staff working at the locations we visited had personal secure access to phones and computers.
Electronic systems were used to log and update patients’ individual care and treatment records
after all contact was made with patients, including following referrals to the local authority. This
was to ensure that the most up to date information was available for relevant staff. However,
during the migration from the previous electronic system, not all information had been transferred
over, causing difficulties for new staff that did not have access to the old system.
Engagement
The service had good links with external organisations including the local authority for support with
accommodation for patients.
Patients had been invited to take part on the interview panel when recruiting staff.
Managers and staff had access to feedback from patients and used it to make improvements,
such as giving families and carers the option to speak privately with staff when required and with
consent of the patient.
Learning, continuous improvement and innovation
Staff were encouraged to discuss improvement and innovative ideas.
Mersey Care NHS Foundation Trust evidence appendix: community-based mental health services for adults of working age Page 213
Staff had been supported to trial the use of a global positioning systems (GPS) when out in the
community. Staff informed us that work still needed to be done because the system was not
consistent in detailing real time location.
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 accreditations for this core service.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 214
Long stay/rehabilitation mental health wards for working age adults
Facts and data about this service
Location site name Ward name Number of beds Patient group (male,
female, mixed)
Walton Centre Brain Injuries Rehabilitation Ward 12 Mixed
Rathbone Rathbone Rehabilitation
Inpatients/Community Team 25 Mixed
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 215
Is the service safe?
Safe and clean care environments
Safety of the ward layout
All wards were safe, clean well equipped, well furnished, well maintained and fit for purpose. Staff
could clearly see all areas of the ward and knew about any ligature anchor points and actions to
mitigate risks to patients who might try to harm themselves.
Over the 12-month period from 1 August 2017 to 31 July 2018 there were no mixed sex
accommodation breaches within this core service.
There were ligature risks on two wards within this core service. The trust had undertaken recent
(from 1 January 2017 to 15 August 2018) ligature risk assessments at two wards.
One ward presented a high risk and the other a low level of ligature risk. The risks are due to
service users being in high risk areas like bathrooms, bedrooms and toilets unsupervised.
However, patients were risk assessed prior to admission, and the nature of the rehabilitation
service was to return the patient to the community, where ligature risks are difficult to overcome.
The Rathbone rehabilitation unit had both male and female patients, each having their own en-
suite bathroom. Male patients sleep on the upper floor of the unit, female patients have their
rooms on the ground floor. The unit met the Department of Health standards expected of a mixed-
sex accommodation. The brain injury rehabilitation unit also had both male and female patients, all
on the same floor, but the patient room areas were clearly defined and monitored to ensure that no
mixed-sex accommodation breaches would happen.
Maintenance, cleanliness and infection control
For the most recent Patient-led assessments of the care environment (PLACE) assessment
(2017) the locations scored similar or higher than the similar trusts for all four aspects overall (with
the exception of the dementia friendly category, as this was not assessed at Rathbone or the Brain
Injury Rehab ward (Sid Watkins unit).
Site name Core service(s) provided Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Rathbone Hospital
Community based mental health
services or adults of working age
Long say/rehabilitation mental
health wards for working age adults
Secure/forensic
Substance Misuse
Wards for people with LD or Autism
99.4% 97.7% - 100%
Brain injury
Rehabilitation (Sid
Watkins unit)
Long stay/rehabilitation mental
health wards for working age adults 99.1% 98.9% - 100%
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 216
Site name Core service(s) provided Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Trust overall 98.8% 97.3% 81.3% 89.9%
England average
(Mental health
and learning
disabilities)
98.0% 95.2% 84.8% 86.3%
Both units were very clean and tidy, with all areas inspected maintained at a high level of
cleanliness. Furniture was well maintained and of a standard that reflected the rehabilitation status
of the wards. Cleaning rosters were up to date. Each room in the service had a nurse call button
and all staff carried alarms. Inspection team members were supplied with alarms as a matter of
procedure.
Each bedroom was en-suite, and male and female areas were segregated. There was no reason
for a male patient to pass a female bedroom to access a toilet, or a female to pass a male
bedroom to access a bathroom.
Clinic room and equipment
Both the Rathbone site and the Sid Watkins site had a separate physical health room, including an
examination couch and machines to measure blood pressure and blood sugar monitoring
equipment. All equipment at both services had been recalibrated and checked prior to the
inspection. Emergency bags were present, both were routinely checked and had labels attached
regarding expiry dates of equipment within the bag. The Rathbone service was situated across
two floors, and both floors had an emergency bag. Oxygen cylinders were checked and found to
be well within expiry dates, with gauges showing full. Drug stocks and drug fridges were checked,
and found to be in order, with relevant checks carried out regularly. Ligature cutters were in
locations that were labelled, and accessible to staff.
Safe staffing
Nursing staff
The service had enough nursing and medical staff, who knew the patients and received basic
training to keep people safe from avoidable harm. Ward managers could bring in extra or covering
staff when needed. We saw that ward inductions were taking place for bank staff, as well as new
permanent staff to the ward. We saw no evidence that leave agreed under the Mental Health Act
was being cancelled, although staff did inform us that leave could be re-arranged depending on
ward circumstances. We were told that ward activities were not being cancelled, and patients told
us this during interviews.
The table below gives an overview of trust staffing levels. It provides data on substantive staff
numbers, vacancies and sickness, and use of bank and agency staff. This data was provided to us
by the trust in August 2018 and covers the period 1 August 2017 to 31 July 2018.
Definition
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 217
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff 31 July 2018 28.1 N/A
Total number of substantive staff leavers 01 August 2017–31 July 2018
2.7 N/A
Average WTE* leavers over 12 months (%) 01 August 2017–31 July 2018
9% 13%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) 31 July 2018 -3.8 N/A
Total vacancies overall (%) 31 July 2018 -6% 5%
Total permanent staff sickness overall (%)
Most recent month (31 July 2018)
9% 8%
01 August 2017–31 July 2018
6% 8%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) 31 July 2018 22.1 N/A
Establishment levels nursing assistants (WTE*) 31 July 2018 30.1 N/A
Number of vacancies, qualified nurses (WTE*) 31 July 2018 -1.4 N/A
Number of WTE vacancies nursing assistants 31 July 2018 0.3 N/A
Qualified nurse vacancy rate 31 July 2018 -6% 5%
Nursing assistant vacancy rate 31 July 2018
1% 5%
Bank and agency Use
Hours bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 01 August 2017–31
July 2018 3058 N/A
Hours filled by agency staff to cover sickness, absence or
vacancies (qualified nurses) 01 August 2017–31
July 2018 256 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (qualified nurses) 01 August 2017–31
July 2018 179 N/A
Hours filled by bank staff to cover sickness, absence or vacancies
(nursing assistants)
01 August 2017–31
July 2018 5259 N/A
Hours filled by agency staff to cover sickness, absence or
vacancies (nursing assistants)
01 August 2017–31
July 2018 1458 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (nursing assistants)
01 August 2017–31
July 2018 88 N/A
*Whole-time Equivalent / minus figures mean that the service is oversubscribed
This core service reported an overall vacancy rate of -6% over establishment for registered nurses
at 31 July 2018.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 218
This core service reported an overall vacancy rate of 1% for registered nursing assistants.
This core service has reported a vacancy rate for all staff of -6% over establishment as of 31July
2018.
Registered nurses Health care assistants Overall staff figures
Ward/Team
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Rathbone Rehab Centre -1.2 12.2 -9% 1.1 14.3 8% -1.1 32.1 -3%
Brain Injury Support -0.2 10.0 -2% -0.7 15.7 -5% -2.7 29.7 -9%
Core service total -1.4 22.1 -6% 0.3 30.1 1% -3.8 61.8 -6%
Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%
NB: All figures displayed are whole-time equivalents
Between 1 August 2017 and 31 July 2018, bank staff filled 3058 hours to cover sickness, absence
or vacancy for qualified nurses.
In the same period, agency staff covered 256 hours for qualified nurses. 179 hours were unable to
be filled by either bank or agency staff.
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Brain Injury
Unit 1629 961 97 33
Rehabilitation
Centre 1776 2097 159 147
Core service
total 3405 3058 256 179
Trust Total 242318 125599 64603`` 31532
Between 1 August 2017 and 31 July 2018, bank staff to cover sickness, absence or vacancy for
nursing assistants filled 5259 hours.
In the same period, agency staff covered 1458 hours. Eighty-eight hours were unable to be filled
by either bank or agency staff.
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by bank
or agency staff
Brain Injury
Unit 2561 2913 953 117
Rehabilitation
Centre 3296 2346 505 -29
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 219
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by bank
or agency staff
Core service
total 5858 5259 1458 88
Trust Total 210729 442987 204924 29961
This core service had 2.7 (9%) staff leavers between 1 August 2017 and 31 July 2018.
Ward/Team Substantive
staff
Substantive staff
Leavers
Average % staff
leavers
350 L9 Brain Injury Support (Z1BK90) 27.0 2.7 11%
350 L9 Rehab Senior Med Staff
(Z1BR10) 1.0 0.0 0%
Core service total 28.1 2.7 9%
Trust Total 2658.6 294.5 13%
The sickness rate for this core service was 6% between 1 August 2017 and 31 July 2018. The
most recent month’s data [31 July 2018] showed a sickness rate of 9%.
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff
sickness (over the past
year)
350 L9 Brain Injury Support (Z1BK90) 9% 7%
350 L9 Rehab Senior Med Staff (Z1BR10) 0% 0%
Core service total 9% 6%
Trust Total 8% 8%
The below table covers staff fill rates for registered nurses and care staff during July, August and
September 2018.
Both wards had under filled for registered nurses for all day shifts across all three months.
The Brain Injury Unit had over filled for care staff for night shifts for all months reported.
Key:
> 125% < 90%
Day Night Day Night Day Night
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 220
Nurses
(%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
July 18 August 18 September 18
Brain Injury
Unit 78.3 127.7 100.0 133.8 87.0 124.6 100.0 148.4 73.0 126.5 100.0 138.2
Rehabilitation
Centre 85.3 108.9 100.0 100.0 84.1 109.9 100.0 99.0 83.2 108.8 100.0 100.0
Where qualified staff numbers were low, the service had a full or higher quota of health care
assistants.
Medical staff
There was no useable data provided for medical locum usage.
Mandatory training
The service provided mandatory training in key skills to all staff and made sure everyone
completed it.
The compliance for mandatory and statutory training courses at 31 July 2018 was 35%. Of the
training courses listed 25 failed to achieve the trust target of between 90% and 95%, and of those,
10 failed to score above 75%. However, data held by ward managers showed that the trust figures
were not accurate, and that recording of the mandatory training of staff did not reflect that the ward
results were higher than the trust data. Mental Health Act training and Mental Capacity Act training
is shown as being 96% for both courses, however data later used in the report stated the figure
was 100% for both courses.
The training compliance data is reported on an ongoing monthly basis. Statutory training is
reported as part of the monthly board report dashboard produced by Workforce and a separate
dashboard is provided by the Learning and Development team for all other courses classified by
ourselves as role essential.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target %
Trust-wide mandatory/ statutory
training total %
Role Specific Mandated Training - Basic Prevent Awareness
(1 Time) 100% 90% 93%
Continuous Professional Development - Fraud Awareness
(Every 3 Years) 99% 95% 89%
Continuous Professional Development - Adverse Incidents
(Every 3 Years) 98% 95% 92%
Continuous Professional Development - Complaints (Every 3
Years) 97% 95% 94%
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 221
Training course This core service %
Trust target %
Trust-wide mandatory/ statutory
training total %
Role Specific Mandated Training - Deprivation of Liberties -
Level 1 (Every 3 Years) 96% 90% 89%
Role Specific Mandated Training - Mental Capacity Act -
Level 1 (Every 3 Years) 96% 90% 88%
Role Specific Mandated Training - Mental Health Act - Level 1
(Every 3 Years) 96% 90% 90%
Role Specific Mandated Training - Controlled Drugs & High
Risk Medicines 95% 90% 67%
Continuous Professional Development - Suicide Prevention
& Safety Planning (Every 3 Years) 94% 95% 90%
Mandatory Training - Safeguarding Children - Level 1 (Every
3 Years) 94% 95% 95%
Role Specific Mandated Training - Safeguarding Adults Level
2 -Trust Model (Every 3 Years) 93% 90% 87%
Role Specific Mandated Training - Safeguarding Children
Level 2 - Trust Model (Every 3 Years) 93% 90% 87%
Continuous Professional Development - Smoking Cessation
(1 Time) 92% 95% 89%
Mandatory Training - Safeguarding Adults - Level 1 (Every 3
Years) 92% 95% 95%
Role Specific Mandated Training - Safe and Effective Use of
Medicines (Every 3 Years) 89% 90% 63%
Mandatory Training - Infection Control (Every 3 Years) 88% 95% 92%
Role Specific Mandated Training - Moving and Handling of
People (Every Year) 88% 90% 48%
Role Specific Mandated Training - Intermediate Life Support
(Every Year) 88% 90% 72%
Mandatory Training - Health & Safety (Every 3 Years) 85% 95% 92%
Mandatory Training - Fire Safety (Every 3 Years) 84% 95% 92%
Mandatory Training - Moving & Handling (Every 3 Years) 84% 95% 90%
Role Specific Mandated Training - Basic Life Support (Every
Year) 82% 90% 70%
Mandatory Training - Equality, Diversity and Human Rights
(Every 3 Years) 80% 95% 91%
Mandatory Training - Conflict Resolution (Every 3 Years) 79% 95% 92%
Role Specific Mandated Training - Personal Safety (Every
Year) 77% 90% 50%
Role Specific Mandated Training - Medicines Calculations
(Every 3 Years) 74% 90% 63%
Role Specific Mandated Training - Safeguarding Adults Level
3 - Trust Model (Every 3 Years) 73% 90% 76%
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 222
Training course This core service %
Trust target %
Trust-wide mandatory/ statutory
training total %
Role Specific Mandated Training - Safeguarding Children
Level 3 - Trust Model (Every 3 Years) 73% 95% 76%
Continuous Professional Development - Dementia
Awareness (1 Time) 72% 95% 78%
Continuous Professional Development - Moving and
Handling of Inanimate Objects 68% 95% 56%
Role Specific Mandated Training - Witness to Medication
(Every 3 Years) 65% 90% 62%
Role Specific Mandated Training - Rapid Tranquilisation
Training 60% 90% 61%
Role Specific Mandated Training - MHA/DoL's Level 2 (Every
3 Years) 56% 90% 53%
Role Specific Mandated Training - Personal Safety
Breakaway - Level 1 (Every 2 Years) 50% 90% 50%
Mandatory Training (IG) - Data Security Awareness - Level 1
(Every Year) 45% 90% 50%
Core Service Total % 85% 87%
Data provided during the inspection showed that mandatory training at both sites had achieved
trust targets.
Assessing and managing risk to patients and staff
Assessment and management of patient risk
Staff completed and updated risk assessments for each patient and used these to understand and
manage risks individually. They minimised the use of restrictive interventions and followed best
practice when restricting a patient. Risk assessments were completed on a weekly basis, with
evidence noted of the updating of risk assessments after any incident. Discharge summaries held
crisis plans, informing patients of what to do and who to approach in the event of a possible
relapsed or need for treatment. We saw no evidence of advance decisions at the service.
Use of restrictive interventions
This core service had four incidents of restraint (on four different service users) and no incidents of
seclusion between 1 August 2017 and 31 July 2018.
The below table focuses on the last 12 months’ worth of data: 1 August 2017 to 31 July 2018.
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Rathbone
Rehabilitatio
n Ward
0 2 2 0 (0%) 0 (0%)
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 223
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Brain
Injuries
Rehabilitatio
n
0 2 2 0 (0%) 0 (0%)
Core service
total 0 4 4 0 (0%) 0 (0%)
There were no incidents of prone restraint.
There were no instances of rapid tranquilisation over the reporting period.
There have been no instances of mechanical restraint over the reporting period.
There have been no instances of seclusion over the 12-month reporting period. Neither ward
inspected has a seclusion room.
There have been no instances of long-term segregation over the 12-month reporting period.
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.
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 three safeguarding referrals between 1 August 2017 and 31 July 2018
year, of which three concerned adults and none children.
Number of referrals
Adults Children Total referrals
3 0 3
The three referrals were made in December 2017, May and July 2018, all with one referral made
in those months.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 224
Mersey Care NHS Foundation Trust has submitted details of three serious case reviews
commenced or published in the last 12 months [1 June 2017 and 31 May 2018]. However, none
relate to this core service.
Staff told us that relationships with local safeguarding structures were good. A policy was in place
for children visiting the units, and this was adhered to.
Staff access to essential information
Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and
easily available to all staff providing care. Staff present were familiar with the system and easily
located information that we were trying to find.
Medicines management
Staff followed best practice when storing, dispensing, and recording. Staff regularly reviewed the
effects of medications on each patient’s physical health. We attended a medicine round taking
place at the Rathbone rehabilitation unit, and saw good practice taking place. Patients were taken
into the clinic, seated, asked for identifying details, symptoms were discussed and questions
asked regarding how the patient felt, before the medication was administered. Staff washed their
hands between patients, and medication administration records completed. We reviewed 31
medication administration records across the service: the records were recorded correctly and
accurately.
All admissions were planned, allowing medicine reconciliation to be well organised and effective. A
pharmacist visited the units weekly, with a pharmacy technician also visiting the wards. We were
told that the pharmacist checked the medication cards on each visit, and we saw evidence of audit
by staff to also check medication records.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS)
within two working days of an incident being identified.
Between 1 August 2017 and 31 July 2018 there were no STEIS incidents reported by this core
service.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the
available preventative measures are in place. This core service reported no never events during
this reporting period.
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.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 225
In the last two years, there have been two ‘prevention of future death’ reports sent to the trust for a
response. A third report involved a patient who died whilst in the trust’s care, but the trust was not
directly asked for a response. None of these related to this core service.
The service managed patient safety incidents well. Staff recognised incidents and reported them
appropriately. 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. We saw evidence that duty of candour policy was being followed
by the service.
De-briefing was available should it be required post-incident: however, it had not been necessary
at the service.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 226
Is the service effective?
Assessment of needs and planning of care
Staff assessed the physical and mental health of all patients on admission. They developed
individual care plans and updated them when needed. We reviewed nine sets of care records that
confirmed this. All patients had copies of their care plans. On the brain injuries unit, a file was kept
in the room of each patient that had copies of care plans for patients to access at any time. Care
plans were holistic, individualised, but some care plans included jargon that might confuse
patients. We saw that physical health monitoring was on-going, and was up to date from
admission to the time of inspection. The Rathbone unit had a physical health nurse in post, with a
trained nurse associate on the brain injury rehabilitation unit. Physical health monitoring was
recorded and assessed against the recommendations of the responsible clinician regarding
existing physical ailments, as well as general physical health monitoring.
Best practice in treatment and care
Staff provided a range of treatment and care for patients based on national guidance and best
practice. Staff supported patients with their physical health and encouraged them to live healthier
lives.
This core service participated in eight clinical audits as part of their clinical audit programme 2017
– 2018.
Audit name Audit scope Audit type Date
completed Key actions following the audit
REILS Red
Bag
(Emergency
bag) Audit
Secure, Local
and SpLD
Divisions
Clinical and
Environment 09/08/2017
The areas for improvement were
signposting to emergency ILS bags and
contents lists being present in the bags.
This has been factored into routine
monitoring at ward level to improve
compliance, and is part of regular reviews.
Individual actions were identified as
follows: SpLD: Staff need instruction
and/or flowchart for restock/resealing of
bag. Needs signage erecting to indicate to
staff the location of the emergency orange
box. Staff to be advised that AED is not
getting checked regularly. Staff to be
advised to check AED on a daily basis and
to sign to say it has been checked daily.
Secure Division: A rota to be put in place
to ensure that daily checks of AED are
done regularly, Aztrax need to check AED
as out of date and needs asset number. 2
x non- rebreather masks need replacing as
out of date. Needs signage erecting to
direct staff to nearest AED and oxygen
location, 2 x size 14g cannulas out of date
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 227
Audit name Audit scope Audit type Date
completed Key actions following the audit
and need replacing. Local Division: Needs
signage erecting to direct staff to nearest
AED and oxygen location, an equipment
list and a flow chart for restock/reseal of
bag. Staff to be advised to check AED on a
daily basis and to sign to say it has been
checked daily. Needs 1 set of defib pads
replacing as out of date and non-
rebreather mask to go with the oxygen.
Oxygen to be reordered along with a new
bag valve mask.
Health
Records Audit
Secure,
Local,SpLD
and LCH
Sefton
Locality
Clinical 14/12/2017
Each Division has a breakdown of data
relating to their own area. The emphasis
for action and improvement is
countersignature of entries by staff that
cannot authorise a clinical note. There is a
review of the electronic patient records
systems in use to review how automation
can improve compliance.
Ward
Transfers
Audit
Local
Division Clinical 27/02/2018 No action Plan (see previous column).
Named Nurse
Audit Report
Local
Division Clinical 27/03/2018
The Audit Findings have been shared with
the Lead Nurse for the Local Division for
her comments / actions.
The Clinical Audit Team recommended the
following:
For all named nurse sessions it should be
clearly stated at the start of the note that it
is a 1:1 Named Nurse Session.
There was evidence to suggest that a lot of
what should be discussed in a Named
Nurse session was being documented but
NOT under this heading – so this was a
documenting issue rather than it not being
done. It was either contained in a general
ward note or MDT note.
The template provided for the audit may
not be appropriate for some patients on
Older Persons Wards in particular those
with an organic diagnosis. This was due to
the weekly planned sessions, which would
not always be appropriate in these cases.
Action Plan formulated to include the
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 228
Audit name Audit scope Audit type Date
completed Key actions following the audit
following: 1. Ward Manager to discuss
with Registered Nurses ways to maximise
opportunities to spend time on 1:1 basis
with named service users. 2. Develop and
share named nurse proforma for named
nurses to use in 1:1 sessions with service
users.
National
Clinical Audit
of Psychosis
Local, Secure
and SpLD
Divisions
Clinical 13/04/2018
Recommendation 1 (by the Royal College
of Psychiatrists)
Ensure that all people with psychosis:
have at least an annual assessment of
cardiovascular risk (using the current
version of Q-Risk) receive appropriate
interventions informed by the results of this
assessment have the results of this
assessment and the details of
interventions offered recorded in their case
record. Recommendation 2
Ensure that all people with psychosis are
offered CBT and family interventions, by:
deploying sufficient numbers of trained
staff who can deliver these interventions
making sure that staff and clinical teams
are aware of how and when to refer people
for these treatments. Recommendation 3
Ensure that all people with psychosis: are
given written or online information about
the antipsychotic medication they are
prescribed are involved in the prescribing
decision, including having a documented
discussion about benefits and adverse
effects of the medication.
Recommendation 4
Ensure that all people with psychosis who
are unable to attend mainstream
education, training or work, are offered
alternative educational or occupational
activities according to their individual
needs; and that interventions offered are
documented in their care plan.
Recommendation 5
An Annual Summary of Care should be
recorded for each patient in the digital care
record. This should: include information on
medication history, therapies offered and
physical health monitoring/interventions be
updated annually be shared with the
patient and their primary care
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 229
Audit name Audit scope Audit type Date
completed Key actions following the audit
team. Recommendation 6
NHS Digital, NWIS, Commissioners, Trusts
and Health Boards should work together to
put in place key indicators for which data
can easily be collected, perhaps using an
Annual Summary of Care (see
Recommendation 5 above). This work
should be informed by the NCAP results
and the experience of the NCAP team.
Hoisting
Equipment
Audit
Local
Division
Clinical and
Environment 08/06/2018
These results have been discussed within
the teams and Action Plan has been
completed:
Loler Inspections have been completed on
all hoists. Other actions include: To
monitor the number of slings available, and
to explore options for purchasing variety of
sling styles.
Datix Incidents
Audit Report
Local
Division Clinical 18/06/2018
These results have been discussed within
the teams and remedial action plans in
development
Nutritional
Screening and
Care Planning
(Adapted
MUST tool)
Local
Division Clinical 01/10/2017 No Action Plan
Psychological input was available at both units. At Rathbone site, the service had a part-time
clinical psychologist who did two days a week, but was assisted by a psychology assistant on a
Tuesday, and two band four psychology assistants during the rest of the week, with a new
psychology assistant due to start on site shortly after the inspection. At the brain injury
rehabilitation unit, there was a part-time psychologist covering a full-time post, the full-time
psychologist returning to the post in January 2019. There was also an assistant psychologist in
post, but this was on a fixed-term contract. We saw that there was a lot of joint working with
occupational therapists, speech and language therapists and physiotherapists at the service,
enhancing the multi-disciplinary approach within the service. We attended a psychology group
activity meeting, and saw good interaction and positive effect for patients.
Staff had access to new information technology, by way of the new care record system and the
provision of laptops. Laptops were used in multi-disciplinary meetings and named nurse one to
ones with patients.
Ratings scales were used to assess and record severity and outcomes, the service using the
Health of the Nation Outcome Scale. Staff were involved in various levels of clinical audit,
including infection control, care plan audits, risk assessment audits and Mental Health Act audits.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 230
Skilled staff to deliver care
Managers made sure they had staff with a range of skills need to provide high quality care. They
supported staff with appraisals, supervision and opportunities to update and further develop their
skills.
The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, the overall appraisal
rates for non-medical staff within this core service was 96%.
The wards/teams failing to achieve the trust’s appraisal target were Brain Injury Support with an
appraisal rate of 93%.
Ward name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
% appraisals
350 L9 Rathbone Rehab Centre (Z1BG11) 30 30 100%
350 L9 Brain Injury Support (Z1BK90) 27 25 93%
Core service total 57 55 96%
Trust wide 5565 4780 86%
The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, there was no data
pertaining to medical staff for this core service.
Between 1 August 2017 and 31 July 2018, the average rate across both teams in this core service
was 53%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different
ways. It is important to understand the data they provide.
Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical
supervision rate
(%)
350 L9 Rathbone Rehab Centre (Z1BG11) 28 21 75%
351 L9 Brain Injury Support (Z1BK90) 81 37 46%
Core service total 109 58 53%
Trust Total 15334 4947 32%
During the inspection, we viewed the supervision records for both Rathbone rehabilitation unit and
the brain injury rehabilitation unit, and found both units had supervision rates above 75% but
below the trust target of 95%. On Rathbone unit, the supervision figure stood at 89%, and could
not go any higher as remaining staff were not available.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 231
We were told that staff performance issues would be addressed promptly and effectively, however
there had been no such issues in the service.
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.
Multi-disciplinary team meetings took place every Monday at the service, as well as ward rounds
where all patients were discussed by the multi-disciplinary team. We were told that care
coordinators were good at keeping in touch at the Rathbone site, whilst the social workers who
represented the patients at the brain injury rehabilitation unit were always available and kept in
touch with staff and patients.
Care records indicated good relationships between the service and other relevant external
organisations.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental
Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.
As of 31 July 2018, 100% of the workforce in this core service had received training in the Mental
Health Act. The trust stated that this training is mandatory for all core services for inpatient and all
community staff and renewed every three years.
Staff had access to administrators who audited the Mental Health Act, and knew how to contact
them. There was a copy of the current Mental Health Act Code of Practice available on both sites.
We saw documented evidence that patient rights were being explained in line with the Code of
Practice. Medication management and documentation followed the requirements of the Mental
Health Act Code of Practice. Both sites had notices to patients admitted informally that they could
leave the ward at any time. We saw that Mental Health Act documentation was being audited in
the service.
Good practice in applying the Mental Capacity Act
Staff supported patients to make decisions on their care for themselves. They understood the trust
policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly. Staff knew
the principles of the Mental Capacity Act when speaking with the inspection team. Care records
clearly showed evidence that capacity was being considered for each patient, and that decisions
were specific to situations. Best interest meetings were taking place. Capacity was being audited
by the service.
As of 31 July 2018, 100% of the workforce in this core service had received training in the Mental
Capacity Act. The trust stated that this training is mandatory for all core services for inpatient and
all community staff and renewed every three years.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 232
The trust told us that no Deprivation of Liberty Safeguard (DoLS) applications were made to the
Local Authority for this core service between 1 August 2017 and 31 July 2018. Staff told us that a
Deprivation of Liberty Safeguard application would be applied for, should it be deemed necessary.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 233
Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity,
and supported their individual needs. The inspection team saw interaction between patients and
staff. Staff approached patient rooms and knocked before entering, and spoke to patients in a
friendly manner. This approach was reflected in patient experience findings
The 2017 Patient-led assessments of the care environment (PLACE) score for privacy, dignity and
wellbeing at two core service location(s) scored better than similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
Rathbone Hospital
Community based mental health services or adults of
working age
Long say/rehabilitation mental health wards for
working age adults
Secure/forensic
Substance Misuse
Wards for people with LD or Autism
94%
Brain injury Rehabilitation (Sid
Watkins unit)
Long stay/rehabilitation mental health wards for
working age adults 100%
Trust overall 92.7%
England average (mental health
and learning disabilities) 90.6%
Involvement in care
Involvement of patients
Staff involved patients and those close to them in decisions about their care, treatment and
changes to the service. Admission to the service was planned, with welcome packs being
available to both patients and carers, and a full introduction to the service. Both units had
information leaflets regarding treatments and rights in accessible areas.
There were noticeboards that had information regarding access to advocacy support for patients.
Patient records showed advocacy involvement in meetings. We noted the use of speech and
language therapist work with patients, designed to aid patients in their communication needs and
physical problems.
We approached many patients across the service for their view concerning the service. Only
seven patients were willing to speak to the inspection team. All patients said they were involved in
their care, had copies of their care plans, and felt that staff on the units listened to them. Patients
told us they felt safe within the service.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 234
The Patient Experience report for September and October 2018 showed an average result of
100% for all aspects reviewed, such as activities, care and treatment, cleanliness, and effective
care.
We reviewed patient community forum minutes from the brain injuries rehabilitation unit from
August to the end of October. These showed active participation by patients, and comments from
patients were noted and acted upon, feedback from patients was clearly considered.
Patient records showed that patient opinions were recorded and considered during multi-
disciplinary meetings. Patient records showed consideration of patient views with regards to
discharge from the service.
Involvement of families and carers
The service ran a carer’s forum, inviting carers of all patients admitted to the service. Carers were
invited regularly to ward reviews, we saw this reflected in care record notes. We spoke to five
carers of patients admitted to the service.
Carers we spoke to told us that they were involved in the care of their relatives at the service,
some more than others. Overall, carers were happy with the service being provided, although we
were told by one carer that they felt the service was not working as hard with their relative as they
did on admission. We saw that information regarding carer’s assessments were available at the
service, and a carer’s lead was available to discuss issues on the brain injury rehabilitation ward.
Carers told us that if they required specific information regarding their relative, or if they had any
questions, staff were always willing to talk to them and find the answers to their questions.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 235
Is the service responsive? Between 1 August 2017 and 31 July 2018, the core service had a number of ward moves, as
outlined in the table below:
During the last 12 months – YR 1 (2017/2018)
During the previous 12 months – YR2 (2016/2017)
Ward name
Number of ward moves
Number of patients
How many were at 'end
of life'*
%-share of all patients
Number of patients
How many were at 'end
of life'*
%-share of all patients
Rathbone Rehab centre
0 12 0 71% 23 0 88%
1 4 0 24% 2 0 8%
2 1 0 6% 1 0 4%
3 0 0 0% 0 0 0%
4+ 0 0 0% 0 0 0%
Total 17 0 100% 26 0 100%
Brain Injury Rehab
0 34 0 85% 39 0 91%
1 5 0 13% 2 0 5%
2 1 0 3% 2 0 5%
3 0 0 0% 0 0 0%
4+ 0 0 0% 0 0 0%
Total 40 0 100% 43 0 100%
.
Access and discharge
People could access the service closest to their home when they needed it. Waiting times from
referral to treatment and arrangements to admit, treat and discharge patients were in line with
good practice. All admissions to the service were planned admissions. There was clear evidence
in care records of discharge planning, discharge being considered from admission. This was
reflected in the involvement of social works and care coordinators of patients on both sites.
Bed management
The trust provided information regarding average bed occupancies for two wards in this core
service between 1 August 2017 and 1 July 2018.
Rathbone rehab centre within this core service reported average bed occupancies ranging above
the national recommended benchmark of 85% over this period.
We are unable to compare the average bed occupancy data to the previous inspection due to
differences in the way we asked for the data and the period that was covered.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 236
Ward name Average bed occupancy range (1 August 2017 – 31
July 2018) (current inspection)
Brain Injury Rehab 58.6% - 96%
Rathbone Rehab Centre 85.6% - 94.9%
The trust provided information for average length of stay for the period 1 August 2017 to 31 July
2018.
We are unable to compare the average bed occupancy data to the previous inspection due to
differences in the way we asked for the data and the period that was covered.
Ward name Average length of stay range (1 August 2017 – 31 July
2018) (current inspection)
Brain Injury Rehab 46.9 – 203.6
Rathbone Rehab Centre 244.1 – 844.9
This core service reported one out area placements between 1 August 2017 and 31 July 2018.
As of 13 August 2018, this core service had no ongoing out of area placements.
There were no placements that lasted less than one day, and the placement that lasted the
longest amounted to 2146 days. The longest stay patient was confirmed to have had very complex
needs regarding placement, and efforts were made to seek suitable placement, resulting in a
successful placement.
The out of area placement was due to the patient being placed with another provider due to this
better suiting their care or personal needs.
Number of out of
area placements
Number due to
specialist needs
Number due to
capacity
Range of lengths
(completed
placements)
Number of ongoing
placements
1 1 0 2146 0
This core service reported two readmissions within 28 days between 1 August 2017 and 31 July
2018.
One of the readmissions (50%) were readmissions to the same ward as discharge.
The average of days between discharge and readmission was six days. There were no instances
whereby patients were readmitted on the same day as being discharged but there were no
instances where patients were readmitted the day after being discharged.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 237
Ward name Number of
readmissions
(to any ward)
within 28 days
Number of
readmissions
(to the same
ward) within 28
days
% readmissions
to the same
ward
Range of days
between
discharge and
readmission
Average days
between
discharge and
readmission
Brain Injury Rehab
1 1 50% 2-10 6
Staff told us that new admissions could be refused to the service. Each new admission was
discussed within the multi-disciplinary team, and the merits of admission were considered, with
possible problems with other patients discussed. Patients had access to their bed on return from
leave.
Discharge and transfers of care
Between 1 August 2017 and 31 July 2018, there were 56 discharges within this core service. This
amounts to 1.5% of the total discharges from the trust overall (3784).
Of the 54 discharges for this core service, 21 (38%) were delayed. We were told that the main
cause of delay in discharge was due to accommodation issues, difficulty finding the appropriate
accommodation to suit the patient. However, external issues within the relevant community could
also impact discharge. At the time of the inspection, neither the Rathbone rehabilitation unit nor
the brain injury rehabilitation unit had any delayed discharges.
The trust identified services as measured on ‘referral to initial assessment’ and ‘assessment to
treatment’. However, there was no information relating to this core service.
Facilities that promote comfort, dignity and privacy
The design, layout, and furnishings of the ward/service supported patients’ treatment, privacy and
dignity. Patients could access their rooms during the day without requesting doors to be unlocked,
and on the Rathbone site patients had their own keys to their rooms. Each room had a small safe
that allowed patients to keep valuable items secure. Patients could access their own mobile
telephone. Patients could access outdoor space. At Rathbone, patients had a large, well
maintained outdoor area with lots of seating and exercise equipment, and kept a barbecue on site,
after patients had requested that barbecues be held during the summer months. The brain injury
rehabilitation unit had a balcony area that overlooked an atrium, with glass walls allowing patients
to view the atrium area easily.
The service had rooms for therapies and activities, quiet areas, male and female lounges. There
were kitchens that allowed patients to cook their own food. This also meant that hot drinks and
snacks were available at any time.
Activities were available seven days a week. The activities were meaningful and relevant to the
patients at the service. Both sites had occupational therapists and assistant occupational
therapists, with on-going recruitment for assistants and speech and language therapists. Activities
were worked around morning routines, such as medication rounds. At Rathbone rehabilitation unit
there were activities that included daily living skills groups, a psychology group (this was attended
by an inspection team member, and excellent communication between staff and patients was
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 238
noted), music therapy, walking groups, pamper groups, computer access for patients to improve
skills, cookery groups and creative arts. The groups were aimed at preparing patients for their
eventual discharge, as well as ensuring they were active whilst admitted.
The 2017 Patient-led assessments of the care environment (PLACE) score for ward food at the
locations scored better than or the same as similar trusts.
Site name Core service(s) provided Ward food
Rathbone Hospital
Community based mental health services or adults of
working age
Long say/rehabilitation mental health wards for
working age adults
Secure/forensic
Substance Misuse
Wards for people with LD or Autism
92.3%
Brain injury Rehabilitation (Sid
Watkins unit)
Long stay/rehabilitation mental health wards for
working age adults 91.3%
Trust overall 95.4%
England average (mental health and learning disabilities) 91.5%
Patients’ engagement with the wider community
There were opportunities for patients to do volunteer work, with courses available to patients who
wanted to learn. These were openly advertised on noticeboards on both units. A brain injury
association was working closely with the brain injury rehabilitation unit, giving many opportunities
to those diagnosed with brain injuries.
Care records indicated support given to patients to develop and maintain relationships, with
patient one to ones showing staff encouragement to patients to maintain contact with family.
Carers we spoke to told us of the input from staff that helped to keep communication open and
people in touch. Carers told us that staff were always approachable and were happy to discuss
patient needs and involve patients in dialogue.
Meeting the needs of all people who use the service
The service was accessible to all who needed it and took account of patients’ individual needs.
Staff helped patients with communication, advocacy and cultural support. There were bathrooms
that had been adapted to enable more disabled patients to maintain personal hygiene. There were
hoists in each bedroom at the brain injury rehabilitation unit that had been built into the rooms, the
hoists allowing less mobile patients to be moved about the room and even into the en-suite
bathroom. Bedroom doors were wide enough to cope with wheelchair access, and rooms had
enough floor space around the beds to ensure mobility aids could be used safely. The Rathbone
unit had a lift to allow patients with limited mobility to move to and from the upper floor of the unit.
There were rooms for activities, and gym equipment available to patients and staff. The
gymnasium on the brain injury rehabilitation unit was very well equipped, with assisted-walking
rails, treadmills, exercise bicycles and steps for practising walking up and down stairs in a safe
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 239
environment. The games room at the Rathbone unit was well equipped, including a pool table and
table tennis equipment, and a punch bag.
We saw leaflets relating to treatments, rights, smoking cessation, advocacy, CQC, medication and
others, all easily accessible on the units. On the Brain injury rehabilitation unit, there was a poster
on a noticeboard in a variety of languages informing the reader of how to access information in
their language or linguistic translation. We were told that such leaflets or information in a different
language could be accessed by staff if required by a patient or carer. There was a variety of food
available, patients told us that the food at the service was good, and the choice was varied. Food
prepared with consideration of cultural needs was available to different faiths.
A chaplain visited the brain injury rehabilitation unit, with the service providing access to other
faiths should they be requested. The Rathbone unit had a multi-faith room on the ward that gave
consideration to a variety of faiths.
Listening to and learning from concerns and complaints
This core service received two complaints between 1 August 2017 and 31 July 2018. One of these
were upheld and one partially upheld. None were referred to the Ombudsman.
Ward
name
Total
Complaints
Fully
upheld
Partially
upheld
Not
upheld
Referred to
Ombudsman
Upheld by
Ombudsman
Brain
Injuries
Rehab
2 1 1 0 0 0
This core service received one compliment during the last 12 months from 1 August 2017 to 31
July 2018 which accounted for <1% of all compliments received by the trust as a whole.
There were noticeboards containing detailed information on how to complain, and this was also
detailed in the welcome pack for both carers and patients. Patients told us they knew how to
complain, but none of those interviewed had exercised that right. Complaints were handled either
informally or formally by the service, depending on the complexity or severity. As the information
provided by the trust indicated, the service only had two complaints in a 12-month period.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 240
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. Unit managers knew who their senior managers were, and could show
that senior managers had visited the ward. Leadership opportunities were available for managers
in the unit, and these opportunities had been taken up by managers in the service.
Vision and strategy
The trust 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 trust also set goals for zero suicides for people in care, no force first (zero physical or
medication-led restraint), physical health and a just culture.
Each site in the service followed the values of the trust, and staff we spoke to were aware of the
values and could talk about what they meant to themselves and the patients. Managers felt that
their opinions had been listened to in the formulation of the values, and the trust often included all
staff in surveys aimed at improving the service.
Culture
Managers across the trust promoted a positive culture that supported and valued staff, creating a
sense of common purpose based on shared values. Focus groups were held prior to the
inspection, and staff told us that they felt that they were respected and valued. Staff at the service
told us that they felt respected and valued. We were told by staff that they felt the team morale in
the service was good, and they felt supported by their line managers.
Relationships between staff and senior multi-disciplinary team members were reported to be good.
An inspection team member observed a discussion between senior medical staff and ward staff,
the discussion showed differences of opinion, but the staff reached an amicable solution to the
problem. Staff knew how to use the whistle-blowing process.
During the reporting period, there were no cases where staff had been either suspended, placed
under supervision or moved to a different ward
Governance
The trust used a systematic approach to continually improve the quality of its services and
safeguarding high standards of care by creating an environment in which excellence in clinical
care would flourish.
The trust used an electronic system to monitor and inform the service of its position in relation to
key performance indicators, to be used as a gauge of performance. Audit results relating to the
service were highlighted, and outlined such aspects as action plans for care plans, medical
revalidation reports, risk assessment audits, infection control, bed occupancy and payment by
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 241
results clustering. These indicators and audits showed that the service was acting upon findings
and using the information to take forward the service.
Mangers felt they had enough authority to do their job, and they had access to administrative
support. The service played an active role in the trust restrictive practice group, with a view to
reviewing restrictive practice across the trust, and this was supported at board level. This was
displayed as it was an active aspect of the board meeting in July 2018, attended by inspection
team members.
Management of risk, issues and performance
The trust had effective systems for identifying risks, planning to eliminate or reduce them, and
coping with both the expected and unexpected.
The trust has provided a document detailing their 34 highest profile risks. One of the 34 corporate
risks had a current risk score of 15 or higher. However, none related to this core service.
Managers told us that entries to the risk register could be made by staff, by relaying such risks to
the manager of the unit, the manager of the unit then applying for the register to be amended
accordingly.
Information management
The trust collected, analysed, managed and used information well to support all its activities, using
secure systems with security safeguards.
The trust had recently changed its computer system. The system was secure with security
safeguards. We viewed the new system in use during the inspection, and it was seen to be
effective, coupled with the auditing of information that had been put securely into the system to
feed into the performance monitoring tool used to gauge performance.
Engagement
Unit managers told us that they were fully engaged with the trust in taking the service forward.
Leadership meetings took place that included service managers. Quality reports for the trust
indicated that the service had identified aspects of the service that needed to be improved, such
as supervision, and it was clear that the service had improved on those aspects. There was also
improvement in wider agency involvement with the trust.
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 provided which services have been awarded an accreditation together with the relevant
dates of accreditation. However, there was no information pertinent to this core service.
Mersey Care NHS Foundation Trust evidence appendix: long stay/rehabilitation mental health wards for adults of working age Page 242
However, the brain injury rehabilitation unit had been accepted on the day of inspection with
accreditation by a national Approved Provider scheme from a national brain injury charity. The
accreditation demonstrated commitment to continuous service improvement and ensuring a
workforce trained and skilled in working with individuals with brain injury
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 243
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)
Broadoak Albert Ward 24 Male
Clock View Alt Ward 17 Mixed
Broadoak Bed management Not applicable Mixed
Broadoak Brunswick Ward 23 Mixed
Clock View Dee Ward 17 Female
Broadoak Harrington ward 19 Female
Clock View Morris Ward 17 Male
Clock View Newton Ward
(PICU) 12 Mixed
Hesketh Centre
Park Unit
(merged
Rowbotham)
24 Mixed
Windsor House Windsor House
inpatient service 24 Mixed
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 244
Is the service safe?
Safe and clean care environments
All wards were safe, clean, well equipped, well furnished, and well maintained.
Safety of the ward layout
The wards were provided across four sites, and each building was of a different age and design.
The older buildings were at the Broadoak Unit, the Hesketh Centre and Windsor House. These
wards were not consistent with current guidance on the design of mental health units. Sleeping
accommodation was mainly provided in dormitories with a small number of single occupancy
rooms on each site. Each dormitory had four beds, and each bed area was curtained off to
maintain patients’ privacy. The units had limited access to outdoor space. Clock House Hospital
was a relatively new build and had been designed with consideration to reducing risks. Wards at
Clock House hospital had ensuite single bedrooms for all patients, and direct access to outdoor
areas.
The wards complied with guidance on eliminating mixed-sex accommodation. There were
designated corridors for men and women’s rooms and dormitories. There were dedicated female
lounges in all wards.
Over the 12-month period from 1 August 2017 to 31 July 2018 there were no mixed sex
accommodation breaches within this core service. However, we were informed that a male patient
had recently been admitted to a bed in a female area at the Broadoak Unit. This had happened at
night, the patient had been on 1-1 observation, and had moved to a male bed the following day.
Four of the nine wards were single sex – two for men and two for women.
Staff could clearly see all areas of the ward, or were aware of blind spots and mitigated against
them. Staff were aware of any ligature anchor points and actions to mitigate risks to patients who
might try to harm themselves. There were ligature risks on all wards within this core service. The
trust had undertaken recent (from 1 January 2017 to 15 August 2018) ligature risk assessments at
nine wards. All nine wards presented a high level of ligature risk, and the trust provided various
reasons for this. However, the trust had taken actions for each to mitigate ligature risks. Bedrooms
and bathrooms were fitted with anti-ligature fittings such as door-less wardrobes, collapsible
curtain rails, and inbuilt sensor taps. Staff had access to alarms, and patients had access to nurse
call systems.
Maintenance, cleanliness and infection control
The wards were mostly clean and well maintained. Infection control audits were carried out, and
personal protective equipment and handwashing equipment was available for staff. Clinical waste
and sharps were disposed of safely.
For the most recent Patient-led Assessments of the Care Environment (PLACE) assessment
(2017) the location(s) scored higher than the similar trusts for three of the four aspects overall.
Dementia friendly environment was the only aspect to score below the England average. People
with dementia are not routinely admitted to wards in this core service.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 245
Site name Core service(s) provided Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
HESKETH
CENTRE
Acute/PICU
MH - Community-based mental
health services for adults of working
age
MH - Community mental health
services for people with a learning
disability or autism
99.5% 96.0% - 96.6%
CLOCK VIEW
HOSPITAL
Acute/PICU
MH - Wards for older people with
mental health problems
MH - Community-based mental
health services for adults of working
age
99.6% 97.2% 79.9% 89.9%
BROADOAK UNIT
(BROADGREEN
HOSPITAL SITE)
Acute/PICU 99.0% 96.0% - 90.3%
WINDSOR HOUSE Acute/PICU 98.4% 97.7% - 96.6%
Trust overall 98.8% 97.3% 81.3% 89.9%
England average
(Mental health
and learning
disabilities)
98.0% 95.2% 84.8% 86.3%
Seclusion room (if present)
Seclusion rooms were equipped in accordance with the Mental Health Act code of practice. There
were two seclusion rooms – one on Newton ward, the psychiatric intensive care unit at Clock View
Hospital, and one at Park ward at the Hesketh Centre. The seclusion room on Newton ward was
part of a dedicated suite. The seclusion room on Park ward was at the end of a corridor near the
clinic and medication rooms. Staff observed the patient from the corridor, and had a screen they
put across the corridor to maintain the patient’s privacy.
Clinic room and equipment
The clinic rooms were clean and well stocked. Each of the wards had a clinic room separate from
the medication. Staff carried out routine checks of the rooms and their contents. Medical devices
were in working order, clean and routinely maintained and calibrated. Each ward had a
resuscitation bag, which included emergency equipment and medication, and an automatic
external defibrillator. The bags were routinely checked, topped up and sealed. Ward staff checked
the expiry date on the seal. The bag on one ward did not have a dated seal, but this was resolved
during our inspection.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 246
Safe staffing
Nursing staff
Maintaining safe staffing levels was an ongoing challenge, as there were difficulties in recruiting
qualified nurses and in some areas healthcare assistants. This led to the regular use of bank and
agency staff. At times, some wards had only one qualified nurse on a shift and some shifts were
not fully staffed. Patients and staff told us that one-to-one sessions, leave and activities were
occasionally cancelled due to staffing levels. Most of the patients and staff we spoke with raised
staffing levels and the pressure this placed on staff as a concern.
The trust had systems for reviewing staffing on a daily and weekly basis, which identified potential
shortfalls and acted to address them. The trust had an ongoing staffing and recruitment strategy,
that aimed to recruit and retain staff. Senior and local managers had a clear understanding of the
challenges, and of the action that was being taken to address them.
The table below gives an overview of trust staffing levels. It provides data on substantive staff
numbers, vacancies and sickness, and use of bank and agency staff. This data was provided to us
by the trust in August 2018 and covers the period 1 August 2017 to 31 July 2018.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff 31 July 2018 206.5 N/A
Total number of substantive staff leavers 01 August 2017–31 July 2018
25.4 N/A
Average WTE* leavers over 12 months (%) 01 August 2017–31 July 2018
12% 12.6%
Vacancies and sickness
Total vacancies overall (excluding seconded staff) 31 July 2018 -45.7 N/A
Total vacancies overall (%) 31 July 2018 15% over
establishment
5%
Total permanent staff sickness overall (%)
Most recent month (31 July 2018)
11% 8%
01 August 2017–31 July 2018
10% 8%
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) 31 July 2018 118.2 N/A
Establishment levels nursing assistants (WTE*) 31 July 2018 135.4 N/A
Number of vacancies, qualified nurses (WTE*) 31 July 2018 -20.5 over
establishment
N/A
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 247
Substantive staff figures Trust target
Number of WTE vacancies nursing assistants 31 July 2018 -12.2 over
establishment
N/A
Qualified nurse vacancy rate 31 July 2018 17% over
establishment
14%
Nursing assistant vacancy rate 31 July 2018 9% over
establishment
-18%
Bank and agency Use
Hours bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 01 August 2017–31
July 2018 12030
N/A
Hours filled by agency staff to cover sickness, absence or
vacancies (qualified nurses) 01 August 2017–31
July 2018 1387
N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (qualified nurses) 01 August 2017–31
July 2018 3010
N/A
Hours filled by bank staff to cover sickness, absence or vacancies
(nursing assistants)
01 August 2017–31
July 2018 104591
N/A
Hours filled by agency staff to cover sickness, absence or
vacancies (nursing assistants)
01 August 2017–31
July 2018 8334
N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (nursing assistants)
01 August 2017–31
July 2018 4994
N/A
*Whole-time Equivalent / minus figures mean that they are oversubscribed
This core service reported an overall rate of 15% over establishment for all staff at 31 July 2018.
This core service reported a rate of 17% over establishment for registered nurses.
This core service reported a rate of 9% over establishment for registered nursing assistants.
However, this information provided by the trust was not consistent with our discussions with ward
staff. The wards had vacancies and were not over establishment, so there appears to be an error
in the information supplied.
Registered nurses Nurses assistants Overall staff figures
Ward/Team
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Windsor House -1.5 12.5 -12 0.9 14.6 6 -3.6 33.1 -11
Albert Ward -3.2 12.2 -26 0.8 12.8 6 -3.4 33.0 -10
Alt Ward (Clockview) -2.7 12.7 -21 -2.5 13.8 -18 -10.3 34.5 -0.-30
Morris Ward (Clockview) -0.7 12.7 -6 -4.0 15.6 -25 -3.1 34.4 --9
Dee Ward (Clockview) -2.4 13.2 -18 -2.3 15.3 -15 -5.9 36.5 --16
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 248
Harrington Ward 0.3 12.2 2 0.5 11.9 4 -1.2 30.1 -4
Brunswick Ward -2.2 12.2 -18 0.0 12.8 0 -4.2 33.0 -13
Newton Ward (Clockview) -4.6 14.3 -33 -4.7 19.7 -24 -8.7 35.0 -25
Park/Rowbotham Unit -3.6 16.4 -22 -0.8 18.9 -5 -5.4 37.2 --15
Core service total -20.5 118.2 --17 -12.2 135.4 -9 -45.7 306.6 -15
Trust total -151.7 1115.9 -14 7.6 643.2 1 -320.9 2741.6 -12
NB: All figures displayed are whole-time equivalents
Between 1 August 2017 and 31 July 2018, of the 18,562 total working hours available, bank staff
filled 12030 hours to cover sickness, absence or vacancy for qualified nurses.
In the same period, agency staff covered 1387 hours for qualified nurses. In addition, 3010 hours
were unable to be filled by either bank or agency staff.
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Albert 1776 1606 152 473
Brunswick 1776 403 120 310
Harrington 1776 651 38 -88
Park/Rowbotha
m 2460 1740 423 701
Windsor House 1831 966 69 202
Alt 1667 936 44 363
Dee 1745 3237 116 148
Irwell 1745 1371 252 -15
Morris 1667 254 44 200
Newton 2118 868 131 715
Core service
total 18562 12030 1387 3010
Trust Total 90109 70728
13446
14705
*Percentage of total shifts
Between 1 August 2017 and 31 July 2018, of the 35179 total working hours available, 104591
hours were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.
In the same period, agency staff covered 83334 Hours. In addition, 4994 hours were unable to be
filled by either bank or agency staff.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 249
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by bank
or agency staff
Albert 3270 5826 5961 77
Brunswick 3270 4109 3025 370
Harrington 3120 8472 6024 285
Park/Rowboth
am 3275 9020 5252 16
Windsor
House 3555 8020 5499 386
Alt 3629 11182 4202 1145
Dee 3880 12958 4308 772
Irwell 3831 20788 14680 828
Morris 3930 13706 12091 303
Newton 3418 10510 22293 811
Core service
total 35179 104591 83334 4994
Trust Total 90109
70728
13446
14705
* Percentage of total shifts
This core service had 25.4 (12%) staff leavers between 1 August 2017 and 31 July 2018.
Ward/Team Substantive
staff
Substantive staff
Leavers
Average % staff
leavers
Acute Senior Med Staff (Z1AR10) 13.5 4.1 28%
Newton Ward (Z1BP01) 26.3 6.0 21%
Assessment Service Clock View
(Z1NW10) 0.0 1.0 15%
Morris Ward (Z1AB73) 31.8 4.0 14%
Windsor House (Z1AA11) 30.5 2.9 10%
Harrington Ward (Z1AD11) 29.9 2.8 10%
Dee Ward (Z1AB74) 30.7 0.6 2%
Park/Rowbotham Unit (Z1NW01) 32.3 3.0 9%
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 250
Ward/Team Substantive
staff
Substantive staff
Leavers
Average % staff
leavers
Inpatient Psychology S&K (Z2AB41) 6.6 0.0 0%
Inpatient Psychology Liverpool (Z2AB38) 5.0 1.0 15%
Core service total 206.5
25.4 12%
Trust Total 2658.6
294.5 13%
The sickness rate for this core service was 10% between 1 August 2017 and 31 July 2018. The
most recent month’s data (31 July 2018) showed a sickness rate of 11%. This compared with the
trust’s overall sickness rate of 8% over the last year, and 8% in the most recent month (July 2018).
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff sickness
(over the past year)
Acute Senior Med Staff (Z1AR10) 0% 1%
Harrington Ward (Z1AD11) 9% 12%
Assessment Service Clock View (Z1NW10) #DI0%/0! 9%
Dee Ward (Z1AB74) 9% 8%
Inpatient Psychology S&K (Z2AB41) 0% 0%
Morris Ward (Z1AB73) 20% 15%
Newton Ward (Z1BP01) 9% 8%
Park/Rowbotham Unit (Z1NW01) 7% 8%
Inpatient Psychology Liverpool (Z2AB38) 20% 21%
Medical North Sefton Acute (Z1NW95) 0% 0%
Windsor House (Z1AA11) 12% 11%
Core service total 11% 10%
Trust Total 8% 8%
The below table covers staff fill rates for registered nurses and care staff during July, August and
September 2018.
Five wards had low fill rates (<90%) for registered nurses for all day shifts across all three months.
This included Brunswick, Harrington, Park/Rowbotham, Alt, Morris and Newton.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 251
Morris ward had over filled (>125%) for care staff for day and night shifts for all months reported.
Key:
> 125% < 90%
Day Night Day Night Day Night
Nurses
(%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
July 18 Aug 18 Sep 18
Albert 81.7 116.7 96.5 105.5 95.2 121.5 100.0 102.2 98.1 114.2 96.4 112.4
Brunswick 64.4 129.0 96.9 114.0 59.2 140.9 100.0 130.1 69.3 141.7 100.0 131.1
Harrington 47.0 140.9 103.4 134.4 47.6 128.0 103.4 104.3 70.0 130.0 100.0 123.3
Park/Rowbotham 84.2 111.0 58.6 109.7 80.9 107.1 57.4 100.8 82.9 112.2 68.0 101.6
Windsor House 94.7 96.1 94.9 98.6 100.8 96.0 100.0 106.5 98.3 105.4 103.2 110.0
Alt 67.2 105.6 96.7 93.1 71.0 108.1 100.0 100.0 65.8 116.7 100.0 100.8
Dee 93.5 105.6 100.0 107.9 64.5 120.7 100.0 114.6 70.0 122.7 100.0 109.1
Morris 88.7 151.7 100.0 162.6 74.9 140.5 100.0 156.9 65.8 155.5 100.0 164.5
Newton 87.1 121.2 49.9 160.9 78.2 128.6 49.9 162.1 88.3 139.6 60.0 184.5
Medical staff
There was adequate medical cover during the day and night, and a doctor could attend the ward
quickly in an emergency. All wards had one or two consultant psychiatrists, and patients were
seen and reviewed regularly by the consultant and other ward doctors. Following the absence of
the consultant on Brunswick ward, senior medical cover had been provided by other consultants in
the service. However, this could be out of hours and patients told us they often had to wait to see
a doctor.
Mandatory training
The service provided mandatory training in key skills to all staff, which the majority of staff had
completed.
The compliance for mandatory and statutory training courses at 31 May 2018 was 86%. Of the
training courses listed 27 failed to achieve the trust target and of those, nine failed to score 75% or
above. At inspection we found that most staff had completed their mandatory training, and were
well above 75%.
Key:
Below CQC 75% Between 75% & trust
targets Trust target and above
Training course This core service %
Trust target % Trustwide mandatory/ statutory training total %
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 252
Mandatory Training - Safeguarding Children - Level 1 (Every 3 Years) 98%
95% 95%
Mandatory Training - Safeguarding
Adults - Level 1 (Every 3 Years) 97%
95%
95%
Continuous Professional
Development - Complaints (Every 3
Years) 97%
95%
94%
Continuous Professional
Development - Adverse Incidents
(Every 3 Years) 96%
95%
92%
Role Specific Mandated Training -
Basic Prevent Awareness (1 Time) 96%
95%
93%
Continuous Professional
Development - Fraud Awareness
(Every 3 Years) 95%
95%
89%
Continuous Professional
Development - Suicide Prevention &
Safety Planning (Every 3 Years) 94%
95%
90%
Mandatory Training - Conflict
Resolution (Every 3 Years) 93%
95%
92%
Mandatory Training - Health & Safety
(Every 3 Years) 92%
95%
92%
Mandatory Training - Fire Safety
(Every 3 Years) 92%
95%
92%
Continuous Professional
Development - Smoking Cessation (1
Time) 91%
95%
89%
Mandatory Training - Equality,
Diversity and Human Rights (Every 3
Years) 91%
95%
91%
Mandatory Training - Moving &
Handling (Every 3 Years) 91%
95%
90%
Mandatory Training - Infection
Control (Every 3 Years) 91%
95%
92%
Role Specific Mandated Training -
Mental Health Act - Level 1 (Every 3
Years) 90%
90%
90%
Role Specific Mandated Training -
Safeguarding Adults Level 2 -Trust
Model (Every 3 Years) 89%
90%
87%
Role Specific Mandated Training -
Safeguarding Children Level 2 -
Trust Model (Every 3 Years) 89%
90%
87%
Role Specific Mandated Training -
Mental Capacity Act - Level 1 (Every
3 Years) 88%
90%
88%
Role Specific Mandated Training -
Deprivation of Liberties - Level 1 88%
90% 89%
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 253
(Every 3 Years)
Role Specific Mandated Training -
Controlled Drugs & High Risk
Medicines 85%
90%
67%
Role Specific Mandated Training -
Safeguarding Adults Level 3 - Trust
Model (Every 3 Years) 83%
90%
76%
Role Specific Mandated Training -
Safeguarding Children Level 3 -
Trust Model (Every 3 Years) 83%
90%
76%
Role Specific Mandated Training -
Safe and Effective Use of Medicines
(Every 3 Years) 82%
90%
63%
Role Specific Mandated Training -
Medicines Calculations (Every 3
Years) 79%
90%
63%
Continuous Professional
Development - Dementia Awareness
(1 Time) 76%
95%
78%
Role Specific Mandated Training -
Personal Safety (Every Year) 66%
90%
80%
Role Specific Mandated Training -
Basic Life Support (Every Year) 66%
90%
70%
Role Specific Mandated Training -
Intermediate Life Support (Every
Year) 66%
90%
72%
Role Specific Mandated Training -
MHA/DoL's Level 2 (Every 3 Years) 64%
90%
53%
Role Specific Mandated Training -
Rapid Tranquilisation Training 64%
90%
61%
Mandatory Training (IG) - Data
Security Awareness - Level 1 (Every
Year) 50%
90%
50%
Role Specific Mandated Training -
Witness to Medication (Every 3
Years) 42%
90%
62%
Continuous Professional
Development - Moving and Handling
of Inanimate Objects 36%
95%
56%
Role Specific Mandated Training -
Personal Safety Breakaway - Level 1
(Every 2 Years) 23%
90%
50%
Core Service Total % 86% 87%
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 254
Assessing and managing risk to patients and staff
Staff completed and updated risk assessments for each patient and used these to understand and
manage risks individually. They minimised the use of restrictive interventions and followed best
practice and the Mental Health Act when restricting patients to keep them and others safe.
Assessment of patient risk
All patients had a risk assessment completed when they were admitted, using a standard risk
assessment tool within the electronic care record. The risk assessments and related care plans
were updated following multidisciplinary team meetings, and after significant incidents.
Management of patient risk
We reviewed 34 care records and found that care plans were usually updated in response to
changes in risk. However, we found one record where a patient had self-harmed/talked of suicide
and although the patient’s care had been reviewed in response to this, there was not a specific
care plan about this. This was acknowledged as an omission by staff, who said this would be
rectified.
Staff aimed to reduce the use of one-to-one observations with patients unless they were deemed
necessary. As alternatives, intermittent observations and activities were used to try and engage
patients. The wards used zoning, so that patients assessed at being at higher risk of harm were in
areas that were more regularly observed. The trust was in the process of implementing safety
plans for patients. These were written with and often by the patient, and contained clear
statements about the support patients needed to keep them safe, and how and when they wanted
staff to respond to them. The self-harm project had implemented alternatives to self-harm such as
ice packs.
Staff were aware of minimising the use of restrictions that applied to all patients. There were items
that were prohibited, such as drugs and alcohol, and other items such as razors that were allowed
on the ward, but were stored securely. Items such as mobile phone chargers were risk assessed
on an individual basis, but were not routinely removed from patients. Patients were not routinely
searched, but searches were carried out following an individual risk assessment.
Smoking was not managed in accordance with the trust’s smoking policy. The policy on all trust
sites was that smoking was not allowed on the premises. However, patients smoked at the
Broadoak Unit and Clock View Hospital, and staff told us it was an ongoing problem at all the
sites. At Clock View Hospital patients smoked in the courtyard. At the Broadoak unit patients
smoked in the entrance to the locked staircase that went down to the garden. On one ward a
patient was observed to be smoking in the lounge. Nicotine replacement therapy was available for
patients. Staff told us it was a difficult situation to manage, as patients were told they could not
smoke on the wards, but it was tolerated as staff did not want to physically restrain a patient to
stop them smoking.
All the wards were locked, and staff controlled access in and out of the ward. Staff told us that
informal patients were free to leave as they wished, but needed to be assessed first. There was
inconsistent use of signage to remind informal patients of their rights regarding leaving the ward.
In the care records, some informal patients had restricted leave. Staff told us this was discussed
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 255
with the patient and they had agreed to this. However, this was not always clearly documented in
the care records, and it was not clear that informal patients were always made aware of their
rights.
Use of restrictive interventions
Staff participated in the provider’s restrictive interventions reduction programme. Staff were clear
about the trust’s ‘no force first’ policy, and used de-escalation and alternatives to manage a
situation, and only used restraint or rapid tranquilisation if this was unsuccessful. This was
discussed with staff, and care records described attempts that had been made to de-escalate
situations before restraining or secluding a patient.
At the last inspection we highlighted that patients who received rapid tranquilisation were not
always routinely monitored afterwards. At this inspection there were few patients who had
received rapid tranquilisation, but the records we saw were completed satisfactorily. If patients
refused to have their observations taken, then they were observed by staff.
The seclusion rooms were not in used during our inspection. A sample of records showed that
when seclusion was used, the rationale was recorded and the patient was monitored.
Consideration was given to the least restrictive option. Patients were reviewed and monitored in
accordance with the Mental Health Act Code of Practice.
This core service had 450 incidents of restraint (on 357 different service users) and 46 incidents of
seclusion between 1 August 2017 and 31 July 2018.
Over the 12 months, there was a decline in the incidence of restraints in the core service until the
last three months of the period when incidents rose again. Prone restraints and rapid
tranquilisations followed a similar pattern.
There were no incidents of long term segregation or mechanical restraints.
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Albert Ward 0 61 75 15 (25%) 18 (30%)
Alt Ward
(Admission) 1 24 18 0 (0%) 7 (29%)
Brunswick
Ward 0 36 37 5 (14%) 8 (22%)
Dee
(Female) 0 24 21 4 (17%) 10 (42%)
Harrington
Ward 0 41 41 6 (15%) 10 (24%)
Morris
(Male) 1 31 38 4 (13%) 6 (19%)
Newton
(PICU) 32 152 63 19 (13%) 37 (24%)
Park Unit
Ward 12 45 30 4 (9%) 4 (9%)
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 256
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Windsor
House
Inpatient
Ward
0 36 34 2 (6%) 12 (33%)
Core service
total 46 450 357 59 (13%) 112 (25%)
There were 59 incidents of prone restraint which accounted for 13% of the restraint incidents.
Over the 12 months, rates of both prone restraint and rapid tranquilisation remained relatively
stable for the majority of the period.
There were no instances of mechanical restraint over the reporting period.
There were 46 instances of seclusion over the reporting period. Over the 12 months, incidences of
seclusion ranged from zero to eight.
53 50
36
48
37 3833
36
2219
32
46
12
6
2
9
46
4 4
0 0
4
8
13
7
13 13
7
10 10
7
2
5
10
15
0
10
20
30
40
50
60
Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18
Total restraints over the 12 month period
Number of incidents of the use of restraints Number of prone restraints
Number of mechnical restraints Number of incidents resulting in the use of rapid tranquilisation
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 257
There were no instances of long-term segregation over the 12-month reporting period.
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. The Broadoak Unit and Clock View Hospital had a police liaison officer, who could be
contacted for advice and support.
The Broadoak Unit and Clock View Hospital both had a family room that could be used by any of
the wards there. Park ward and Windsor House did not have a dedicated family room, but made
arrangements for children to visit the unit safely.
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 135 safeguarding referrals between 1 August 2017 and 31 July 2018, of
which 131 concerned adults and four children.
8
3
7
6
4 4
5
0
3
0
3 3
0
1
2
3
4
5
6
7
8
9
Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18
Total seclusions over the 12 month period
Number of incidents of the use of seclusion
Referrals
Adults Children Total referrals
131 4 135
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 258
The number of adult safeguarding referrals in ranged from four to 19. With peaks in referrals
occurring in August 17 and November 17 with 19 each.
The number of child safeguarding referrals ranged from zero to three.
Mersey Care NHS Foundation Trust has submitted details of four serious case reviews
commenced or published in the last 12 months, however none that relate to this core service.
Staff access to essential information
Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and
easily available to staff providing care. Patients’ care records were stored electronically. All clinical
staff had access to the electronic system, by using their own access card and password. Any
paper records were scanned into the electronic system. Information on the system was accessible
by both inpatient and community staff.
Medicines management
Staff followed best practice when storing, dispensing, and recording. Staff regularly reviewed the
effects of medications on each patient’s physical health.
All the wards had regular visits from a pharmacist and technician, and routine checks of
medication procedures were carried out by nursing staff. Overall, medication was stored correctly,
although we found some liquid medication on two wards that did not have an open date recorded.
(Liquid medication can have a shortened shelf-life when opened, before the printed expiry date).
Medicines reconciliation was carried out initially by the doctor admitting a patient, and followed up
by the pharmacist.
Medication charts were completed correctly. The capacity to consent to medication was
documented in most care records, but was not always easy to find. Physical health monitoring was
usually carried out, but again was not always consistently. We found three occasions where
physical health monitoring with regards to medication was not carried out as stated. This was
acknowledged by the manager who told us they would address this. Patients were not given ‘as
necessary’ medication for extended periods, as its use was regularly reviewed.
Most patients were on medication within the recommended British National Formulary limits. The
trust’s policy was clear about the action that should be taken and the documentation that should
be used when patients were on high dose antipsychotic therapy. However, although patients were
monitored correctly, the recording and implementation of this was not consistently applied by staff,
and we were told of different approaches by staff. Patients who were on high dose antipsychotic
therapy (anti-psychotic dose above recommended British National Formulary limits) had the
necessary physical health checks carried out, and their medication reviewed.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS)
within two working days of an incident being identified.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 259
Between 1 August 2017 and 31 July 2018 there were 26 STEIS incidents reported by this core
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 eight. The only unexpected
death was an instance of ‘Sub-optimal care of the deteriorating patient meeting SI criteria’.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the
available preventative measures are in place. This core service reported no never events during
this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months.
The number of the most severe incidents recorded by the trust incident reporting system was
comparable with STEIS.
Number of incidents reported
Type of incident reported
on STEIS
Albert Alt AMH
Servic
e
(inpati
ent)
Harrin
gton
Bruns
wick
Dee Park
Unit
Morris Newt
on
Total
Apparent/actual/suspected
self-inflicted harm meeting SI
criteria
0 2 2 1 1 0 2 0 0
8
Unauthorised absence
meeting SI criteria
2 0 1 0 0 2 0 1 1
7
Environmental incident
meeting SI criteria
1 1 0 0 1 0 0 0 0
3
Abuse/alleged abuse of adult patient by staff
1 0 0 0 1 0 0 0 0 2
Disruptive/ aggressive/ violent
behaviour meeting SI criteria
0 1 0 0 1 0 0 0 0
2
Confidential information
leak/information governance
breach meeting SI criteria
0 0 0 1 1 0 0 0 0
2
Accident e.g. collision/scald
(not slip/trip/fall) meeting SI
criteria
1 0 0 0 0 0 0 0 0
1
Sub-optimal care of the
deteriorating patient meeting
SI criteria
0 1 0 0 0 0 0 0 0
1
Total 5 5 3 2 5 2 2 1 1 26
Reporting incidents and learning from when things go wrong
Staff knew what incidents to report, and how to report them. Most staff we spoke with were familiar
with the duty of candour, and the need to be open and honest with patients and their families if
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 260
things went wrong. Staff received feedback following incidents through supervision, team meetings
or trust-wide emails.
Staff told us post-incident debriefs were carried out and discussed in the handovers and safety
huddles on the wards. Staff told us that following serious incidents they had been supported by
their managers, and contacted by the trust’s staff support team which included occupational health
and psychological support.
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 two ‘prevention of future death’ reports sent to the trust for a
response. A third report involved a patient who died whilst in the trust’s care, but the trust was not
directly asked for a response. This third case was related to this core service. It involved the death
of a patient following self-harm. The trust had taken action following this which included
improvements to the support available to patients who self-harm or have a personality disorder.
This included the introduction/increase of psychologists to the inpatient ward, an emotional coping
skills group, and care plans developed with patients and caseworkers from the personality
disorder hub.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 261
Is the service effective?
Assessment of needs and planning of care
Staff assessed the physical and mental health of all patients on admission. They developed
individual care plans and updated them when needed. All patients had a comprehensive
assessment of their needs, and a care plan which was regularly reviewed. The quality of the care
plans varied between patients. Not all the care plans were personalised, recovery orientated and
clearly included the views of the patient. We saw care plans that were more prescriptive, and the
patient’s views, strengths and weaknesses were not clearly identified. The trust had introduced a
new electronic care record (RiO) in June 2018, and information was not consistently recorded in
the same place. However, we did not find evidence that this had impacted on patients’ care. The
trust had identified this as an issue, and were in the process of introducing care plans with
standard domains across the trust.
Best practice in treatment and care
Staff provided a range of treatment and care for patients based on national guidance and best
practice. Staff supported patients with their physical health and encouraged them to live healthier
lives.
Patients had access to occupational therapy and psychology. Patients had their physical health
assessed, responded to and monitored effectively. Most wards had a band four assistant
practitioner, who was trained in physical health care, and carried out physical health monitoring.
Patients prescribed clozapine (an antipsychotic with potentially severe side effects) were
monitored correctly. Prescribing of antipsychotic medication was in accordance with the National
Institute for Health and Care Excellence guidance. Most patients were prescribed medication
within the recommended British National Formulary limits.
Staff used rating scales to monitor and improve outcomes for patients. These included the routine
use of health of the nation outcome scales, and the Liverpool University neuroleptic side effect
rating scale.
Occupational therapists routinely used the model of human occupation assessment tool, and
others as necessary such as the occupational case analysis interview record and assessment of
motor and process skills. The occupational therapists also carried out activities of daily living
assessments of patients and did home visits as required. They provided groups on the wards and
in the occupational therapy department where available. Some of the wards were piloting the use
of the dynamic appraisal of situational aggression tool, and working with patients to manage and
lower their potential for aggressive behaviour.
Psychologists provided individual sessions with patients, therapeutic groups, reflective sessions
with staff, and assessments and formulations of patients. The range of groups provided included
an emotional coping skills groups (dialectic behaviour therapy focused for people with a
personality disorder), kind mind (compassion focused therapy), and making sense (for people
experiencing hallucinations or delusional thinking).
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 262
The trust had a Perfect Care team who worked with staff to implement initiatives such as the self-
harm project and no force first. For example, they had worked with staff on Dee ward to reduce
self-harm by increasing consistency, structure and how activities were implemented on the ward.
The self-harm project was part of a wider trust focus that included an emotional coping skills
group, psychology, alternatives to self-harm (such as ice), self-soothe boxes (which included
objects that were nice to stroke), setting mutual expectations with patients, and the daily huddle
where the multidisciplinary team to discuss issues of concern. There was a personality disorder
hub, with specialised staff working as case workers to patients with a personality disorder. As part
of this, staff could develop a plan with the patient to try and avoid admission to hospital, or if this
required it would be a crisis admission for up to 72 hours.
This core service participated in 24 clinical audits as part of their clinical audit programme 2017 –
2018.
Audit name Audit scope Audit type Date
completed Key actions following the audit
REILS Red Bag (Emergency bag) Audit
Secure,
Local and
SpLD
Divisions
Clinical and Environment
09/08/2017
The areas for improvement were signposting to emergency ILS bags and contents lists being
present in the bags. This has been factored into routine monitoring at ward level to improve compliance, and is part of regular reviews.
Individual actions were identified as follows: SpLD: Staff need instruction and/or flow chart for restock/resealing of bag. Needs signage erecting to indicate to staff the location of the emergency orange box. Staff to be advised that AED is not getting checked regularly. Staff to be advised to check AED on a daily basis and to sign to say it
has been checked daily. Secure Division: A rota to be put in place to ensure that daily checks of AED are done regularly, Aztrax need to check AED as
out of date and needs asset number. 2 x non rebreather masks need replacing as out of date. Needs signage erecting to direct staff to nearest AED and oxygen location, 2 x size 14g cannulas out of date and need replacing. Local Division:
Needs signage erecting to direct staff to nearest AED and oxygen location, an equipment list and a
flow chart for restock/reseal of bag. Staff to be advised to check AED on a daily basis and to sign to say it has been checked daily. Needs 1 set of
defib pads replacing as out of date and non rebreather mask to go with the oxygen. Oxygen
to be reordered along with a new bag valve mask. GP
Communication
Community
Clinic and
Inpatient Q2
(July 2017 to
September
2017)
Local
Division Clinical 22/11/2017
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel the
backlog of letters has been outsourced to bring all
correspondence in line with the NHS contract
requirements.
Health Records
Audit
Secure,
Local,SpLD
and LCH
Sefton
Locality
Clinical 14/12/2017
Each Division has a breakdown of data relating to
their own area. The emphasis for action and
improvement is countersignature of entries by
staff that cannot authorise a clinical note. There is
a review of the electronic patient records systems
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 263
Audit name Audit scope Audit type Date
completed Key actions following the audit
in use to review how automation can improve
compliance.
Nutrition
Support for
Adults
Secure,
Local and
SpLD
Divisions
Clinical 31/01/2018 No action plan - requested by CCG to show
compliance with NICE guidance.
GP
Communication
Community
Clinic and
Inpatient Q3
(October 2017
to December
2017)
Local
Division Clinical 29/01/2018
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel the
backlog of letters has been outsourced to bring all
correspondence in line with the NHS contract
requirements.
CQUIN GP
Communication
Inpatient - taken
from Q2
Local
Division Clinical 22/02/2018
These results have been discussed within the
teams and remedial action plans in development.
Ward Transfers
Audit
Local
Division Clinical 27/02/2018 No action Plan (see previous column).
Consent to
Medical
Treatment
Audit
Local
Division Clinical 28/02/2018
The following actions have been taken:
Update referring consultants on the
importance of ensuring all parts of the ECT
paperwork are complete
Review ECT paperwork to ensure that
unnecessary data in not being requested
• Ensure that RiO system properly records the
consent process for ECT
Clinical
Handover at
Nurse Shift
Change
Local
Division Clinical 05/03/2018
The focus of the action plan has been to continue
to communicate the importance of handover
standards. There is a requirement for teams to
locally audit the quality of handovers two times
per month and compliance is monitored via the
self-assessment process. This audit is to be
repeated in 2018.
Named Nurse
Audit Report
Local
Division Clinical 27/03/2018
The Audit Findings have been shared with the
Lead Nurse for the Local Division for her
comments / actions.
The Clinical Audit Team recommended the
following:
For all named nurse sessions it should be clearly
stated at the start of the note that it is a 1:1
Named Nurse Session.
There was evidence to suggest that a lot of what
should be discussed in a Named Nurse session
was being documented but NOT under this
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 264
Audit name Audit scope Audit type Date
completed Key actions following the audit
heading – so this was a documenting issue rather
than it not being done. It was either contained in a
general ward note or MDT note.
The template provided for the audit may not be
appropriate for some patients on Older Persons
Wards in particular those with an organic
diagnosis. This was due to the weekly planned
sessions which would not always be appropriate
in these cases.
Action Plan formulated to include the following: 1.
Ward Manager to discuss with Registered Nurses
ways to maximise opportunities to spend time on
1:1 basis with named service users. 2. Develop
and share named nurse proforma for named
nurses to use in 1:1 sessions with service users.
Risk
Assessments
on Admission
Local
Division Clinical 11/04/2018
The audit findings have been shared widely with
Liaison Services and Single Point of Access to
ensure that the requirements to update risk
assessment prior to admission is fully understood.
This audit is to be repeated in 18/19 and the
scope increased to include 'stepped up care'.
National Clinical
Audit of
Psychosis
Local,
Secure and
SpLD
Divisions
Clinical 13/04/2018
Recommendation 1 (by the Royal College of
Psychiatrists)
Ensure that all people with psychosis:
have at least an annual assessment of
cardiovascular risk (using the current version of
Q-Risk) receive appropriate interventions
informed by the results of this assessment have
the results of this assessment and the details of
interventions offered recorded in their case
record.
Recommendation 2
Ensure that all people with psychosis are offered
CBTp and family interventions, by:
deploying sufficient numbers of trained staff who
can deliver these interventions making sure that
staff and clinical teams are aware of how and
when to refer people for these treatments.
Recommendation 3
Ensure that all people with psychosis: are given
written or online information about the
antipsychotic medication they are prescribed are
involved in the prescribing decision, including
having a documented discussion about benefits
and adverse effects of the medication.
Recommendation 4
Ensure that all people with psychosis who are
unable to attend mainstream education, training or
work, are offered alternative educational or
occupational activities according to their individual
needs; and that interventions offered are
documented in their care plan. Recommendation
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 265
Audit name Audit scope Audit type Date
completed Key actions following the audit
5
An Annual Summary of Care should be recorded
for each patient in the digital care record. This
should: include information on medication history,
therapies offered and physical health
monitoring/interventions be updated annually be
shared with the patient and their primary care
team.
Recommendation 6
NHS Digital, NWIS, Commissioners, Trusts and
Health Boards should work together to put in
place key indicators for which data can easily be
collected, perhaps using an Annual Summary of
Care (see Recommendation 5, above). This work
should be informed by the NCAP results and the
experience of the NCAP team.
Level 1
Observations
Audit
Local
Division Clinical 16/04/2018
The ward managers for each in-patient ward will
carry out a spot check every week of the Level 1
observation sheets. Also, this issue will be
documented as an agenda item at future ward
managers' meetings.
GP
Communication
Community
Clinic and
Inpatient Q4
(January 2018
to March 2018)
Local
Division Clinical 20/04/2018
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel the
backlog of letters has been outsourced to bring all
correspondence in line with the NHS contract
requirements.
Ligature Audit
Report
Local
Division
Clinical and
Environment 06/06/2018
These results have been discussed within the
teams and remedial action plans in development.
GP
Communication
Community
Clinic and
Inpatient April
2018
Local
Division Clinical 07/06/2018
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel the
backlog of letters has been outsourced to bring all
correspondence in line with the NHS contract
requirements.
Datix Incidents
Audit Report
Local
Division Clinical 18/06/2018
These results have been discussed within the
teams and remedial action plans in development
GP
Communication
Community
Clinic and
Inpatient May
2018
Local
Division Clinical 28/06/2018
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel the
backlog of letters has been outsourced to bring all
correspondence in line with the NHS contract
requirements.
Audit of
Adherence to
NICE Guidance
on Long Acting
Reversible
Contraception
Local
Division Clinical 18/04/2018
Discuss at local audit meetings. Disseminate to
Ward Managers. Add to physical health
pathway/admission pack. Discuss
mechanism/pathway for referring eg GP. Re-audit
in 12 months.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 266
Audit name Audit scope Audit type Date
completed Key actions following the audit
Audit - DVLA
guidance in
Psychiatry
Local
Division Clinical 14/05/2018
Posters regarding DVLA driving restrictions
displayed on the ward to prompt the conversation.
Advice leaflets available to patients - these are
already produced by MIND and Mersey Care.
Education of clinicians - juniors and consultants
as well as nursing staff. It is part of social history
when clerking in. Should it be part of our risks
assessment? Guidance isn't limited to inpatient
discharges - we should be considering in all our
patients.
A cross
sectional audit
of inpatient
antipsychotic
depot injection
prescribing
practice
Local
Division Clinical 17/05/2018
Depots signed for on one document only. The
name, dose, time and site of injection should be
clearly documented on electronic records utilising
a brief, standardised proforma. Electronic
prescribing should be rolled out which most
certainly is the best way of avoiding these errors.
Learning must occur from avoidable errors.
Smoking Audit Local
Division Clinical 27/07/2018
To ensure that all patient admitted to the general
adult ward has their smoking status checked on
admission and that, those patients that smoke,
are offered brief smoking cessation advice,
referral to the hospital smoking cessation adviser
and nicotine replacement therapy (NRT) or an e-
cigarette. To ensure that any patient that is a
smoker has an individualised smoking cessation
care plan. To ensure that any patients who smoke
who request NRT have this reviewed on their
prescription card(s) on a regular basis to ensure
the NRT should continue to be prescribed (i.e. is
being accepted by the patient on a consistent
basis).
Physical Health
Schizophrenia
Audit (Inpatient)
Local
Division Clinical 29/07/2018
Inpatient Action Plan:
1. Continue to promote importance of screening
for HbA1c and Lipids – around cardo metabolic
risks
2. PHYSLOC8 can continue to monitor the
inpatient performance. This has been suspended
during the change to RIO. This needs to be active.
3. Target the key teams that have produced fewer
results and work out local actions to improve their
outcomes
4. Continue to support teams to understand the
importance of the physical health the need to
complete relevant nursing assessment forms.
5. The local division will continue to support the
priority of this agenda at all levels.
Nutritional
Screening and
Care Planning
(Adapted MUST
tool)
Local
Division Clinical 01/10/2017 No Action Plan
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 267
Skilled staff to deliver care
Managers made sure they had staff with a range of skills need to provide high quality care. They
supported staff with appraisals, supervision, opportunities to update and further develop their
skills.
Patients had access to psychologists and assistants, occupational therapists and assistants and
activity workers were employed across the wards. Patients accessed other services when
required, such as dietitians, physiotherapists and speech and language therapists.
The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, the overall appraisal
rates for non-medical staff within this core service was 91%.
Ward name
Total number of
permanent non-
medical staff
requiring an
appraisal
Total number
of permanent
non-medical
staff who have
had an
appraisal
%
appraisals
Liverpool Operational (Z1AF90) 2 2 100%
Hope Unit (Z1AB77) 19 19 100%
Specialist O.A.Ts (Z1WA22) 1 1 100%
Catering Windsor House (Z2BD50) 3 3 100%
Liverpool Deputy Director of Operations (Z1CH50) 2 2 100%
Deputy Director of Operations S&K (Z1AD01) 2 2 100%
Park/Rowbotham Unit (Z1NW01) 33 33 100%
FMA's Arundel (Z2BA10) 2 2 100%
FMA's Broadoak (Z2BA30) 20 20 100%
FMA's Windsor House (Z2BA50) 3 3 100%
Windsor House (Z1AA11) 27 26 96%
Hospital Assistants Rathbone (Z2BA40) 25 24 96%
Newton Ward (Z1BP01) 24 23 96%
Harrington Ward (Z1AD11) 27 25 93%
FMA's Clock View (Z2CN70) 37 34 92%
Dee Ward (Z1AB74) 28 25 89%
Inpatient Psychology Liverpool (Z2AB38) 5 4 80%
Catering Broadoak (Z2BD30) 4 3 75%
Liverpool Neighbourhood 3 (Z1NW79) 4 3 75%
Morris Ward (Z1AB73) 29 21 72%
Inpatient Psychology S&K (Z2AB41) 6 3 50%
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 268
Liverpool Health & Wellbeing (Z1AF93) 3 1 33%
Core service total 306
279 91%
Trust wide 5986
5106 85%
The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, there was no appraisal
data for medical staff.
The trust did not provide a narrative regarding how they measure clinical supervision.
Between 1 May 2017 and 31 July 2018, the average rate across all 14 teams in this core service
was 72%. No target was provided.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different
ways, it’s important to understand the data they provide.
Ward name Clinical supervision
sessions required
Clinical
supervision
sessions delivered
Clinical
supervision rate
(%)
Inpatient Psychology Liverpool (Z2AB38) 9 9 100%
Liverpool Deputy Director of Operations
(Z1CH50) 3 3 100%
Park/Rowbotham Unit (Z1NW01) 37 36 97%
Harrington Ward (Z1AD11) 27 26 96%
Windsor House (Z1AA11) 83 76 92%
S&K Neighbourhood 2 (Z1NW78) 9 8 89%
Dee Ward (Z1AB74) 26 22 85%
Morris Ward (Z1AB73) 33 26 79%
Newton Ward (Z1BP01) 28 20 71%
Talk Liverpool (Z2AB40) 277 176 64%
Liverpool Health & Wellbeing (Z1AF93) 8 5 63%
Hope Unit (Z1AB77) 64 36 56%
Inpatient Psychology S&K (Z2AB41) 12 4 33%
Liverpool Neighbourhood 3 (Z1NW79) 10 3 30%
Core service total 626
450 72%
Trust Total 15334
4947 32%
Multi-disciplinary and inter-agency 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.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 269
There were daily ‘red to green’ meetings on each of the wards. The multidisciplinary team
discussed the key issues for each patient, and focused on what each patient needed in order to be
discharged from hospital. This included medication, therapies, social interactions and activities,
and accommodation and support after discharge.
There were regular (usually weekly) multidisciplinary team meetings for each patient. Patients
attended the meeting, and their needs and care was discussed. When decisions were made that
the patient did not agree with, the rationale was explained to them and the patient’s views
recorded.
Staff made sure they shared clear information about patients and any changes in their care during
handover meetings. Nurses and care support workers attended a handover meeting at the
beginning of each shift.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental
Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.
Staff received training on the Mental Health Act and the Mental Health Act Code of Practice and
were able to describe the Code of Practice guiding principles. As of 31 July 2018, 90% of the
workforce in this core service had received training in the Mental Health Act. The trust stated that
this training is mandatory for all core services for inpatient and all community staff and renewed
every three years.
Staff had access to support and advice on implementing the Mental Health Act and its Code of
Practice. Staff knew who the Mental Health Act administrators were and when to ask them for
support. The administrators checked and managed the original paper Mental Health Act
documents. The paper documents were scanned into the electronic care record so that it was
accessible to staff. The service had clear, accessible, relevant and up to date policies and
procedures that reflected all relevant legislation and the Mental Health Act Code of Practice.
Patients had access to an independent Mental Health Act advocate.
Patients were aware of their rights under the Mental Health Act. Staff explained to each patient
their rights under the Mental Health Act in a way that they could understand, and repeated this as
necessary in accordance with the Mental Health Act Code of Practice.
Consent to treatment forms were completed for patients when necessary, and prescription charts
were consistent with the medication listed on the T2 or T3 form. We found one form where a
prescribed medication was not on the T3, and highlighted this to the manager who said they would
follow this up.
Good practice in applying the Mental Capacity Act
Staff supported patients to make decisions on their care for themselves. They understood the trust
policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 270
Staff gave patients support to make specific decisions for themselves and presumed patients had
the capacity to do so unless an assessment indicated otherwise. 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.
We saw examples of decisions being made in a person’s best interest when they were deemed
not to have the capacity to do this themselves. This was specific to each decision, and the
patient’s family members or an independent mental capacity advocate were part of the discussion.
Patient’s capacity to consent to treatment, including medication, was routinely assessed upon
admission. This was recorded in most cases, but not consistently in all records.
As of 31 July 2018, 88% of the workforce in this core service had received training in the Mental
Capacity Act. The trust stated that this training is mandatory for all core services for inpatient and
all community staff and renewed every three years.
The trust told us that there were no Deprivation of Liberty Safeguard (DoLS) applications made to
the Local Authority for this core service between 1 August 2017 and 31 July 2018.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 271
Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity,
and supported their individual needs.
The patients we spoke with were mostly positive about the staff. They told us that most staff had a
positive attitude and were caring and helpful. Staff usually knocked on doors, or shouted into the
dormitories before entering. The interactions we observed between staff and patients were
supportive and respectful. Staff engaged with patients to talk about their care, even when the
patient disagreed with the staff’s opinion or it was about a difficult or distressing subject. In staff
meetings, discussions about patients was respectful and showed an understanding of each
patient’s needs.
The 2017 Patient-led Assessments of the Care Environment (PLACE) score for privacy, dignity
and wellbeing, three of the four core service locations scored higher than similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
HESKETH CENTRE
Acute/PICU
MH - Community-based mental health services for
adults of working age
MH - Community mental health services for people
with a learning disability or autism
95.9%
CLOCK VIEW HOSPITAL
Acute/PICU
MH - Wards for older people with mental health
problems
MH - Community-based mental health services for
adults of working age
94.0%
BROADOAK UNIT (BROADGREEN
HOSPITAL SITE)
Acute/PICU 93.2%
WINDSOR HOUSE Acute/PICU 89.0%
Trust overall 92.7%
England average (mental health
and learning disabilities) 90.6%
Involvement in care
Staff involved patients and those close to them in decisions about their care, treatment and
changes to the service.
Involvement of patients
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 272
Patients were given a welcome or admission pack when they came to the ward, although it was
not clear if this always happened.
The patients we spoke with had mixed views as to how involved they were in their care planning.
The care records we looked at were also variable in the level of patient involvement. Patients were
invited to attend a multidisciplinary team meeting, usually once a week, and could ask questions
and give their views at this. Patients had their medication discussed with them and were provided
with information about it.
There were routine community meetings on each of the wards. These gave patients the
opportunity to raise concerns and give their views about the ward. This included discussions about
food, the environment, ward policies, and the activity programme. It was also an opportunity for
staff to give patients feedback, for example changes to staffing. The meetings were documented,
and showed that changes had been made in response to patient feedback. For example, changes
had been made to the menu, and visiting times had been extended at weekends. Ward activities
such as fundraising events and seasonal parties were organised through the meetings.
Involvement of families and carers
The trust website had a section specifically for carers that provided information and advice, and
signposted them to support. We received mixed views from carers about staff and the service
provided.
Carers and families were invited to the multidisciplinary team meetings, in agreement with the
patient. Patients were asked what information they wanted to share with others, and this was
documented.
Patients were usually admitted to a bed in the trust, but could be admitted to a bed in a different
part of the trust if their local wards were full. This caused potential difficulties for visitors if they had
to travel to a hospital that was further away.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 273
Is the service responsive?
Access and discharge
People could access the service closest to their home when they needed it. Waiting times from
referral to treatment and arrangements to admit, treat and discharge patients were in line with
good practice.
Bed management
All the wards in use at the time of our inspection reported average bed occupancies ranging above
the minimum benchmark of 85% in the year up to 31 July 2018. Managers and staff confirmed that
the wards were usually full. Most patients were admitted to a hospital in the trust, but some
patients were admitted to hospitals outside their catchment area if their local hospital was full.
Patients were found a bed when they returned from leave.
At the last inspection, all female patients needing a psychiatric intensive care bed were transferred
out of area, as they were not available in the trust. Newton ward had been extended since our last
inspection, to provide care for men and women. Staff told us that if a patient needed a psychiatric
intensive care bed and one was not available on Newton ward then a private bed would be found.
However, we were told that a patient who required seclusion was transferred to the seclusion
room at Park ward as the seclusion room at Newton ward was in use. The person was transferred
back to Newton ward when a bed/the seclusion room there became free.
The trust provided information regarding average bed occupancies for 14 wards in this core
service between 1 August 2017 and 31 July 2018.
The trust did not provide a target for this metric.
Ward name Average bed occupancy range (1 August 2017 – 31
July 2018) (current inspection) %
Acorn1 Ward MHH
83.4%
Albert 100.1%
Alt 100.2%
Boothroyd 90.9%
Brunswick 95.1%
Dee 98.1%
Harrington 95.3%
Irwell 85.7%
Morris 100.1%
Oak1 Ward MHH 94.5%
Park & Rowbotham 98.4%
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 274
Park Unit 90.2%
Rowbotham Asses Unit 76.5%
Windsor House 95.8%
The trust provided information for average length of stay for the period 1 August 2017 to 31 July
2018.
We are unable to compare the average bed occupancy data to the previous inspection due to
differences in the way we asked for the data and the period that was covered.
Ward name Average length of stay range in days (1 August 2017 – 31
July 2018) (current inspection)
Acorn1 Ward MHH 38-77
Albert 17-47
Alt 21-52
Boothroyd 44-75
Brunswick 26-37
Dee 26-51
Harrington 17-42
Irwell 47-94
Morris 26-38
Oak1 Ward MHH 49-101
Park & Rowbotham 15-48
Park Unit 43-58
Rowbotham Asses Unit 0-209
Windsor House 30-51
This core service reported nine out of area placements between 1 August 2017 and 31 July 2018.
There were four ongoing out of area placements.
The range of out of area placements was between 22 days and 3711 days.
Four of the nine out of area placements were due to capacity.
Number of out of
area placements
Number due to
specialist needs
Number due to
capacity
Range of lengths
(completed
placements)
Number of ongoing
placements
9 5 4 22-3711 days 4
This core service reported 242 readmissions within 28 days between 1 August 2017 and 31 July
2018.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 275
Of the total, 81 readmissions (33%) were readmissions to the same ward as discharge. Brunswick
accounted for the most with 17.
The average of days between discharge and readmission was 11 days. There was one instance
whereby patients were readmitted on the same day as being discharged but there were 16
instances where patients were readmitted the day after being discharged.
Number of
readmissions (to
any ward) within 28
days
Number of
readmissions (to
the same ward)
within 28 days
% readmissions to
the same ward
Range of days
between discharge
and readmission
Average days
between discharge
and readmission
242 81 33 0-28 11
Discharge and transfers of care
Between 1 August 2017 and 31 July 2018 there were 2124 discharges within this core service.
This amounts to 56% of the total discharges from the trust overall (3784). Of these, 198 (9%) were
delayed. Staff held daily ‘red to green’ meetings to discuss each patient’s progress, and the action
that needed to be taken to discharge them from hospital. This included ongoing care and
treatment on the ward, and support and accommodation required in order for a patient to be
discharged. There were routine bed management systems throughout the trust, which identified
and attempted to resolve any delayed transfers of care.
The core service met the referral to assessment target in all wards.
There were no assessment to treatment targets listed.
Name of
hospital
site or
location
Name of in-
patient ward Service Type
Days from
referral to initial
assessment
Days from
assessment to
treatment Comments,
clarification Target Actual
(mean)
Target Actual
(mean)
Clock View Inpats - Clock
View Mental Illness Acute 30 Days 9
Broadoak
Hospital Albert Ward Adult Mental Illness 30 Days 8 14.5
Clock View Alt Ward Adult Mental Illness 30 Days 5 10
Broadoak
Unit Brunswick Ward Adult Mental Illness 30 Days 11.5 19.5
Clock View Dee Ward Adult Mental Illness 30 Days 6 9
Broadoak
Hospital Harrington Ward Adult Mental Illness 30 Days 9 10
Clock View Morris Ward Adult Mental Illness 30 Days 9 13
Clock View Newton Ward
(PICU) Adult Mental Illness 30 Days 5.5 14
Hesketh
Centre
Park/Rowbotham
Unit Adult Mental Illness 30 Days 5 21.5
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 276
Windsor
House Windsor House Adult Mental Illness 30 Days 11.5 18
Clock View Morris Ward Adult Mental Illness 30 Days 9 13
Clock View Newton Ward
(PICU) Adult Mental Illness 30 Days 5.5 14
Hesketh
Centre
Park/Rowbotham
Unit Adult Mental Illness 30 Days 5 21.5
Windsor
House Windsor House Adult Mental Illness 11.5 18
Scott
Clinic
Medium Secure
(Urgent) Medium Secure Services 0 days
0.2
days
Assessments have been completed before the referral date.
Scott
Clinic
Medium Secure
(Non urgent) Medium Secure Services 20 days
32
days
Facilities that promote comfort, dignity and privacy
The design, layout, and furnishings of the wards at Clock View Hospital supported patients’
treatment, privacy and dignity. The other wards had dormitories which did not promote patients’
privacy and dignity. Patients had a lockable room or cupboard where they could keep personal
belongings safely.
All four wards at Clock View hospital had single rooms with ensuite facilities. The other five wards
at the other three sites had some single rooms, but most beds were provided in 4-bed dormitories
with shared bathroom and toilet facilities. In the dormitories there was limited space for patients to
personalise the area. Patients in the dormitories had a lockable drawer or cupboard to secure their
belongings.
The four wards at Clock View Hospital each had direct and open access to a private courtyard
garden. The other wards had their own garden, but access was supervised due to potential
ligature risks and several of the wards were on the first floor so were only accessible through an
enclosed staircase. Two of the wards at the Broadoak unit shared a garden, so patients only had
access to it for half of each hour. The courtyard gardens at Clock View Hospital were used by
patients to smoke. Patients at the other sites used the locked ‘cage’ entrance to the garden stairs
to smoke when the garden stairs were locked.
The trust’s estates strategy prioritised the replacement of ward environments that were not fit for
purpose. The trust was building a new hospital, Hartley Hospital, in Southport to replace the
Hesketh Centre. The build was due to be completed in January 2020. The trust was also
undertaking a feasibility study of potential sites for a new hospital to replace wards at Broadoak
and Windsor House, with a view to submitting a business case in the near future. The trust told us
that they hoped to be able to open this new hospital in Liverpool within the next three years.
The layout of each of the wards varied, but there were quiet areas, activity rooms, lounges and
laundry rooms on each of the wards. There was a family visiting room at the Broadoak Unit and
Clock View Hospital.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 277
Most patients had their own mobile phone, but a payphone or landline was available for patients
on all the wards if required. Patients kept their phones when they were admitted, unless there was
a specific risk or reason for the phone to be removed.
The 2017 Patient-led Assessments of the Care Environment (PLACE) score for ward food at four
locations scored higher than similar trusts. The patients we spoke with had mixed views about the
quality and portion sizes of the food. The food was cooked offsite and brought to the ward and
reheated. Patients could make hot drinks at any time.
Site name Core service(s) provided Ward food
HESKETH CENTRE
Acute/PICU
MH - Community-based mental health services for
adults of working age
MH - Community mental health services for people
with a learning disability or autism
95.4%
CLOCK VIEW HOSPITAL
Acute/PICU
MH - Wards for older people with mental health
problems
MH - Community-based mental health services for
adults of working age
100.0%
BROADOAK UNIT (BROADGREEN
HOSPITAL SITE) Acute/PICU 96.9%
WINDSOR HOUSE Acute/PICU 97.3%
Trust overall 95.4%
England average (mental health and learning disabilities) 91.5%
Patients’ engagement with the wider community
Staff supported patients with activities outside the service, such as work, education and family
relationships. The trust ran a recovery college, called life rooms. This was based in the community
in Walton and Southport, and was accessible by the public and users of Mersey Care services. It
offered patients employment opportunities, workshops and courses, and information.
Meeting the needs of all people who use the service
The service was accessible to all who needed it and took account of patients’ individual needs.
Staff helped patients with communication and cultural support.
The service made adjustments for patients with a disability. There was an accessible bathroom
and toilet on each of the wards, and lift access to wards that weren’t on the ground floor.
There were noticeboards and leaflets on each of the wards, and in the reception areas of each of
the hospitals. These provided information to patients such as about the service, illnesses, local
facilities and how to raise concerns or get support.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 278
Staff told us that interpreters were available when required, for patients or carers who did not
speak English or who were hard of hearing.
Patients’ spiritual and cultural dietary needs were provided for. This included vegetarian food,
gluten free meals, and Halal or Kosher food.
Patients could access spiritual support. The trust had chaplains from a variety of faiths which
included Catholic, Anglican, Muslim and Buddhist. They provided support for patients and staff.
Religious materials and holy books were available for different faiths.
Listening to and learning from concerns and complaints
The service treated concerns and complaints seriously, investigated them and learned lessons
from the results. Most patients we spoke with said they knew how to complain, and those that had
made a complaint had received a response or feedback about it. Information was on display about
how to make a complaint. Staff told us they tried to resolve complaints, and would escalate to the
nurse in charge, manager or patient advice and liaison team when required.
This core service received 40 complaints between 1 August 2017 and 31 July 2018. Five of these
were upheld, eight were partially upheld and 15 were not upheld. One complaint was referred to
the Ombudsman and five were under investigation.
Total
Complaints
Fully upheld Partially
upheld
Not upheld Other Withdrawn Under
Investigation
Referred to
Ombudsman
40 5 8 15 5 2 5 1
This service received no compliments during the last 12 months from 1 August 2017 and 31 July
2018.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 279
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. Managers had the skills and knowledge to perform their roles, and had a
good understanding of the services they managed. They were visible in the service, and
approachable for patients and staff. Leadership training programmes were available for ward and
senior managers. However, most inpatient occupational therapists were in relatively junior
positions and there wasn’t a clear pathway for career progression.
Vision and strategy
The trust had a vision for what it wanted to achieve and workable plans to turn it into action
developed with involvement from staff and patients. These were reflected by the staff we spoke
with.
The staff we spoke with were clear about the trust’s goals, and were aware of the practical
implementation of the no force first and zero suicide initiatives. Patients’ physical health care was
activity assessed and any concerns followed up upon.
Culture
Managers across the trust promoted a positive culture that supported and valued staff, creating a
sense of common purpose based on shared values.
The staff we spoke with were mostly positive about their local teams and managers, and felt
supported by them. Many staff felt that staffing levels put pressure on them, but believed they
worked together as a team to provide good care for patients.
Staff knew how to raise their concerns, either with their local managers or within the wider trust.
Some staff were off work because of work-related incidents, and some staff had been off but had
now returned. Some staff told us they had been positively supported by the trust following
incidents at work. The trust had an awards system, and we spoke with staff whose teams had won
or be nominated for awards for the service they had provided.
The sickness level within this core service was 10% in the year up to July 2018. This was higher
than across the NHS in July 2018 where the rate was 4.09%, as reported by NHS Employers. The
trust had a policy for managing and supporting staff during sickness.
During the reporting period there were no cases where staff have been either suspended, placed
under supervision or were moved to a different ward.
Governance
The trust used a systematic approach to continually improve the quality of its services and
safeguarding high standards of care by creating an environment in which excellence in clinical
care would flourish.
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 280
Managers submitted information about their wards, and used this to monitor and improve the
running of and care provided on the ward. This included several systems such as staff reporting,
incident reporting, and the business intelligence system. This information was used to reviews the
quality and safety of the environment, manage the safe staffing of the wards and their training and
supervision, manage the effective use of beds across the trust, and learn from incidents and
audits. We saw examples where changes had been made following learning from incidents. For
example, following deaths changes had been made to the environment, and psychology provision
had been implemented or increased on all the acute inpatient wards.
Management of risk, issues and performance
The trust had effective systems for identifying risks, planning to eliminate or reduce them, and
coping with both the expected and unexpected. This included several systems such as staff
reporting, incident reporting, and the business intelligence system. This was used for recording
and monitoring the ward’s progress against key performance indicators, such as audits and
training. The information fed into the trust’s broader governance system.
Most of the wards had a daily safety huddle. The purpose of this meeting was for members of the
multidisciplinary to get together and discuss any issues of concern on the ward, and either reflect
on previous issues or plan to address what may happen in the near future. This could include
issues such as staffing levels, bed management, or potential patient concerns. Most staff we
spoke with found this positive and useful.
The trust provided a document detailing their 34 highest profile risks. Only one of these has a
current risk score of 15 or higher (high risk) however it does not relate to this core service.
The staffing levels were identified as a risk. There were strategies for managing this, and an
ongoing recruitment and retention programme.
The service had contingency plans for responding to emergencies.
Information management
The trust collected, analysed, managed and used information well to support all its activities, using
secure systems with security safeguards. This included several systems such as staff reporting,
incident reporting, and the business intelligence system. This was used for recording and
monitoring the ward’s progress against key performance indicators, such as audits and training.
The information fed into the trust’s broader governance system.
Care records were stored electronically. They were stored securely, and access was through an
individual ID card and password. A new system had been implemented in July 2018 and staff were
still getting used to it. Staff were not always clear about where information was or should be
stored, and there were differences across the wards. The trust had identified this as an issue, and
was introducing a set of standard domains within care plans to promote consistency.
Engagement
Patients and carers could get information about the trust at its services, or through the trust
website. The website had specific sections for patients and for carers. There were various direct
Mersey Care NHS Foundation Trust evidence appendix: acute wards for adults of working age and psychiatric intensive care units Page 281
and electronic methods for patients and carers to give feedback to the trust, in addition to talking
directly to ward staff.
Staff accessed information about the trust through the trust intranet and website. Information was
also shared at team meetings, and by emails within the trust.
Learning, continuous improvement and innovation
Trust-wide initiatives were ongoing within the trust, that impacted on the care provided on the
acute wards and psychiatric intensive care unit. This included the self-harm project which worked
with patients who self-harmed, and aimed to improve their coping strategies and give them less-
damaging means of dealing with their emotions.
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 accreditations for this core service. Staff told us the wards were no longer part of
the Royal College of Psychiatrists accreditation scheme. The trust had its own internal quality
review visits, where trust staff from other service areas carried out reviews of different parts of the
trust.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 282
Wards for people with a learning disability or autism
Facts and data about this service
Location site name Ward name Number of beds Patient group (male,
female, mixed)
STAR Unit, William House
Rathbone Hospital
L13 4AW STAR Unit 9 Mixed
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 283
Is the service safe?
Safe and clean care environments
Safety of the ward layout
The ward was safe, clean, well equipped, well furnished, and well maintained. Day and communal
areas were arranged around a main corridor. This meant that staff could not easily see all areas of
the ward. Staff used individual observations to reduce any risk to patients.
The ward was mixed-sex, with bedrooms for men leading off the main corridor and bedrooms for
women leading off a separated area at the end of the ward. There were closed-circuit television
cameras in communal areas. Each patient had a gender and dignity care plan. Staff explained to
each patient how their privacy and dignity would be maintained. Each patient was given easy-read
information about the closed circuit television and about privacy on the ward.
Over the 12-month period from 1 August 2017 to 31 July 2018 there were no mixed sex
accommodation breaches within this core service.
Just before our inspection, a male patient was temporarily accommodated in a single, en-suite
room in the female area of the ward due to a clinical emergency. Staff had completed a full risk
assessment. Staff had increased their observation levels during this period to ensure the safety,
privacy and dignity of the male and all of the female patients. Managers had reported this to the
NHS Commissioning Board.
Staff knew about any ligature anchor points and actions to mitigate risks to patients who might try
to harm themselves. Environmental risk assessments were completed and up to date. Bedroom
furniture and ensuite bathroom fittings were anti-ligature.
The ward had an up to date fire risk assessment in place and staff were trained in fire safety.
Eleven staff were trained to fire warden standard. Personal emergency evacuation plans were in
place for all patients who needed them. Two planned fire drills and one unplanned activation of the
fire alarm had taken place in the year prior to inspection. The ward was evacuated safely on each
occasion.
The fire safety file that we viewed on the day of inspection contained out of date information. The
trust has since provided assurance that they have archived this file.
Maintenance, cleanliness and infection control
The ward was clean and well-maintained. Certificates confirmed that the ward’s fire safety
equipment and electrical installations were checked regularly.
Staff adhered to infection control principles and completed regular infection control audits.
However, we found that soap dispensers had been removed from patients’ communal bathrooms.
Staff told us that this was due to a patient pulling them off the wall, leading to incidents. We were
concerned that patients using the communal bathrooms would be unable to wash their hands
effectively after using the toilet. This posed a risk of infection being spread on the ward. The risk
was mitigated by each patient having access to their own en-suite bathroom at all times. Wipes
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 284
and pump-action soap were also available. The trust told us that they planned to re-attach the
soap dispensers to the walls with Velcro (so that they could easily be removed again if needed)
and issue all staff with alcohol-free hand gel.
The trust had removed metal plates from door closures on the ward’s main corridor, exposing
some of the doors’ inner workings. The trust had done this following a risk assessment in 2015.
The trust had identified that the plates were not secure and could be used by patients to harm
themselves. The removal of the metal plates did not affect the integrity of the fire door and did not
pose any additional risk to patients.
For the most recent Patient-led Assessments of the Care Environment (PLACE) 2017, Rathbone
Hospital, which is where STAR unit is based, scored lower than the similar trusts for two of the
four aspects overall. Rathbone Hospital received a score similar to other trusts for condition,
appearance and maintenance scoring 97.3% compared to 97.7% nationally.
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
Rathbone Hospital
Secure wards/forensic inpatient
Community based mental health services for adults of working age
Long stay/rehabilitation for adults of working age
Wards for people with learning disabilities or autism.
99.4% 97.7% - 81.3%
Trust overall 98.8% 97.3% 81.3% 89.9%
England average (Mental
health and learning
disabilities)
99.4% 97.7% - 100.0%
Staff did not use seclusion and there was no seclusion room on the ward.
The clinic room was clean, and the fittings met infection control guidelines. The trust’s medical
devices team had checked and calibrated the clinic room’s equipment. Ward staff regularly
checked emergency equipment and emergency medication. However, there had been no
resuscitation drill during the year preceding the inspection. This meant that the trust could not be
fully assured that staff would respond quickly and effectively in a medical emergency. The ward
had planned their next resuscitation drill to take place in January 2019.
Safe staffing
Nursing staff
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 285
The service had enough nursing and medical staff, who knew the patients and received basic
training to keep people safe from avoidable harm.
At our last inspection of STAR unit, in March 2017, we found that there were not sufficient
numbers of staff on duty to manage the level of observations.
At this inspection we found that staffing establishment was six staff (two nurses and four support
workers) for day shifts and four staff (one nurse and three support workers) for night shifts. The
ward manager told us that, as part of a recent yearly safe staffing review, the trust had agreed to
increase the staffing establishment to seven staff during the day and five at night. Staffing rotas
showed that additional staff had been brought in to support the high level of individual
observations. The usual staffing for the ward was ten staff (two nurses and eight support workers)
for both day and night shifts. The ward manager felt able to request additional staff to ensure the
safety of the unit. This meant that there were enough staff to carry out physical interventions, take
patients on escorted leave, and offer ward activities.
Support staff had designed and used their own template to allocate their duties for each shift. The
template ensured that no member of staff undertook more than two hours of continuous
observations.
The unit frequently used bank or agency staff. All bank and agency staff received an induction
before working on the ward. Most bank and agency staff did regular shifts. They knew the patients
well, and accessed supervision and incident debriefs from substantive staff.
The tables below show the numbers of substantive staff, turnover, sickness and use of bank and
agency staff.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 July 2018 31.0 N/A
Total number of substantive staff leavers 1 August 2017–31 July 2018
2.8 N/A
Average WTE* leavers over 12 months (%) 1 August 2017–31 July 2018
10% N/A
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31 July 2018 -6 N/A
Total vacancies overall (%) At 31 July 2018 -14% 5%
Total permanent staff sickness overall (%)
Most recent month (At 31 July 2018)
20% N/A
1 August 2018 –31 July 2018
12% N/A
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 286
Substantive staff figures Trust target
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 July 2018 11.1 N/A
Establishment levels nursing assistants (WTE*) At 31 July 2018 22.5 N/A
Number of vacancies, qualified nurses (WTE*) At 31 July 2018 -2.3 N/A
Number of vacancies nursing assistants (WTE*) At 31 July 2018 -2.5 N/A
Qualified nurse vacancy rate At 31 July 2018 -21% 5%
Nursing assistant vacancy rate At 31 July 2018 -11% 5%
Bank and agency Use
Hours bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 August 2017-31 July
2018 1832 N/A
Hours filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses) 1 August 2017-31 July
2018 263 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses) 1 August 2017-31 July
2018 207 N/A
Hours filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 August 2017-31 July
2018 24599 N/A
Hours filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 August 2017-31 July
2018 18103 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants) 1 August 2017-31 July
2018 402 N/A
*Whole-time Equivalent / minus figures = oversubscribed
This core service reported an overall vacancy rate of -21% over establishment for registered
nurses at 31 July 2018.
This core service reported an overall vacancy rate of -11% over establishment for registered
nursing assistants.
This core service has reported a vacancy rate for all staff of -14% over establishment as of 31 July
2018.
Registered nurses Health care assistants Overall staff figures
Ward/Team
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%
)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%
)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%
)
Star Unit -2.3 11.1 -21% -2.5 22.5 -11% -4.7 33.6 -14%
Core service total -2.3 11.1 -21% -2.5 22.5 -11% -4.7 33.6 -14%
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 287
Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%
NB: All figures displayed are whole-time equivalents
Between 1 August 2017 and 31 July 2018, bank staff filled 1832 hours to cover sickness, absence
or vacancy for qualified nurses.
In the same period, agency staff covered 263 hours for qualified nurses. Two hundred and seven
hours were unable to be filled by either bank or agency staff. We did not identify any negative
impact to patients relating to unfilled shifts.
Ward/Team Available
hours
Hours filled by
bank staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
STAR Unit 1804 1832 263 207
Core service total 1804 1832 263 207
Trust Total 242318 125599 64603 31532
Between 1 August 2017 and 31 July 2018, bank staff to cover sickness, absence or vacancy for
nursing assistants filled 24599 hours.
In the same period, agency staff covered 18103 hours. Four hundred and two hours were unable
to be filled by either bank or agency staff. We did not identify any negative impact to patients
relating to unfilled shifts.
Ward/Team Available
hours
Hours filled by
bank staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
STAR Unit 3673 24599 18103 402
Core service total 3673 24599 18103 402
Trust Total 210729 442987 204924 29961
This core service had 2.8 (10%) staff leavers between 1 August 2017 and 31 July 2018. The ward
manager told us that generally turnover was low, and that the most recent member of staff to leave
had been offered another position in the trust.
Ward/Team Substantive staff Substantive staff Leavers Average % staff leavers
350 L9 Star Unit (Z1FY30) 31.0 2.8 10%
Core service total 31.0 2.8 10%
Trust Total 2658.6 294.5 13%
The sickness rate for this core service was 12% between 1 August 2017 and 31 July 2018. The
most recent month’s data [31 July 2018] showed a sickness rate of 20%.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 288
Sickness had reduced to around the trust average of 8% since July 2018. We saw that some staff
who had been on long-term sickness absence due to musculoskeletal issues had returned to work
with light duties.
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff
sickness (over the past
year)
350 L9 Star Unit (Z1FY30) 20% 12%
Core service total 20% 12%
Trust Total 8% 8%
The below table covers staff fill rates for registered nurses and care staff during July, August and
September 2018.
Star Unit had over-filled for care staff for day and night shifts for all months reported.
Key:
> 125% < 90%
Day Night Day Night Day Night
Nurses
(%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Jul 18 Aug 18 Sep 18
STAR Unit 89.5 131.8 103.4 200.1 97.5 136.3 100.0 226.9 106.7 147.1 100.0 221.1
Medical staff
Between 1 August 2017 and 31 July 2018 data was provided by the trust, however it was not in a
useable format.
A consultant psychiatrist and three junior doctors covered the STAR unit and the trust’s community
learning disability teams. There was always a doctor either based on the unit or able to respond
immediately between 9am and 5pm weekdays. Staff were able to access hospital on-site medical
cover in an emergency at all other times.
Mandatory training
The compliance for mandatory and statutory training courses at 31 July 2018 was 94%. Of the
training courses listed eight failed to achieve the trust target of 95% and of those, one failed to
score above 75%.
The trust monitored training compliance data on an ongoing monthly basis. Statutory training was
reported as part of the monthly board report dashboard produced by the trust’s Workforce team
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 289
and a separate dashboard was provided by the trust’s Learning and Development team for all
other courses classified as role essential.
The training compliance reported for this core service during this inspection was lower than the
88% reported in the previous year.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service %
Trust target % Trust wide mandatory/ statutory training total %
Continuous Professional Development -
Adverse Incidents (Every 3 Years) 100 95 92
Continuous Professional Development -
Complaints (Every 3 Years) 100 95 94
Mandatory Training - Conflict Resolution
(Every 3 Years) 100 95 92
Mandatory Training - Infection Control
(Every 3 Years) 100 95 92
Mandatory Training - Safeguarding Adults
- Level 1 (Every 3 Years) 100 95 95
Mandatory Training - Safeguarding
Children - Level 1 (Every 3 Years) 100 95 95
Role Specific Mandated Training -
Deprivation of Liberties - Level 1 (Every 3
Years) 100 90 89
Role Specific Mandated Training - Mental
Capacity Act - Level 1 (Every 3 Years) 100 90 88
Role Specific Mandated Training - Mental
Health Act - Level 1 (Every 3 Years) 100 90 90
Role Specific Mandated Training -
Safeguarding Adults Level 3 - Trust Model
(Every 3 Years) 100 90 76
Role Specific Mandated Training -
Safeguarding Children Level 3 - Trust
Model (Every 3 Years) 100 90 76
Continuous Professional Development -
Smoking Cessation (1 Time) 97 95 89
Continuous Professional Development -
Suicide Prevention & Safety Planning
(Every 3 Years) 97 95 90
Mandatory Training - Equality, Diversity
and Human Rights (Every 3 Years) 97 95 91
Mandatory Training - Fire Safety (Every 3 97 95 92
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 290
Training course This core service %
Trust target % Trust wide mandatory/ statutory training total %
Years)
Mandatory Training - Health & Safety
(Every 3 Years) 97 95 92
Mandatory Training - Moving & Handling
(Every 3 Years) 97 95 90
Role Specific Mandated Training - Basic
Prevent Awareness (1 Time) 97 95 93
Role Specific Mandated Training -
Safeguarding Adults Level 2 -Trust Model
(Every 3 Years) 97 90 87
Role Specific Mandated Training -
Safeguarding Children Level 2 - Trust
Model (Every 3 Years) 97 90 87
Role Specific Mandated Training - Safe
and Effective Use of Medicines (Every 3
Years) 91 90 63
Role Specific Mandated Training - Rapid
Tranquilisation Training 91 90 61
Role Specific Mandated Training -
Controlled Drugs & High Risk Medicines 91 90 67
Role Specific Mandated Training -
Medicines Calculations (Every 3 Years) 91 90 63
Role Specific Mandated Training -
Intermediate Life Support (Every Year) 91 90 72
Continuous Professional Development -
Fraud Awareness (Every 3 Years) 87 95 89
Role Specific Mandated Training - Basic
Life Support (Every Year) 87 95 70
Role Specific Mandated Training -
Personal Safety Breakaway - Level 1
(Every Year) 87 90 74
Role Specific Mandated Training -
Personal Safety (Every Year) 87 90 80
Continuous Professional Development -
Dementia Awareness (1 Time) 86 95 78
Mandatory Training (IG) - Data Security
Awareness - Level 1 (Every Year) 79 95 50
Role Specific Mandated Training -
MHA/DoL's Level 2 (Every 3 Years) 75 90 53
Role Specific Mandated Training -
Witness to Medication (Every 3 Years) 50 90 62
Core Service Total % 94% 87%
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 291
When we inspected STAR unit we viewed an updated training record. This showed that all staff
who were not on long-term absence were compliant with all training topics. The only exception
was the ‘witness to medication’ training for nursing assistants. The ward manager had planned for
a trainer to visit the ward. We did not identify any negative impact on patients due to low
compliance with this training.
Assessing and managing risk to patients and staff
Assessment and management of patient risk
Staff completed and updated risk assessments for each patient and used these to understand and
manage risks individually. They minimised the use of restrictive interventions and followed best
practice when restricting a patient.
We looked at all nine patient risk assessments. Staff completed risk assessments within 48 hours
of patients’ admission, and updated them regularly. At our previous inspection, we found that not
all patients with epilepsy at Wavertree Bungalow had a detailed epilepsy care plan. At this
inspection of STAR unit, we found that patients with epilepsy did have a detailed epilepsy care
plan. This meant that staff knew how to keep those patients safe.
Use of restrictive interventions
This core service had 169 incidents of restraint (on 39 different service users) and zero incidents
of seclusion between 1 August 2017 and 31 July 2018.
The below table focuses on the last 12 months’ worth of data: 1 August 2017 and 31 July 2018
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Star Unit 0 169 39 2 (1%) 0 (0%)
There were four incidents of prone restraint, which accounted for 2% of the restraint incidents.
Over the 12 months, there were peaks in the use of restraint in November 2017 and January
2018, when there were 25 instances and 24 instances respectively.
There were no instances of mechanical restraint over the reporting period.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 292
We reviewed all nine patient care records and spoke with staff about their use of restraint.
Evidence showed that restraint was used competently, safely and only as a last resort with
minimum force.
Over the 12 months, there were no reported instances of seclusion in this core service.
There were no instances of long-term segregation over the 12-month reporting period.
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.
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 117 safeguarding referrals between 1 August 2017 and 31 July 2018, of
which 117 concerned adults and no children.
Number of referrals
Adults Children Total referrals
1
5
15
25
14
1212 12
1513
24
21
0 0 0 01 1
0 0 0 0 0 00
5
10
15
20
25
30
Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18
Total restraints over the 12 month period
Number of incidents of the use of restraintsNumber of prone restraints
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 293
117 0 117
There were two peaks identified in adult referrals across the period in November 2017 and July
2018 with 13 and 16 respectively.
The majority of safeguarding referrals were made following altercations between patients where
no injury was sustained. None had resulted in an investigation by the local authority or police. The
ward manager told us that she was planning to work with staff and the local authority to clarify
thresholds for referral.
Staff we spoke with understood the trust safeguarding policy and knew how to raise a
safeguarding alert.
There was a police liaison officer linked to the ward. Staff told us that the police liaison officer had
a good understanding of the needs of people with a learning disability or autism.
Mersey Care NHS Foundation Trust submitted details of three serious case reviews commenced
or published in the last 12 months (1 June 2017 and 31 May 2018). However, none related to this
core service.
Staff access to essential information
Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and
easily available to all staff providing care.
A new electronic record system had been put in place a month prior to our inspection. A group of
senior staff had transferred all of the patients’ current care plans and risk assessments over to the
new system on the day of migration. Staff were still able to access the old system to review
historic records.
Staff had created portable ‘keyrings’ with brief summaries of patients’ risk management and care
plans. This meant that staff caring for individual patients could easily access important information
when they were on the ward and in the community.
Medicines management
Staff followed best practice when storing, dispensing and recording medication. Staff regularly
reviewed the effects of medication on each patient’s physical health.
At our last inspection we found that there was out of date clinical stock at STAR unit. At this
inspection we found that clinical stock was in date and that there were robust systems in place to
monitor this.
At our last inspection we found that some patients’ treatment had been delayed as medication was
not available. At this inspection, all prescribed medications were available when needed.
Patients who were prescribed antipsychotics either had a reduction plan in place, or had reasons
documented in their care record for continuing these medications. This was in line with NHS
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England’s ‘stopping over medication of people with a learning disability, autism or both’ (‘STOMP’)
project.
There was a clear risk assessment and management plan in place for a female patient who was
prescribed sodium valproate. Sodium valproate is associated with risks for babies exposed to the
drug during pregnancy.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS)
within two working days of an incident being identified.
Between 1 August 2017 and 31 July 2018 there were three STEIS incidents reported by this core
service. Of the total number of incidents reported, the most common type of incident was
‘Abuse/alleged abuse of adult patient by staff’ with two.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the
available preventative measures are in place. This core service reported no never events during
this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months.
The number of the most severe incidents recorded by the trust incident reporting system was
broadly comparable with STEIS.
Type of incident reported on STEIS
Ab
use/a
lleg
ed
ab
use
of
ad
ult
pati
en
t b
y
sta
ff
Dis
rup
tiv
e/
ag
gre
ssiv
e/ vio
len
t
beh
avio
ur
meeti
ng
SI c
rite
ria
Gra
nd
To
tal
Star Unit 1 1
Star Unit - Rathbone Hospital 1 1
Star Unit - Rathbone site 1 1
Total 2 1 3
Reporting incidents and learning from when things go wrong
The service managed patient safety incidents well. Staff recognised incidents and reported them
appropriately. Managers investigated incidents and shared lessons learned with the whole team
and wider service. When things went wrong, staff apologised and gave patients honest information
and suitable support.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 295
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 two ‘prevention of future death’ reports sent to the trust for a
response. A third report involved a patient who died whilst in the trust’s care, but the trust was not
directly asked for a response. However, none of these related to this core service.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 296
Is the service effective?
Assessment of needs and planning of care
Staff assessed the physical and mental health of all patients on admission. They developed
individual care plans and updated them when needed.
Staff had received support from the specialist learning disability division around effective care
planning. They were now using the trust’s ‘complex case and recovery management’ care plans.
We reviewed all nine patients’ care records. All included up to date, personalised, holistic,
recovery-oriented care plans. Patients who presented with behaviours that challenged each had a
positive behaviour support plan in place. Positive behaviour support plans stated, in detail, all the
interventions required to change behaviour proactively and manage behaviour reactively. The
ward’s recovery-based approach was consistent with the Department of Health recommendations
outlined in Positive and Proactive Care: reducing the need for restrictive interventions (2014).
Staff had created portable ‘keyrings’ with brief summaries of patients’ risk management and care
plans. This meant that staff caring for individual patients could easily access important information
when they were moving around the ward and out in the community.
The ward’s admission checklist included information about trauma and protected characteristics.
This meant that staff were quickly able to plan around patients’ specific needs, for example if a
patient was only able to work with staff of a particular gender.
All patients were clerked on to the ward by a medic. This included a physical health check. All
patients also had a full nursing health review, including optometry, diet and podiatry. All patients
were assessed for pressure ulcers.
Best practice in treatment and care
Staff provided a range of treatment and care for patients based on national guidance and best
practice. Staff supported patients with their physical health and encouraged them to live healthier
lives.
Staff consistently applied effective proactive strategies to prevent behaviour that challenges. This
had improved since our last inspection. For example, the ward manager had brought ear
defenders into the ward to offer to patients who struggled with high noise levels. When staff
applied reactive strategies, including restrictive interventions, they did so effectively and safely.
We saw that there was an embedded culture of learning and improving positive behaviour support
plans, as part of an overall multi-disciplinary approach to reviewing restraints and risks. Staff
revisions to care plans had resulted in reduced risk of staff injury following restraint of one patient,
and enabled another to continue accessing the community following an incident.
The ward’s speech and language therapist was supporting staff to communicate with a patient
using intensive interactions. The occupational therapist undertook sensory assessments and
management plans to enable effective care planning for patients with autism.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 297
We also saw evidence of best practice in relation to patients who did not present with behaviour
that challenges. For example, staff were using cognitive-behavioural strategies to help a patient
challenge their negative thoughts about themselves and others.
This core service participated in 10 clinical audits as part of their clinical audit programme 2017 –
2018.
Audit name Audit scope Audit type Date
completed Key actions following the audit
REILS Red Bag
(Emergency bag)
Audit
Secure, Local
and SpLD
Divisions
Clinical and
Environment 09/08/2017
The areas for improvement were signposting
to emergency ILS bags and contents lists
being present in the bags. This has been
factored into routine monitoring at ward level
to improve compliance, and is part of regular
reviews. Individual actions were identified as
follows: SpLD: Staff need instruction and/or
flowchart for restock/resealing of bag. Needs
signage erecting to indicate to staff the
location of the emergency orange box. Staff to
be advised that AED is not getting checked
regularly. Staff to be advised to check AED on
a daily basis and to sign to say it has been
checked daily. Secure Division: A rota to be
put in place to ensure that daily checks of
AED are done regularly, Aztrax need to check
AED as out of date and needs asset number.
2 x non rebreather masks need replacing as
out of date. Needs signage erecting to direct
staff to nearest AED and oxygen location, 2 x
size 14g cannulas out of date and need
replacing. Local Division: Needs signage
erecting to direct staff to nearest AED and
oxygen location, an equipment list and a flow
chart for restock/reseal of bag. Staff to be
advised to check AED on a daily basis and to
sign to say it has been checked daily. Needs
1 set of defib pads replacing as out of date
and non rebreather mask to go with the
oxygen. Oxygen to be reordered along with a
new bag valve mask.
Health Records
Audit
Secure,
Local,SpLD
and LCH
Sefton
Locality
Clinical 14/12/2017
Each Division has a breakdown of data
relating to their own area. The emphasis for
action and improvement is countersignature
of entries by staff that cannot authorise a
clinical note. There is a review of the
electronic patient records systems in use to
review how automation can improve
compliance.
Nutrition Support
for Adults
Secure, Local
and SpLD
Divisions
Clinical 31/01/2018 No action plan - requested by CCG to show
compliance with NICE guidance.
Ward Transfers
Audit Local Division Clinical 27/02/2018 No action Plan (see previous column).
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 298
Audit name Audit scope Audit type Date
completed Key actions following the audit
Named Nurse Audit
Report Local Division Clinical 27/03/2018
The Audit Findings have been shared with the
Lead Nurse for the Local Division for her
comments / actions.
The Clinical Audit Team recommended the
following:
For all named nurse sessions, it should be
clearly stated at the start of the note that it is a
1:1 Named Nurse Session.
There was evidence to suggest that a lot of
what should be discussed in a Named Nurse
session was being documented but NOT
under this heading – so this was a
documenting issue rather than it not being
done. It was either contained in a general
ward note or MDT note.
The template provided for the audit may not
be appropriate for some patients on Older
Persons Wards in particular those with an
organic diagnosis. This was due to the weekly
planned sessions, which would not always be
appropriate in these cases. Action Plan
formulated to include the following: 1. Ward
Manager to discuss with Registered Nurses
ways to maximise opportunities to spend time
on 1:1 basis with named service users. 2.
Develop and share named nurse proforma for
named nurses to use in 1:1 sessions with
service users.
Cleanliness Audit Secure and
SpLD Division
Clinical and
Environment 28/06/2018
These results have been discussed within the
teams and remedial action plans in
development
Inpatient Diabetes
Audit
Secure and
SpLD
Divisions
Clinical 02/10/2017
1. All diabetic inpatients should have
frequency of CBG monitoring determined at
their First Ward review and is at the discretion
of the consultant. 2. All CBG monitoring
should be consistent - i.e. before meals. 3.
Ensure that serum cholesterol / triglyceride
profile has been done on admission bloods, if
not done within the last 6 months. If serum
cholesterol high, statin therapy should be
started as an inpatient unless contraindicated.
Levels should be checked every 6 months - if
no longer an inpatient, can be at discretion of
GP upon discharge. 4. Ensure any
hyperglycaemia, and hypoglycaemia is acted
upon and documented. For persistent
hyperglycaemia, advice should be sought
from Diabetes Specialist Nurses at RLUH,
Aintree - time frame TBC. Advice should be
documented. For hypoglycaemia, adoption of
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 299
Audit name Audit scope Audit type Date
completed Key actions following the audit
a Trust-wide hypoglycaemia protocol should
be used and followed as much as reasonably
practical. 5. Review of diabetic status should
be done at every ward review; any episodes
of hypoglycaemia should be taken into
account, and acted upon if they haven't been
already. 6. All wards should have a named
person and designation regarding who to
contact for advice regarding diabetes
management - there should be a written
agreement regarding this and all members of
staff should be made aware. 7. Ensure blood
pressure is monitored at least daily in all
diabetic patients. If not on appropriate
antihypertensive therapy, this should be
started as an inpatient. 8. Re-audit should be
done in one year to allow for implementation
of the above.
Epilepsy
Management in
Learning
Disabilities (An
inpatient audit)
SpLD Clinical 12/12/2017
Epilepsy care plan and risk assessment to be
created by the MDT when a patient with
epilepsy is admitted to the Star Unit. This
should include contact details of the patient's
epilepsy specialist nurse. If evidence of
prolonged or repeated seizures ensure that
there is an emergency care plan in place.
Ensure that all staff involved are aware of the
care plan and where to find it on ePEX. A
local template or checklist should be
developed to ensure consistency in the
content of each epilepsy care plan based on
NICE clinical guideline 137 recommendation
1.3.1. The plan should be reviewed on at least
annually.
Mersey Care
Treasure Hunt: A
Trust Wide Audit of
Medical Equipment
Available on
Psychiatric Wards
Local and
Secure
Division
Clinical and
Environment 05/02/2018 No Action Plan
Nutritional
Screening and Care
Planning (Adapted
MUST tool)
Local Division Clinical 01/10/2017 No Action Plan
Skilled staff to deliver care
Managers made sure they had staff with a range of skills needed to provide high quality care.
They supported staff with appraisals, supervision, and opportunities to update and further develop
their skills.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 300
The ward multi-disciplinary team was comprised of registered learning disability nurses, a nurse
clinical lead, a ward manager, support workers, a consultant psychiatrist, an occupational
therapist, a speech and language therapist, a social worker and a clinical psychologist.
At the time of inspection, the ward’s clinical psychologist was on long-term leave. Managers had
been unable to recruit a fixed-term replacement. Psychologists from the community teams
continued to work with their own patients, and offered consultation and support to the ward. This
meant that patients continued to receive psychologically-informed care.
Team away days took place four times a year, and included training and reflective practice
sessions. Staff from another learning disability service in the trust worked on the ward during the
away days so that the whole team could attend.
At our last inspection, we found that staff had not had sufficient training in a range of areas
essential to this core service, and that there was no system to record additional training. At this
inspection we found that staff had received training in autism awareness, learning disability
awareness, epilepsy, communication skills and dysphagia. Managers were able to check staff
compliance with additional training through attendance records for away days. New staff attended
the specialist learning disability division induction, which included all of these essential topics.
The trust supported staff to implement positive behaviour support through protected time, training
and supervision. One of the trust’s specialists in positive behaviour support had delivered training
to all staff, and remained available on the ward at regular times to provide consultation around
individual patients’ needs. This meant that positive behaviour support was led by the nursing team
and was therefore central to patient care.
The trust’s target rate for appraisal compliance is 95%. As at 31 July 2018, the overall appraisal
rates for non-medical staff within this core service was 83%. There was no data for medical staff.
Ward name
Total number of
permanent non-
medical staff
requiring an
appraisal
Total number of
permanent non-
medical staff
who have had
an appraisal
%
appraisals
350 L9 Star Unit (Z1FY30) 30 25 83%
Core service total 30 25 83%
Trust wide 5565 4780 86%
Between 1 August 2017 and 31 July 2018, the average rate of compliance for clinical supervision
was 60%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different
ways. It is important to understand the data they provide.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 301
Ward name Clinical supervision
sessions required
Clinical
supervision
sessions delivered
Clinical
supervision rate
(%)
351 L9 Star Unit (Z1FY30) 282 170 60%
Core service total 282 170 60%
Trust Total 15334 4947 32%
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.
Multi-disciplinary meetings took place twice a week. These ensured that staff understood and
reviewed patients’ needs. The handover between two shifts that we observed was effective; staff
shared information about patients’ risks and positive behaviour support plans.
The ward had good working relationships with the community learning disability teams. Staff kept
care coordinators, social workers and general practitioners informed of patients’ progress. Staff
also involved general practitioners in care planning for patients’ physical health. They linked in with
the community health services regarding high-risk areas such as acquired pressure ulcers, sepsis
and pneumonia.
The ward worked closely with commissioners and local care providers to plan patients’ discharge
into the community. We saw from patients’ care records that their needs, for example the need for
a safe long-term bespoke placement took priority over pressures to make beds available. The
trust’s approach to transition was in line with NHS England’s Transforming Care agenda.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental
Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.
All qualified staff had access to a flowchart explaining what needed to be done when a patient was
admitted under the Mental Health Act. Patients’ detention paperwork was stored on the electronic
record system. The ward kept clear records of leave granted to patients. Staff were aware of the
parameters of leave granted, including risk and contingency/crisis measures.
There was an Independent Mental Health Advocate attached to the ward. Staff knew how to
access and support patients to engage with the advocate.
Staff explained patients’ rights under the Mental Health Act to them at admission and routinely
thereafter. Information about patient rights was available in easy-read format. If patients lacked
capacity to understand their rights after three attempts then the multi-disciplinary team discussed
and documented that it was not in the patient’s best interest to continue to explain their rights to
them. However, there was insufficient documentation of any steps staff had taken to safeguard the
rights of a patient who lacked capacity to understand those rights. For example, it was unclear
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 302
whether staff had referred patients to the independent mental health advocate, or considered
whether to refer the patient for a tribunal. We had highlighted this same issue at a Mental Health
Act review of the ward in June 2018. The ward had not fully taken action to improve.
As 31 July 2018, 100% of the workforce in this core service had received training in the Mental
Health Act. The trust stated that this training is mandatory for all core services for inpatient and all
community staff and renewed every three years.
The training compliance reported during this inspection was higher than the 82% reported in the
previous year.
Good practice in applying the Mental Capacity Act
Staff supported patients to make decisions on their care for themselves. They understood the trust
policy on the Mental Capacity Act 2006 and assessed and recorded capacity clearly.
Care records showed that capacity to consent was assessed and recorded appropriately. Patients
were given assistance to make decisions for themselves. Staff recognised the importance of the
person’s wishes, feelings, culture and history when making best interest decisions for patients who
lacked capacity.
As of 31 July 2018, 100% of the workforce in this core service had received training in the Mental
Capacity Act. The trust stated that this training is mandatory for all core services for inpatient and
all community staff and renewed every three years.
The training compliance reported during this inspection was higher than the 81% reported in the
previous year.
Staff made Deprivation of Liberty Safeguards applications when required. The trust told us that 10
Deprivation of Liberty Safeguard applications were made to the Local Authority for this core
service between 1 August 2017 and 31 July 2018.
The greatest number of Deprivation of Liberty Safeguard applications were made in October 2017
with three.
CQC received nine direct notifications from Mersey care NHS Foundation Trust between 1 August
2017 and 31 July 2018.
Number of DoLS applications made by month
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Apr
18
May
18
Jun
18
Jul
18 Total
Applications made
0 0 3 2 0 0 0 0 1 0 2 2 10
Applications approved
6 0 0 1 8 0 0 0 1 0 1 1 18
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 303
Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity,
and supported their individual needs.
We observed staff and patient interactions on the ward and undertook a short observational
framework for inspection. CQC inspectors use the short observational framework for inspection to
capture the experiences of patients who may not be able to express this for themselves. At our
previous inspection, we found negative interactions between staff and patients at Wavertree
Bungalow and we found that staff were not following a patient’s positive behaviour support plan at
STAR unit. At this inspection, all of the interactions we observed were positive. Staff were
responsive, inclusive and respectful. They provided appropriate practical and emotional support.
For example, a patient lay down in the corridor. A staff member approached, got down on the floor
with the patient, and gently encouraged them to get up and ‘have a chat’.
We spoke with two patients. One patient said that, although they were not happy about being on
the ward, it was comfortable and safe and the staff were ‘great’. The other patient said the ward
was good. They felt able to speak to their named nurse when they felt worried.
The independent mental health advocate told us that patients were generally complimentary about
staff and the care they received.
When we spoke with staff and observed the handover meeting, we found that staff spoke about
patients in a way that was consistent with a culture of positive behaviour support. Staff had a good
understanding of individual patients’ needs.
The 2017 Patient-led Assessments of the Care Environment (PLACE) score for privacy, dignity
and wellbeing at Rathbone Hospital scored higher than similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
Rathbone Hospital
Secure Wards/forensic Inpatient
Community based mental health services for adults of working age
Long stay/rehabilitation mental health wards for adults of working age
Wards for people with learning disability or autism
94.0%
Trust overall 92.7%
England average (mental health
and learning disabilities) 90.6%
Involvement in care
Staff involved patients and those close to them in decisions about their care, treatment and
changes to the service.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 304
Involvement of patients
The admission process oriented patients to the ward and the service. There was a standard trust
‘welcome pack’ available to patients but it was in a format that was not appropriate for people with
a learning disability. Staff had written an easy-read welcome pack, which was in the process of
being finalised ready for use.
Patients were actively involved in care planning. One patient had an advanced decision in place to
ensure that her wishes were respected at times when she lacked capacity. Another patient had
decorated her ward-provided ear defenders with glitter. However, the two patients we spoke with
told us that they had not been offered a copy of their care plans.
There were regular community meetings on the wards, facilitated by the occupational therapist.
We saw that issues raised by patients had been acted on. Most of the patients chose not to attend
the community meetings. The ward manager planned to move the meetings into the patients’
kitchen and encourage involvement by baking bread for breakfast. Staff gave patients the
opportunity to give feedback about the ward individually during named nurse sessions. We saw
that the ward manager also encouraged patients to approach her if they had any concerns.
Staff offered debriefs to patients following an incident.
Patients were able to get involved in decisions about their service. The new ‘complex care and
recovery management’ care plans had been co-produced with patients from the specialist learning
disability division. Patients from the specialist learning disability division were also involved in
recruiting staff. A member of the trust’s people participation programme worked at STAR unit’s
reception. He provided valued administrative support to staff and was a popular member of the
team.
Involvement of families and carers
Carers were actively involved in patients’ care planning (with consent or in the best interests of
patients).
We spoke with two carers. One described the staff as ‘brilliant’ and the other said that staff were
‘marvellous’. Both said they felt involved in their relative’s care, and that they had received regular
updates. Both carers said that they did not know how to complain, but would be able to find out if
they needed to.
All staff had completed a ‘carer awareness’ training. They used the Triangle of Care to promote a
working collaboration between patients, carers and staff.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 305
Is the service responsive?
Access and discharge
People could access the service closest to their home when they needed it. Arrangements to
admit, treat and discharge patients were in line with good practice.
The ward was able to take emergency admissions, but the majority of admissions were carefully
planned. Senior staff from two different disciplines undertook pre-admission assessments to
ensure that the ward was adapted as far as possible for patients’ individual needs before they
arrived.
The ward’s consultant psychiatrist attended care and treatment review meetings with
commissioners to discuss potential admissions.
Bed management
The trust provided information regarding average bed occupancies for STAR unit between 1
August 2017 and 31 July 2018.
We are unable to compare the average bed occupancy data to the previous inspection due to
differences in the way we asked for the data and the period that was covered.
Ward name
Average bed occupancy range
(1 August 2017 – 31 July 2018)
(average 12 months)
Star Unit 44.4% - 71.1% (56.3%)
The trust provided information for average length of stay for the period 1 August 2017 to 31 July
2018.
We are unable to compare the average length of stay data to the previous inspection due to
differences in the way we asked for the data and the period that was covered.
Ward name Average length of stay range
in days (1 August 2017 – 31
July 2018) (average 12
months)
Star Unit 210-438 (320)
This core service reported no out area placements between 1 August 2017 and 31 July 2018.
This core service reported no readmissions within 28 days between 1 August 2017 and 31 July
2018.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 306
The trust provided us with information pertinent to the number of patients who have moved wards
per admission. In the table below is information for this core service between 1 August 2017 and
31 July 2018.
During the last 12 months – YR 1
(August 2017 to July 2018)
During the previous 12 months – YR2 (August 2016 to July 2017)
Ward name
Number of ward moves
Number of
patients
How many were
at 'end of
life'*
%-share of all patients
Number of
patients
How many were
at 'end of
life'*
%-share of all patients
Star Unit 0 5 0 100% 19 0 95%
1 0 0 0% 1 0 5%
2 0 0 0% 0 0 0%
3 0 0 0% 0 0 0%
4+ 0 0 0% 0 0 0%
Total 5 0 100% 20 0 100%
Discharge and transfers of care
Between 1 August 2017 and 31 July 2018, there were five discharges within this core service. This
amounts to less than 1% of the total discharges from the trust overall (3784).
In the same period the trust reported 31 delayed discharges in this core service.
At the time of inspection, two patients were on the ward despite being clinically well enough to be
discharged. This was because there was no suitable community placement available to them.
Staff told us that this was the most common reason for delayed discharges. Staff met or spoke
with commissioners regularly to try to resolve these issues. Staff also created documents,
including positive behaviour support plans and communication portfolios, to assist patients and
new care providers with the transition.
The ward’s social worker took the lead on discharge planning. They started the process as soon
as patients were admitted.
The core service did not provide the number of days from assessment to treatment.
Facilities that promote comfort, dignity and privacy
Patients had their own rooms, in which they could keep personal belongings safely. There were
quiet areas for privacy and where patients could be independent of staff.
The ward had a full range of rooms and equipment to support treatment and care, including an
external courtyard, lounge, dining room, sensory room, clinic room, multi-faith room, laundry room,
patient kitchen and arts and crafts room. The lounge, dining room, sensory room and multi-faith
room were permanently unlocked. Patients were only able to access the kitchen and the arts and
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 307
crafts room with staff support, as these rooms contained potentially dangerous items. Patients
could choose whether to keep their own bedrooms locked.
Most patients had access to their own mobile telephone to make private calls. There was a clear
risk assessment and management plan in place for those patients who did not have free access to
their mobile telephones. All patients were able to use the ward’s handheld telephone if they
wished.
At our last inspection we found that patients were not accessing meaningful activity. At this
inspection we saw that patients had access to a wide range of activities, including at weekends.
Each patient had an easy-read activity schedule that was meaningful to them and that included an
emphasis on building independence. The ward manager had released a support worker, who had
a special interest in activities, to improve patients’ activity plans.
The occupational therapist had assessed all patients’ use of the ward kitchen. Patients could use
the ward kitchen to make hot drinks and/or food at any time with the level of staff support that was
appropriate to their needs.
The 2017 Patient-led Assessments of the Care Environment (PLACE) score for ward food at the
locations scored better than similar trusts.
Site name Core service(s) provided Ward food
Rathbone Hospital Secure wards/forensic inpatient
Community based mental health services for adults of
working age
Long stay/rehabilitation mental health wards for adults
of working age
Wards for people with learning disabilities or autism
92.3%
Trust overall 95.4%
England average (mental health and learning disabilities) 91.5%
Patients’ engagement with the wider community
Staff supported patients with activities outside the service, such as work, education and family
relationships.
At our last inspection we found that patients were not accessing community leave. At this
inspection we found that all patients who were granted community leave were regularly leaving the
ward to engage in meaningful activity. Staff used positive behaviour support plans to ensure that
patients who presented with behaviour that challenged were still able to engage.
The ward liaised with a colleague at the local acute trust to arrange reasonable adjustments for
patients’ visits to hospital for appointments. For example, during our visit ward staff ensured that a
parking space would be available close to the hospital entrance to reduce waiting times and
overstimulation.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 308
Meeting the needs of all people who use the service
The service was accessible to all who needed it and took account of patients’ individual needs.
Staff helped patients with communication, advocacy and cultural support.
Notices and leaflets (with the exception of the ward welcome pack) were available to patients in
easy-read format. There was accessible information on treatments, local services, patient rights
and how to complain.
Staff were able to request interpreters and/or signers when required. There were pictorial symbols
on doors to help patients understand the ward layout. Noticeboards included easy-read
information and photographs of staff. Staff we spoke with were able to tell us the best way to
communicate with individual patients.
There was a choice of food to meet requirements of religious and ethnic groups and those with
dysphagia or other dietary care plans. There was a multi-faith room on the ward for patients to use
for practising their faith or for quiet reflection. A chaplain visited the ward weekly. Staff were able
to support patients to attend a place of worship (depending on patient’s leave). ‘Cultural needs’
was a standard heading in the ‘complex care and recovery management’ care plan.
The ward was accessible to people with physical disabilities, including wheelchair users.
Listening to and learning from concerns and complaints
The service treated concerns and complaints seriously, investigated them and learned lessons
from the results, and shared these with all staff.
This core service received no formal complaints between 1 August 2017 and 31 July 2018.
This core service received no formal compliments during the last 12 months from 1 August 2017
and 31 July 2018.
Patients we spoke with knew how to complain. Information about how to complain was available
on the ward in easy-read format. Staff knew how to handle complaints appropriately.
Staff received feedback on the outcome of complaints through team meetings and staff
newsletters.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 309
Is the service well led?
Leadership
Managers had the right skills and abilities to run a service providing high-quality sustainable care.
Staff told us that the ward manager had an ‘open door policy’ and that senior managers (the
modern matron and deputy chief operating officer) were approachable and visible on the ward.
Several staff said that the ward manager had made positive changes.
The ward manager had the discretion and authority to make decisions about the ward. She told us
that the trust chief executive had visited, shown a keen interest in her vision to improve the ward
environment, and personally approved the funding.
The modern matron, clinical lead nurse and staff nurses had completed the trust’s leadership
development programme, and the ward manager (who was relatively new in post) was planning to
complete it.
Vision and strategy
The trust had a vision for what it wanted to achieve and workable plans to turn it into action.
Quality and sustainability were the top priorities. The trust’s vision was developed with involvement
from staff, patients and key groups representing the local community.
The trust’s vision was to strive for perfect care. Staff we spoke with knew and understood the
trust’s vision. They were able to name the values (continuous improvement, accountability,
respect, enthusiasm and support). They said that the values were meaningful.
The ward had a local vision, which was to provide specialist care and assessment to service users
living with a learning disability. Their aim was to assess and identify treatment needs and support
patients through recovery and transition in line with the Transforming Care agenda. Staff attitudes
and behaviours were consistent with this vision and aim.
Culture
Managers promoted a positive culture that supported and valued staff, creating a sense of
common purpose based on shared values.
Staff told us that they felt happy, supported and respected. Some staff told us that they felt proud
to work on STAR unit and valued as learning disability nurses.
The ward manager’s interactions with staff and patients demonstrated a person-centred, positive
behaviour support culture. In the ward handover, each member of staff was encouraged to
contribute.
Staff knew about the trust’s whistleblowing policy and speak up guardian. The speak up guardian
had attended an away day. Staff felt confident in being able to raise concerns without fear of
retribution.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 310
The ward manager told us that not all of her staff team were happy, and that she was aware of the
potential impact on staff of working with high-acuity patients. The ward manager had arranged for
staff to be able to access the staff support service on a drop-in basis at set times each week, and
planned an Aston team-based working session for January 2019.
Poor staff performance had been addressed promptly and effectively. Managers were able to refer
staff to occupational health if they were concerned about sickness levels. Several staff mentioned
the trust’s ‘just and learning culture’. They felt that the trust was moving towards examining
processes rather than ‘blaming’ individuals when things went wrong.
During the reporting period, there were six cases where staff had been either suspended, placed
under supervision or were moved to a different ward. Five staff had been suspended and one was
placed under supervision.
Of the six cases, all involved grade 3 staff group.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these
should be noted.
Ward name Suspended Under
supervision
Ward move Total
Star Unit 5 1 0 6
Core service total 5 1 0 6
Governance
The ward used a systematic approach to continually improving the quality of its services and
safeguarding high standards of care by creating an environment in which excellence in clinical
care would flourish.
At the time of our previous inspection, STAR unit was provided in the trust’s local division.
Following our inspection it was moved over to the trust’s specialist learning disability division. This
meant that the governance of the service was now more focused around the specific needs of the
patient group. Staff were able to access training, supervision and shadowing.
Staff at all levels were clear about their roles. They understood what they were accountable for.
Information about risk was communicated effectively from ward to board.
The trust had a transparent policy on the use of restrictive interventions, with an overarching
restrictive intervention reduction programme. The ward monitored changes in the numbers of
incidents and use of restrictive interventions, and reported this to the senior leadership team on a
weekly basis. Managers could easily use this data to compare against other factors, for example a
recent increase in short-admission patients. Staff had identified one patient as being subject to a
high number of restraints due to self-harming behaviour. The ward manager was due to present
this patient’s case at the trust’s restrictive practice meeting in November. This would give them the
opportunity to get supervision and advice from the trust’s specialists.
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 311
The trust has provided a document detailing their 34 highest profile risks. One of the 34 corporate
risks had a current risk score of 15 or higher. However, there were no high risks pertaining to this
core service.
Management of risk, issues and performance
The ward had effective systems for identifying risks, planning to eliminate or reduce them, and
coping with both the expected and unexpected.
There was a systematic programme of clinical and internal audit to monitor quality and operational
processes. Audits identified where action should be taken.
The ward manager could add risks to the division or trust risk register through senior leadership
team meetings. She could also raise immediate risks directly with the chief operating officer.
Information management
The ward collected, analysed, managed and used information well to support all its activities,
using secure systems with security safeguards.
There were clear and robust service performance measures, which were reported and monitored.
These included incidents, length of stay, delayed discharge and engagement in activity. There
were effective arrangements to ensure that notifications were submitted to external bodies.
Arrangements for patient identifiable records met data security standards.
Engagement
Patients views and experiences were gathered and acted on to shape and improve the service.
Staff were also actively engaged. There was transparency and openness with all stakeholders
about performance.
Managers attended regular tracker meetings with Liverpool Clinical Commissioning Group and
Liverpool City Council.
Learning, continuous improvement and innovation
Staff attended four away days per year to work together to resolve problems and review team
objectives, processes and performance.
There was evidence of innovation on the ward in line with the culture of positive behaviour
support. Staff thought creatively to make the ward environment fit the needs of patients, for
example by making the sensory room fully soft, by providing ear defenders to patients with autism
and by taking the stance that all patients would be able to use the kitchen. It was clear from
listening to staff that they felt passionate about empowering people with a learning disability. Staff
saw incidents as challenges to be overcome rather than barriers to inclusion.
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
Mersey Care NHS Foundation Trust evidence appendix: wards for people with a learning disability or autism Page 312
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 provided a list of services, which have been awarded an accreditation together with the
relevant dates of accreditation. However, there was nothing pertaining to this core service.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 313
Wards for older people with mental health problems
Facts and data about this service
Location site name Ward name Number of beds Patient group (male,
female, mixed)
Mossley Hill Acorn Ward (OP) 15 Mixed
Boothroyd Unit Boothroyd Ward
(OP) 20 Mixed
Clock View Irwell Ward 17 Mixed
Mossley Hill Oak ward (OP) 20 Mixed
Heys Court Heys Court 16 Mixed
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 314
Is the service safe?
Safe and clean care environments
All wards were safe, clean well equipped, well furnished and well maintained. There were blind spots
on Boothroyd ward, Acorn ward, Oak ward and Heys Court. Staff could not clearly see all areas to
observe patients. There were no mirrors on these wards to support observation. However, staff knew
about any ligature anchor points and observations were increased in these areas. Environmental
audits had been completed and actions put in place to mitigate any risks.
Safety of the ward layout
Over the 12-month period from 1 August 2017 to 31 July 2018 there were no mixed sex
accommodation breaches within this core service.
Bedroom areas were clearly designated into male and female areas with the appropriate bathroom
facilities. Patients did not need to walk past patient bedrooms of the opposite sex to reach
bathroom facilities. Each ward had a female only lounge. Guidance from the NHS Confederation
states that shared bedrooms should be separated by solid walls. Safety issues were managed by
increased observation. There were enough staff to ensure that patients were observed
appropriately.
There were single en-suite bedrooms on Irwell ward that were in separate male and female areas
of the ward. A new ward was being built to replace Boothroyd ward and was due to be open by
October 2019. New premises had been sought to replace other wards but had been found to be
unsuitable for the needs of the patient group.
There were ligature risks on three wards within this core service. The trust had undertaken recent
(From September 2017 onwards) ligature risk assessments at all locations. One of the wards
presented a high level of ligature risk due to fixtures and fittings and two wards presented a lower
risk due to fixtures and fittings. The trust had taken action to mitigate ligature risks.
Maintenance, cleanliness and infection control
For the most recent patient-led assessments of the care environment (PLACE) assessment
(2017), the location(s) scored better than the similar trusts for three of the four aspects overall,
with the exception of the dementia friendly aspect, which was lower.
During the onsite inspection each ward was seen to be clean and tidy. We saw cleaning rotas that
confirmed cleaning regularly took place. Infection control policies were being followed. Staff and
patients confirmed that the wards were always clean. A deep clean was in process during our visit
to the Mossley Hill site.
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
HEYS COURT, GARSTON Long Stay / 97.9% 97.3% 83.2% 93.1%
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 315
Site name Core service(s)
provided
Cleanliness Condition
appearance
and
maintenance
Dementia
friendly
Disability
rehabilitation mental
health wards for
working age adults
Wards for older people
with mental health
problems
CLOCK VIEW HOSPITAL
Acute wards for adults
of working age and
psychiatric intensive
care units
Wards for older people
with mental health
problems
Community based
mental health services
for adults of working
age
99.6% 97.2% 79.9% 89.9%
LIVERPOOL EMI (MOSSLEY
HILL HOSPITAL)
Wards for older people
with mental health
problems
Community based
mental health services
for older people
99.9% 98.4% 83.6% 95.4%
BOOTHROYD WARD
Wards for older people
with mental health
problems
Community based
mental health services
for older people
100.0% 98.4% - 100.0%
Trust overall 98.8% 97.3% 81.3% 89.9%
England average (Mental
health and learning
disabilities)
98.0% 95.2% 84.8% 86.3%
Clinic room and equipment
All clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs
that staff regularly checked. Staff maintained equipment well and kept it clean. Any “clean” stickers
were visible and in date. All equipment was now cleaned according to policy and records
completed to ensure this had taken place. Clinic fridge temperatures were monitored and action
was now taken when temperatures were not in range. This had improved since our last inspection.
Safe staffing
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 316
The service had enough nursing and medical staff, who knew the patients and received basic training
to keep people safe from avoidable harm. Ward managers could use regular bank staff who were
familiar with the ward, procedures and patients. For short notice staff absences; ward managers had
access to regular agency staff. The service had a high sickness rate and used bank and agency staff
to compensate for this.
Nursing staff
The table below gives an overview of trust staffing levels. It provides data on substantive staff
numbers, vacancies and sickness, and use of bank and agency staff. This data was provided to us
by the trust in August 2018 and covers the period 1 August 2017 to 31 July 2018.
Definition
Substantive – All filled allocated and funded posts.
Establishment – All posts allocated and funded (e.g. substantive + vacancies).
Substantive staff figures Trust target
Total number of substantive staff At 31 July 2018 160 N/A
Total number of substantive staff leavers 1 August 2017–31 July 2018
14.2 N/A
Average WTE* leavers over 12 months (%) 1 August 2017–31 July 2018
9% N/A
Vacancies and sickness
Total vacancies overall (excluding seconded staff) At 31July 2018 -14.6 N/A
Total vacancies overall (%) At 31 July 2018 -9% 5%
Total permanent staff sickness overall (%)
Most recent month (At 31 July 2018)
9% N/A
1 August 2017–31 July 2018
10% N/A
Establishment and vacancy (nurses and care assistants)
Establishment levels qualified nurses (WTE*) At 31 July 2018 56.5 N/A
Establishment levels nursing assistants (WTE*) At 31 July 2018 66.9 N/A
Number of vacancies, qualified nurses (WTE*) At 31 July 2018 -1.6 N/A
Number of vacancies nursing assistants (WTE*) At 31 July 2018 -5.0 N/A
Qualified nurse vacancy rate At 31 July 2018 -7% 5%
Nursing assistant vacancy rate At 31 July 2018 -7% 5%
Bank and agency Use
Hours bank staff filled to cover sickness, absence or vacancies
(qualified nurses) 1 August 2017-31 July
2018 7991 N/A
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 317
Substantive staff figures Trust target
Hours filled by agency staff to cover sickness, absence or vacancies
(Qualified Nurses) 1 August 2017-31 July
2018 1116 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Qualified Nurses) 1 August 2017-31 July
2018 142 N/A
Hours filled by bank staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 August 2017-31 July
2018 55049 N/A
Hours filled by agency staff to cover sickness, absence or vacancies
(Nursing Assistants) 1 August 2017-31 July
2018 29723 N/A
Hours NOT filled by bank or agency staff where there is sickness,
absence or vacancies (Nursing Assistants) 1 August 2017-31 July
2018 1678 N/A
*Whole-time Equivalent / minus figures = oversubscribed.
This core service was over-established for registered nurses and nursing assistants by 7%. The
qualified nursing fill rate was low for day time shifts. This was due to a high sickness rate of 10%.
Registered nurses Health care assistants Overall staff figures
Ward/Team
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Vac
an
cie
s
Esta
bli
sh
men
t
Vac
an
cy r
ate
(%)
Acorn Ward (Mossley Hill) -1.3 11.3 -12% -1.5 15.1 -10% -2.4 33.3 -7%
Boothroyd Ward 0.0 12.0 0% 0.8 15.0 5% 0.2 35.4 1%
Irwell Ward (Clockview) -0.2 12.0 -1% -2.3 16.3 -14% -4.8 36.0 -13%
Oak Ward (Mossley Hill) -0.2 10.0 -2% -2.1 12.9 -16% -4.3 29.9 -14%
Heys Court -2.3 11.3 -21% 0.1 7.7 1% -3.3 26.0 -13%
Core service total -3.9 56.5 -7% -4.9 66.9 -7% -14.6 160.7 -9%
Trust total -151.7 1115.9 -14% 7.6 643.2 1% -320.9 2741.6 -12%
NB: All figures displayed are whole-time equivalents
Between 1 August 2017 and 31 July 2018, bank staff filled 7991 hours to cover sickness, absence
or vacancy for qualified nurses.
In the same period, agency staff covered 1116 hours for qualified nurses. 142 hours were unable
to be filled by either bank or agency staff.
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Boothroyd 1747 1258 350 -46
Acorn Ward 1629 2831 75 176
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 318
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by
bank or agency staff
Oak Ward 1629 2531 439 26
Irwell 1745 1371 252 -15
Core service
total 6751 7991 1116 142
Trust Total 242318 125599 64603 31532
Between 1 August 2017 and 31 July 2018, bank staff to cover sickness, absence or vacancy for
nursing assistants filled 55049 hours.
In the same period, agency staff covered 29723 hours. 1678 hours were unable to be filled by
either bank or agency staff.
Ward/Team Available hours Hours filled by bank
staff
Hours filled by
agency staff
Hours NOT filled by bank
or agency staff
Boothroyd 3647 6215 4089 -264
Acorn Ward 3635 16167 6015 605
Oak Ward 3407 11879 4939 510
Irwell 3831 20788 14680 828
Core service
total 14520 55049 29723 1678
Trust Total 210729 442987 204924 29961
This core service had 14.2 (9%) staff leavers between 1 August 2017 and 31 July 2018.
Ward/Team Substantive
staff
Substantive staff
Leavers
Average % staff
leavers
350 L9 Biu Senior Medical Staff (Z1BK10) 1.0 1.0 71%
350 L9 Medical Aintree Older People (Z1AA04) 5.0 1.0 20%
350 L9 Oak Ward - Mossley Hill (Z1CH21) 27.6 3.6 14%
350 L9 Irwell Ward (Z1AB31) 31.7 2.6 9%
350 L9 Acorn Ward - Mossley Hill (Z1CH35) 32.9 2.0 7%
350 L9 Boothroyd Ward SGI (Z1NW33) 34.8 2.0 6%
350 L9 Liverpool Older Peoples Senior Medical 5.0 0.0 0%
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 319
Ward/Team Substantive
staff
Substantive staff
Leavers
Average % staff
leavers
Staff (Z1CR10)
350 L9 Heys Court (Z1CH75) 22.7 2.0 9%
Core service total 160.7 14.2 9%
Trust Total 2658.6 294.5 13%
The sickness rate for this core service was 10% between 1 August 2017 and 31 July 2018. The
most recent month’s data [31 July 2018] showed a sickness rate of 9%.
Ward/Team Total % staff sickness
(at latest month)
Ave % permanent staff
sickness (over the past
year)
350 L9 Irwell Ward (Z1AB31) 15% 18%
350 L9 Heys Court (Z1CH75) 9% 12%
350 L9 Oak Ward - Mossley Hill (Z1CH21) 16% 10%
350 L9 Boothroyd Ward SGI (Z1NW33) 6% 7%
350 L9 Liverpool Older Peoples Senior Medical Staff (Z1CR10) 20% 7%
350 L9 Acorn Ward - Mossley Hill (Z1CH35) 1% 3%
350 L9 Medical Aintree Older People (Z1AA04) 0% 2%
350 L9 Biu Senior Medical Staff (Z1BK10) 0% 0%
350 L9 Medical North Sefton Older Persons (Z1NW85) 0% 0%
Core service total 9% 10%
Trust Total 8% 8%
The below table covers staff fill rates for registered nurses and care staff during July, August and
September 2018.
Irwell ward and Heys Court had under-filled for registered nurses for all day shifts across the full
three-month period.
Irwell ward had over-filled for care staff for day and night shifts for all months reported.
Ward managers of Irwell ward and Heys Court explained that a shortage of registered nurses had
impacted on the quality of risk assessments, care plans and one to one time with patients. Both
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 320
ward managers had implemented an action plan. Staffing issues and the quality of patient care
had improved in the last three months.
Key:
> 125% < 90%
Day Night Day Night Day Night
Nurses
(%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
Nurses (%)
Care staff (%)
July 18 August 18 September 18
Boothroyd 113.2 105.6 100.0 122.6 98.1 103.8 100.0 116.2 126.0 113.4 100.0 120.1
Acorn
Ward 99.2 137.9 100.0 121.7 97.6 148.4 100.0 130.6 96.7 135.0 100.0 120.0
Oak Ward 85.5 146.6 100.0 135.5 105.6 113.9 103.4 107.6 86.7 134.5 100.0 126.7
Irwell 76.5 170.2 94.4 166.7 60.4 163.2 100.0 163.5 61.1 189.0 96.5 211.2
Heys
Court 86.3 119.9 100.0 104.8 82.3 117.7 100.0 125.8 83.3 113.9 100.0 133.3
Medical staff
There was no useable data for medical locum shifts.
Mandatory training
The service provided mandatory training in key skills to all staff and made sure everyone
completed it. During the inspection we found that each ward had now completed mandatory
training to an appropriate level. This included basic life support, immediate life support and moving
and handling which had previously been low at the last inspection. Mandatory training figures had
also improved since the figures below were produced.
We examined mandatory training figures during the onsite inspection. All mandatory training
courses were now above 75%. Ward managers were able to demonstrate that where mandatory
training was below the trust target, staff had been booked on these courses in the near future. Or
that some staff were exempt due to being on long-term sick or maternity leave.
The compliance for mandatory and statutory training courses at 31 July 2018 was 87%. Of the
training courses listed 23 failed to achieve the trust target and of those, nine failed to score above
75%.
The training compliance data is reported on an ongoing monthly basis. Statutory training is
reported as part of the monthly board report dashboard produced by Workforce and a separate
dashboard is provided by the Learning and Development team for all other courses classified by
ourselves as role essential.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 321
The training compliance reported for this core service during this inspection was lower than the
92% reported in the previous year.
Key:
Below CQC 75% Between 75% & trust
target Trust target and above
Training course This core service
% Trust target %
Trustwide mandatory/ statutory training total
%
Continuous Professional Development -
Adverse Incidents (Every 3 Years) 98% 95% 92%
Continuous Professional Development -
Complaints (Every 3 Years) 98% 95% 94%
Continuous Professional Development -
Smoking Cessation (1 Time) 98% 95% 89%
Role Specific Mandated Training - Basic
Prevent Awareness (1 Time) 98% 90% 93%
Mandatory Training - Safeguarding Children
- Level 1 (Every 3 Years) 97% 95% 95%
Continuous Professional Development -
Fraud Awareness (Every 3 Years) 96% 95% 89%
Continuous Professional Development -
Suicide Prevention & Safety Planning
(Every 3 Years)
96% 95% 90%
Role Specific Mandated Training -
Deprivation of Liberties - Level 1 (Every 3
Years)
96% 90% 89%
Mandatory Training - Safeguarding Adults -
Level 1 (Every 3 Years) 95% 95% 95%
Role Specific Mandated Training - Mental
Capacity Act - Level 1 (Every 3 Years) 94% 90% 88%
Role Specific Mandated Training - Mental
Health Act - Level 1 (Every 3 Years) 94% 90% 90%
Role Specific Mandated Training - Safe and
Effective Use of Medicines (Every 3 Years) 92% 90% 63%
Mandatory Training - Infection Control
(Every 3 Years) 91% 95% 92%
Mandatory Training - Health & Safety (Every
3 Years) 90% 95% 92%
Mandatory Training - Moving & Handling
(Every 3 Years) 90% 95% 90%
Mandatory Training - Equality, Diversity and
Human Rights (Every 3 Years) 89% 95% 91%
Mandatory Training - Fire Safety (Every 3
Years) 89% 95% 92%
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 322
Training course This core service
% Trust target %
Trustwide mandatory/ statutory training total
%
Continuous Professional Development -
Dementia Awareness (1 Time) 88% 95% 78%
Role Specific Mandated Training -
Safeguarding Adults Level 2 -Trust Model
(Every 3 Years)
88% 90% 87%
Role Specific Mandated Training -
Safeguarding Adults Level 3 - Trust Model
(Every 3 Years)
88% 90% 76%
Role Specific Mandated Training -
Safeguarding Children Level 3 - Trust Model
(Every 3 Years)
88% 90% 76%
Role Specific Mandated Training -
Controlled Drugs & High Risk Medicines 88% 90% 67%
Role Specific Mandated Training -
Medicines Calculations (Every 3 Years) 88% 90% 63%
Role Specific Mandated Training -
Safeguarding Children Level 2 - Trust Model
(Every 3 Years)
87% 90% 87%
Mandatory Training - Conflict Resolution
(Every 3 Years) 86% 95% 92%
Continuous Professional Development -
Moving and Handling of Inanimate Objects 82% 90% 56%
Role Specific Mandated Training - Basic
Life Support (Every Year) 72% 90% 70%
Role Specific Mandated Training -
MHA/DoL's Level 2 (Every 3 Years) 70% 90% 53%
Role Specific Mandated Training - Personal
Safety (Every Year) 60% 90% 80%
Role Specific Mandated Training -
Intermediate Life Support (Every Year) 60% 90% 72%
Role Specific Mandated Training - Moving
and Handling of People (Every Year) 59% 90% 48%
Role Specific Mandated Training - Witness
to Medication (Every 3 Years) 53% 90% 62%
Role Specific Mandated Training - Personal
Safety Breakaway - Level 1 (Every 2 Years) 50% 90% 50%
Role Specific Mandated Training - Rapid
Tranquilisation Training 43% 90% 61%
Mandatory Training (IG) - Data Security
Awareness - Level 1 (Every Year) 40% 95% 50%
Core Service Total % 87% 87%
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 323
Assessing and managing risk to patients and staff
Assessment of patient risk
Staff completed and updated risk assessments for each patient and used these to understand and
manage risks individually. Staff followed best practice, the Mental Capacity Act and the Mental
Health Act when restricting patients’ freedoms to keep them and others safe. We checked eleven
patient care records and examined the risk assessments of each patient. Risk assessments were
completed for all patients on their admission to the ward. We found that staff regularly updated risk
assessments as patients’ needs or risks changed and following incidents.
Management of patient risk
Staff were aware of and dealt with any specific risk issues, such as nutrition, falls or pressure
ulcers. Following assessment, staff developed risk management plans for each individual patient.
Each patient had a falls risk assessment which was reviewed weekly. Frailty reviews were
completed weekly with input from the physiotherapist on each ward.
Staff identified and responded to changing risks to, or posed by, patients. They updated records at
least weekly and whenever clinically indicated. Staffing levels had been increased during the
evenings on each ward. The service had identified an increase in incidents during evening meal
and bed time routines. As a result, a twilight shift had been introduced to minimise risks.
Staff followed good policies and procedures for use of observation, including to minimise risk from
potential ligature points.
Use of restrictive interventions
The wards in this service participated in the provider’s restrictive interventions reduction
programme. Sharp items were kept in a locked cupboard which patients could access on request.
All other risks were individually assessed and care planned. For patients with shared bedrooms
access to some items needed further care planning to minimise the risk to other patients. For
example, staff would increase observations whilst particular items were being used to minimise
risks. This was evident in care plans and risk assessments.
This core service had 204 incidents of restraint (on 117 different service users) and no incidents of
seclusion between 1 August 2017 and 31 July 2018.
Over the 12 months, there was an increase in the incidence of restraint in November 2017 where
30 incidents were reported.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 324
The below table focuses on the last 12 months’ worth of data: 1 August 2017 to 31 July 2018.
Ward name Seclusions Restraints Patients
restrained
Of restraints, incidents of
prone restraint
Rapid
tranquilisations
Acorn Ward 0 102 50 0 (0%) 4 (4%)
Boothroyd
Ward 0 49 21 1 (2%) 12 (24%)
Irwell Ward 0 17 19 0 (0%) 4 (24%)
Oak Ward 0 31 20 0 (0%) 8 (26%)
Heys Court
Ward 0 5 7 0 (0%) 0 (0%)
Core service
total 0 204 117 1 (1%) 28 (14%)
There was one incident of prone restraint, which accounted for 1% of the restraint incidents.
Over the 12 months, there were four peaks in the use of restraint in September 2017 (29), October
(28), November 2017 (29) and May 20187 (27).
Incidents resulting in rapid tranquilisation for this core services seem to have been variable with
the highest numbers in October 2017 with 10 instances. We reviewed one record of rapid
tranquilisation on Boothroyd ward. The patient had refused any physical health observations. Staff
had recorded this and utilised the correct monitoring form.
There were no instances of mechanical restraint over the reporting period.
The number of restraint incidents reported during this inspection was lower than the 256 reported
in the previous 12 months.
7
2928
30
10
6
1815
7
27
17
10
0
5
10
15
20
25
30
35
Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18 Apr 18 May 18 Jun 18 Jul 18
Total restraints over the 12 month period
Number of incidents of the use of restraints
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 325
Staff used restraint only after de-escalation had failed and used correct techniques. Staff received
training in the management of violence and aggression and moving and handling. All staff were up
to date or had been booked on the training course in the near future. We saw care records that set
out the risks when patients presented with violence and aggression and clear and detailed care
plans on the action to take. A tool to gather personal information about patients from their family
and carers had been developed. This allowed staff to understand patients triggers and de-
escalation techniques.
There were no instances of seclusion over the 12-month reporting period. We found no instances
of de-facto seclusion during the inspection visit.
There were no instances of long-term segregation over the 12-month reporting period.
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 were able to describe recent safeguarding events and how they were addressed.
Staff had completed safeguarding adults and children training and there was a safeguarding policy
that staff could access.
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 138 safeguarding referrals between 1 August 2017 and 31 July 2018, of
which 137 concerned adults and one child.
Number of referrals
Adults Children Total referrals
137 1 138
There were three peaks identified in adult referrals across the period in November 2017 (17) and
December 2017 (16) and June 2018 with 16 referrals.
Mersey Care NHS Foundation Trust submitted details of three serious case reviews commenced
or published in the last 12 months [1 June 2017 and 31 May 2018]. One serious case review does
relate to this core service.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 326
SCR/SAR Ref Number
Team/Ward Unit
Recommendation
Actions taken
Outstanding actions
SAR 5TF Older Peoples.
SAR 5TF met criteria for SAR at Liverpool Sar Sub Group and is
currently awaiting to be allocated to a reviewer/chair
N/A N/A
Staff access to essential information
Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and
easily available to all staff providing care. A new electronic record system had been introduced in
June 2018. Staff could navigate the system and locate documents without difficulty.
Medicines management
Staff followed best practice when storing, dispensing, and recording medication. Staff regularly
reviewed the effects of medications on each patient’s physical and mental health. Prescription
cards now clearly noted any allergies. This had improved since our last inspection. However, the
disposal of medication on Oak ward was not clearly recorded. Medication that had been dropped
on the floor was not documented. The ward manager planned to rectify this immediately and
implement recording practices in line with other wards.
Covert medication was used in line with best practice and was clearly documented. We saw
examples of best interests decision checklists and mental capacity assessments. Decisions were
discussed during multi-disciplinary meetings with pharmacist input. Covert medicines care plans
with clear instructions to staff had been created and were being used.
Track record on safety
Providers must report all serious incidents to the Strategic Executive Information System (STEIS)
within two working days of an incident being identified.
Between 1 August 2017 and 31 July 2018 there were 15 STEIS incidents reported by this core
service. Of the total number of incidents reported, the most common type of incident was
‘Slips/trips/falls’, with eight meeting the serious incident criteria. One of the unexpected deaths
was an instance of reason ‘Other’.
A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the
available preventative measures are in place. This core service reported no never events during
this reporting period.
We asked the trust to provide us with the number of serious incidents from the past 12 months.
The number of the most severe incidents recorded by the trust incident reporting system was
broadly comparable with STEIS.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 327
Number of incidents reported
Type of incident reported on STEIS
Ap
pare
nt/
actu
al/su
sp
ect
ed
self
-in
flic
ted
harm
meeti
ng
SI
cri
teri
a
Dis
rup
tiv
e/ ag
gre
ss
ive
/
vio
len
t b
eh
avio
ur
meeti
ng
SI
cri
teri
a
Pen
din
g r
evie
w (
a
cate
go
ry m
ust
be
sele
cte
d b
efo
re in
cid
en
t
is c
los
ed
)
Pre
ssu
re u
lcer
meeti
ng
SI c
rite
ria
Slip
s/t
rip
s/f
all
s m
eeti
ng
SI c
rite
ria
Gra
nd
To
tal
Acorn Ward 1 1
Boothroyd Ward 1 1 2
Clock View 1 1
Complex Care - Boothroyd Ward 1 1
Complex Care Services - Mossley Hill
Hospital - Acorn Ward 1 1
Heys Court Ward 1 1
Irwell OP Ward 1 1
Mossley Hill Hospital 1 1
Mossley Hill Hospital - Acorn Ward 1 1
Mossley Hill Hospital - Oak Ward 1 1
North Liverpool (OP) CMHT 1 1
Oak Ward 1 1 2
Older People Complex Care Services
Acorn Ward 1 1
Total 3 1 2 1 8 15
Reporting incidents and learning from when things go wrong
The service managed patient safety incidents well. Staff recognised incidents and reported them
appropriately. 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. Staff were aware of duty of candour responsibilities and gave
examples of when this was applied.
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 two ‘prevention of future death’ reports sent to the trust for a
response. A third report involved a patient who died whilst in the trust’s care, but the trust was not
directly asked for a response. None of these related to this core service.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 328
Is the service effective? Assessment of needs and planning of care
During the inspection we examined 11 sets of patient notes or care plans.
Staff assessed patients’ physical and mental health on admission, using recognised assessment
tools. From these assessments, they developed person centred care plans so that patients
received individual care that met their needs as identified by them. Care plans were personalised,
holistic and recovery-oriented. They reflected patients’ lives and interests. Staff ensured the
records were updated at least every month and when clinically indicated. At Heys Court, some
records had not been reviewed regularly but the new management team had addressed this and
the records we saw had been reviewed in the last two weeks.
Best practice in treatment and care
Staff provided a range of treatment and care for patients based on national guidance and best
practice. This included psychological interventions such as cognitive behavioural therapy.
Staff supported patients with their physical health and encouraged them to live healthier lives. This
included encouraging exercise, healthy food choices and providing support with smoking cessation. All
the wards had a physical health lead. Care plans contained a section on ‘living a good life’.
Patients had good access to physical healthcare, including access to specialists when needed,
such as chiropody and diabetes. This included patient referrals to other services when this was
required. At Heys Court, a local G.P. visited every week.
Staff assessed and met patients’ needs for food and drink and for specialist nutrition and
hydration.
Staff used recognised rating scales to assess and record severity and outcomes, such as the
modified early warning scores and health of the nation outcomes scales. At Heys Court, there
were plans in place to introduce the national early warning scores 2 and training had been
arranged for the staff. This is the early warning system for identifying acutely ill patients, including
those with sepsis, in hospitals in England. Recording a patient’s score regularly means trends in
their clinical responses can be monitored to provide early warning of potential clinical deterioration
and prompt escalation of clinical care. Recording of the trends provides guidance about the
patient’s recovery and return to stability, enabling a lessening in the frequency and intensity of
clinical monitoring towards patient discharge.
This core service participated in 24 clinical audits as part of their clinical audit programme 2017 –
2018.
Audit name Audit scope Audit type Date
completed Key actions following the audit
Supportive
Observations
Audit
Acorn Ward
and Keats
Ward - audit
1
Clinical 06/11/2017
The head of nursing for infection control, Maria
Tyson, is to work with the 2 wards to try to
improve results, and to ensure that patient's
care plans are kept up-to-date. Also, a further
audit of the 2 wards was to be completed (see
below).
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 329
Audit name Audit scope Audit type Date
completed Key actions following the audit
Supportive
Observations
Audit
Acorn Ward
and Keats
Ward - audit
2
Clinical 08/12/2017
Maria Tyson was to continue to work with the
ward managers on their patient care plans, and
another Trust-wide audit of Supportive
Observations will be commenced in August
2018.
REILS Red Bag
(Emergency bag)
Audit
Secure,
Local and
specific
learning
disability
Divisions
Clinical and
Environment 09/08/2017
The areas for improvement were signposting to
emergency ILS bags and contents lists being
present in the bags. This has been factored into
routine monitoring at ward level to improve
compliance, and is part of regular reviews.
Individual actions were identified as follows:
specific learning disability: Staff need instruction
and/or flowchart for restock/resealing of bag.
Needs signage erecting to indicate to staff the
location of the emergency orange box. Staff to
be advised that automated external defibrillator
is not getting checked regularly. Staff to be
advised to check automated external
defibrillator on a daily basis and to sign to say it
has been checked daily. Secure Division: A rota
to be put in place to ensure that daily checks of
automated external defibrillator are done
regularly, Aztrax need to check automated
external defibrillator as out of date and needs
asset number. 2 x non-rebreather masks need
replacing as out of date. Needs signage
erecting to direct staff to nearest automated
external defibrillator and oxygen location, 2 x
size 14g cannulas out of date and need
replacing. Local Division: Need automated
external defibrillator signage erecting to direct
staff to nearest and oxygen location, an
equipment list and a flow chart for
restock/reseal of bag. Staff to be advised to
check automated external defibrillator on a daily
basis and to sign to say it has been checked
daily. Needs 1 set of defib pads replacing as out
of date and non-rebreather mask to go with the
oxygen. Oxygen to be reordered along with a
new bag valve mask.
GP
Communication
Community Clinic
and Inpatient Q2
(July 2017 to
September 2017)
Local
Division Clinical 22/11/2017
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel, the
backlog of letters has been outsourced to bring
all correspondence in line with the NHS contract
requirements.
Health Records
Audit
Secure,
Local,
specific
learning
disability and
LCH Sefton
Clinical 14/12/2017
Each Division has a breakdown of data relating
to their own area. The emphasis for action and
improvement is countersignature of entries by
staff that cannot authorise a clinical note. There
is a review of the electronic patient records
systems in use to review how automation can
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 330
Audit name Audit scope Audit type Date
completed Key actions following the audit
Locality improve compliance.
Nutrition Support
for Adults
Secure,
Local and
specific
learning
disability
Divisions
Clinical 31/01/2018 No action plan - requested by CCG to show
compliance with NICE guidance.
GP
Communication
Community Clinic
and Inpatient Q3
(October 2017 to
December 2017)
Local
Division Clinical 29/01/2018
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel, the
backlog of letters has been outsourced to bring
all correspondence in line with the NHS contract
requirements.
CQUIN GP
Communication
Inpatient - taken
from Q2
Local
Division Clinical 22/02/2018
These results have been discussed within the
teams and remedial action plans in
development.
Ward Transfers
Audit
Local
Division Clinical 27/02/2018 No action Plan (see previous column).
Consent to
Medical Treatment
Audit
Local
Division Clinical 28/02/2018
The following actions have been taken:
• Update referring consultants on the
importance of ensuring all parts of the
electroconvulsive therapy paperwork are
complete
• Review electroconvulsive therapy paperwork
to ensure that unnecessary data in not being
requested
• Ensure that electronic patient recording
system properly records the consent process
for electroconvulsive therapy
Clinical Handover
at Nurse Shift
Change
Local
Division Clinical 05/03/2018
The focus of the action plan has been to
continue to communicate the importance of
handover standards. There is a requirement for
teams to locally audit the quality of handovers
two times per month and compliance is
monitored via the self-assessment process.
This audit is to be repeated in 2018.
Named Nurse
Audit Report
Local
Division Clinical 27/03/2018
The Audit Findings have been shared with the
Lead Nurse for the Local Division for her
comments / actions.
The Clinical Audit Team recommended the
following:
For all named nurse sessions, it should be
clearly stated at the start of the note that it is a
1:1 Named Nurse Session.
There was evidence to suggest that a lot of
what should be discussed in a Named Nurse
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 331
Audit name Audit scope Audit type Date
completed Key actions following the audit
session was being documented but NOT under
this heading – so this was a documenting issue
rather than it not being done. It was either
contained in a general ward note or
multidisciplinary team note.
The template provided for the audit may not be
appropriate for some patients on Older Persons’
Wards, in particular those with an organic
diagnosis. This was due to the weekly planned
sessions, which would not always be
appropriate in these cases. Action Plan
formulated to include the following: 1. Ward
Manager to discuss with Registered Nurses
ways to maximise opportunities to spend time
on 1:1 basis with named service users. 2.
Develop and share named nurse proforma for
named nurses to use in 1:1 sessions with
service users.
Risk Assessments
on Admission
Local
Division Clinical 11/04/2018
The audit findings have been shared widely with
Liaison Services and Single Point of Access to
ensure that the requirements to update risk
assessment prior to admission is fully
understood. This audit is to be repeated in
18/19 and the scope increased to include
'stepped up care'.
National Clinical
Audit of Psychosis
Local,
Secure and
specific
learning
disability
Divisions
Clinical 13/04/2018
Recommendation 1 (by the Royal College of
Psychiatrists)
Ensure that all people with psychosis:
have at least an annual assessment of
cardiovascular risk (using the current version of
Q-Risk) receive appropriate interventions
informed by the results of this assessment have
the results of this assessment and the details of
interventions offered recorded in their case
record.
Recommendation 2
Ensure that all people with psychosis are
offered cognitive behavioural therapy and family
interventions, by:
deploying sufficient numbers of trained staff
who can deliver these interventions making
sure that staff and clinical teams are aware of
how and when to refer people for these
treatments.
Recommendation 3
Ensure that all people with psychosis: are given
written or online information about the
antipsychotic medication they are prescribed
are involved in the prescribing decision,
including having a documented discussion
about benefits and adverse effects of the
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 332
Audit name Audit scope Audit type Date
completed Key actions following the audit
medication.
Recommendation 4
Ensure that all people with psychosis who are
unable to attend mainstream education, training
or work, are offered alternative educational or
occupational activities according to their
individual needs; and that interventions offered
are documented in their care plan.
Recommendation 5
An Annual Summary of Care should be
recorded for each patient in the digital care
record. This should: include information on
medication history, therapies offered and
physical health monitoring/interventions be
updated annually be shared with the patient and
their primary care
team.
Recommendation 6
NHS Digital, NWIS, Commissioners, Trusts and
Health Boards should work together to put in
place key indicators for which data can easily
be collected, perhaps using an Annual
Summary of Care (see Recommendation 5,
above). This work should be informed by the
NCAP results and the experience of the NCAP
team.
Level 1
Observations
Audit
Local
Division Clinical 16/04/2018
The ward managers for each in-patient ward will
carry out a spot check every week of the Level
1 observation sheets. Also, this issue will be
documented as an agenda item at future ward
managers' meetings.
GP
Communication
Community Clinic
and Inpatient Q4
(January 2018 to
March 2018)
Local
Division Clinical 20/04/2018
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel, the
backlog of letters has been outsourced to bring
all correspondence in line with the NHS contract
requirements.
Hoisting
Equipment Audit
Local
Division
Clinical and
Environment 08/06/2018
These results have been discussed within the
teams and Action Plan has been completed:
Lifting Operations and Lifting Equipment
Regulations 1998 inspections have been
completed on all hoists. Other actions include:
To monitor the amount of slings available, and
to explore options for purchasing variety of sling
styles.
GP
Communication
Local
Division Clinical 07/06/2018 There is a full programme of work reviewing the
provision of administrative support to both
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 333
Audit name Audit scope Audit type Date
completed Key actions following the audit
Community Clinic
and Inpatient April
2018
inpatient and community teams. In parallel, the
backlog of letters has been outsourced to bring
all correspondence in line with the NHS contract
requirements.
Datix Incidents
Audit Report
Local
Division Clinical 18/06/2018
These results have been discussed within the
teams and remedial action plans in
development
Falls Audit Report Local
Division Clinical 02/07/2018
1. Standard 4 Frailty Review Documentation
To extend the use of Frailty MDT form used on
Boothroyd Ward and to adapt it for use on
dementia services. 2. To ensure staff who are
completing the frailty review documentation
identify referrals made to other health care
professionals in the action plan on review
documentation.
GP
Communication
Community Clinic
and Inpatient May
2018
Local
Division Clinical 28/06/2018
There is a full programme of work reviewing the
provision of administrative support to both
inpatient and community teams. In parallel, the
backlog of letters has been outsourced to bring
all correspondence in line with the NHS contract
requirements.
Inpatient Diabetes
Audit
Local
Division Clinical 23/05/2018
All diabetic inpatients should have frequency of
capillary blood glucose monitoring determined
at their first ward review and is at the discretion
of the consultant. All CBG monitoring should be
consistent, i.e. before meals. Ensure that serum
cholesterol / triglyceride profile has been done
on admission bloods, if not done within the last
6 months. If serum cholesterol high, statin
therapy should be started as an inpatient unless
contraindicated. Levels should be checked
every 6 months - if no longer an inpatient, can
be at discretion of GP upon discharge. Ensure
any hyperglycaemia is acted upon and
documented. For persistently hyperglycaemia,
advice should be sought from Diabetes
Specialist Nurses at Royal Liverpool Hospital/
Aintree - time frame to be confirmed Advice
should be documented. For hypoglycaemia,
adoption of a Trust -wide hypoglycaemia
protocol should be used and followed as much
as reasonably practical. Re-audit should be
done in one year to allow for implementation of
all the above.
Audit looking at
the quality of the
discharge process
in comparison to
the standards set
by the SD40
transfer /
Local
Division Clinical 14/06/2018
To ensure section 117 status is documented on
discharge letter. Educate trainees on 117
importance. Ensure all attendees at
multidisciplinary team re documented on w/r
notes. Re-audit in 12 months' time.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 334
Audit name Audit scope Audit type Date
completed Key actions following the audit
discharge policy
produced by
Mersey Care
Nutritional
Screening and
Care Planning
(Adapted MUST
tool)
Local
Division Clinical 01/10/2017 No Action Plan
Skilled staff to deliver care
Managers made sure they had staff with a range of skills needed to provide high quality care.
The teams comprised a range of disciplines who were appropriately qualified, skilled and
experienced, including managers, nurses, nursing assistants, occupational therapists,
pharmacists, physiotherapists, psychologists, social workers, a speech and language therapist,
activities co-ordinators and doctors, including psychiatrists and general practitioners. Some staff
took a lead role in specific areas, such as physical health care and falls.
Managers supported staff with appraisals, supervision, opportunities to update and further develop
their skills.
The trust’s target rate for appraisal compliance was 95%. As at 31 July 2018, the overall appraisal
rates for non-medical staff within this core service was 88%.
The wards/teams failing to achieve the trust’s appraisal target were Irwell Ward with an appraisal
rate of 38%. During the inspection we reviewed updated appraisal data and found this had
increased to 97%.
Overall, the rate of appraisal compliance for non-medical staff reported during this inspection was
higher than the 74% reported in the previous year.
Ward name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
%
appraisals
350 L9 Acorn Ward - Mossley Hill (Z1CH35) 32 32 100%
350 L9 Mossley Hill Site Management (Z2GA30) 2 2 100%
350 L9 Mossley Hill Admin (Z1CH90) 3 3 100%
350 L9 Boothroyd Ward SGI (Z1NW33) 32 32 100%
350 L9 Oak Ward - Mossley Hill (Z1CH21) 25 25 100%
350 L9 FMA's Heys Court (Z1CH77) 8 8 100%
350 L9 Heys Court (Z1CH75) 22 21 95%
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 335
Ward name
Total number of
permanent non-medical
staff requiring an
appraisal
Total number of
permanent non-
medical staff who
have had an appraisal
%
appraisals
350 L9 Irwell Ward (Z1AB31) 29 11 38%
Core service total 153 134 88%
Trust wide 5565 4780 86%
As at 31 July 2018, there was no data for medical staff.
Between 1 August 2017 and 31 July 2018, the average rate for supervision compliance across all
five teams in this core service was 72%.
Caveat: there is no standard measure for clinical supervision and trusts collect the data in different
ways; it is important to understand the data they provide.
Ward name Clinical supervision
sessions required
Clinical supervision
sessions delivered
Clinical supervision
rate (%)
350 L9 Oak Ward - Mossley Hill (Z1CH21) 26 26 100%
350 L9 Acorn Ward - Mossley Hill (Z1CH35) 30 27 90%
350 L9 Boothroyd Ward SGI (Z1NW33) 114 97 85%
350 L9 Irwell Ward (Z1AB31) 26 22 85%
350 L9 Heys Court (Z1CH75) 24 18 75%
Unknown 42 19 45%
Core service total 262 209 72%
Trust Total 15334 4947 32%
Supervision, appraisals and dysphagia training had all improved since the last inspection.
Supervision provided opportunity for staff and managers to identify learning needs. Staff had
undertaken specialist training, such as dementia and dysphagia training. Dysphagia training had
now been completed by 78% of staff. Supervision helped managers ensure staff were experienced
and qualified, and had the right skills and knowledge to meet the needs of the patient group. Staff
were now receiving regular supervision and appraisals as per the trusts policy.
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. However, for all the wards, access to
speech and language therapy was problematic due to staff sickness. Managers told us there were
plans to restructure the service so that the impact of sickness was reduced.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 336
Each ward held regular multi-disciplinary team meetings. There were effective handover meetings
within the team, where staff shared information about patients. The ward teams had effective
working relationships with other relevant teams within the organisation, such as care co-ordinators
and community mental health teams.
There were good relationships with external organisations, such as the local safeguarding
authority, local and national service user and carer support groups, local dementia clinical network
and universities.
Adherence to the Mental Health Act and the Mental Health Act Code of
Practice
Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental
Health Act Code of Practice. Managers made sure that staff could explain patients’ rights to them.
As of 31 July 2018, 94% of the workforce in this core service had received training in the Mental
Health Act. The trust stated that this training is mandatory for all core services for inpatient and all
community staff and renewed every three years.
The training compliance reported during this inspection was lower than the 97% reported in the
previous year.
There were policies to provide guidance for staff, and they could seek support from the trust’s
Mental Health Act administrators.
Independent Mental Health Act advocates visited the wards and there was information about
advocacy services displayed in communal areas.
Staff explained patients’ rights under the Mental Health Act to them in a way that they could
understand, repeated it as required and recorded that they had done it. If after three attempts
patients did not retain the information, they were referred to the multi-disciplinary team where
capacity was considered.
Staff ensured that patients could take Section 17 leave (permission for patients to leave hospital)
when this had been granted. Informal patients were aware of their rights to leave.
Staff stored copies of patients' detention papers and associated records (for example, Section 17
leave forms) correctly and so that they were available to all staff that needed access to them.
Care plans referred to identified Section 117 aftercare services to be provided for those who had
been subject to detention under section 3 of the Mental Health Act.
Staff carried out regular audits to ensure that the Mental Health Act was being applied correctly.
The hospital managers monitored compliance with the Mental Health Act.
Good practice in applying the Mental Capacity Act
Staff supported patients to make decisions about their care for themselves. They understood the
trust policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 337
As of 31 July 2018, 94% of the workforce in this core service had received training in the Mental
Capacity Act. The trust stated that this training is mandatory for all core services for inpatient and
all community staff and renewed every three years.
The training compliance reported during this inspection was lower than the 97% reported in the
previous year.
Deprivation of liberty is a situation in which a person’s freedom, or aspects of freedom, is
removed. Deprivation of Liberty Safeguards are the protections set out by the Mental Capacity Act
for people who need to be deprived of their liberty in their best interests so they can receive care
or treatment for which they do not have the capacity to consent themselves.
The trust told us that 49 Deprivation of Liberty Safeguard (DoLS) applications were made to the
Local Authority for this core service between 1 August 2017 and 31 July 2018.
The greatest number of DoLS applications were made in August 2017 with eight.
CQC received 63 direct notifications from Mersey Care NHS Foundation Trust between 1 August
2017 and 31 July 2018. Forty-six of those notifications were for this core service. This meant that
the service were now notifying the CQC of Deprivation of Liberty Safeguards authorisations for
patients. This was an improvement since the last inspection.
Number of DoLS applications made by month
Aug
17
Sep
17
Oct
17
Nov
17
Dec
17
Jan
18
Feb
18
Mar
18
Apr
18
May
18
Jun
18
Jul
18 Total
Applications made
8 3 4 3 1 4 7 7 1 4 3 4 49
Applications approved
1 0 0 1 0 3 3 5 1 0 3 2 19
There were policies about the Mental Capacity Act to provide guidance for staff, including a policy
on consent. The policy cross-referenced the Department of Health guidance ‘Reference to consent
for examination or treatment.’
Staff knew where to get advice from within the provider regarding the Mental Capacity Act,
including deprivation of liberty safeguards.
Staff gave patients every possible assistance to make a specific decision for themselves before
they assumed that the patient lacked the mental capacity to make it.
For patients who might have impaired mental capacity, staff assessed and recorded capacity to
consent appropriately. They did this on a decision-specific basis with regard to significant
decisions.
When patients lacked capacity, staff made decisions in their best interests, recognising the
importance of the person’s wishes, feelings, culture and history.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 338
Staff made deprivation of liberty safeguards applications when required and monitored the
progress of applications to supervisory bodies.
The hospital managers monitored compliance with the Mental Capacity Act and Deprivation of
Liberty Safeguards.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 339
Is the service caring?
Kindness, privacy, dignity, respect, compassion and support
Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity, and
supported their individual needs.
On admission, patients were allocated a nurse who welcomed them to the ward and spent time
helping them settle in. The nurse also contacted the patient’s carer or family within the first 24
hours. There were welcome packs for patients and carers. Patients had access to advocacy. The
patient advice and liaison service ran a monthly patients’ forum and there were monthly carers’
meetings.
We saw patients and staff engaging in activities together. At meal times, staff assisted those
patients who needed it, in a caring and compassionate way that helped them maintain their
independence.
The 2017 patient-led assessments of the care environment (PLACE) score for privacy, dignity and
wellbeing at the core service location(s) scored higher than similar organisations.
Site name Core service(s) provided Privacy, dignity
and wellbeing
HEYS COURT, GARSTON Long Stay / rehabilitation mental health wards for
working age adults
Wards for older people with mental health problems
92.3%
CLOCK VIEW HOSPITAL
Acute wards for adults of working age and psychiatric
intensive care units
Wards for older people with mental health problems
Community based mental health services for adults of
working age
94.0%
LIVERPOOL EMI (MOSSLEY HILL
HOSPITAL)
Wards for older people with mental health problems
Community based mental health services for older
people
93.3%
BOOTHROYD WARD
Wards for older people with mental health problems
Community based mental health services for older
people
97.7%
Trust overall 92.7%
England average (mental health
and learning disabilities) 90.6%
Involvement in care
Staff involved patients and those close to them in decisions about their care, treatment and changes to
the service.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 340
There was a policy on people participation that set out a framework for patients and carers to
become volunteers. All the locations in this core service had volunteers working with them.
Involvement of patients
Staff helped patients to understand their care and treatment. They found ways to communicate
with patients who had communication difficulties, such as involving speech and language
therapists. This was described in care plans. Patients’ involvement in care planning was
sometimes challenging because of their conditions but staff made efforts to include them as much
as possible. Care plans were person centred and written so that the patient could understand,
using plain language. There was evidence of staff and patients discussing the care plan and
having regular one-to-one discussions about their care, although this was sometimes documented
in general notes rather than as a ‘named nurse’ session. Patients attended multi-disciplinary team
meetings and were involved in discussions about their care and plans for moving on.
Patients could give feedback on the service and staff supported them to do this. Each ward held a
community meeting every week. The meetings were recorded and actions from previous meetings
were updated and completed. Patients views were clearly recorded. The minutes were displayed
in the ward communal areas. Staff also used an electronic handheld device to gather patients’
views.
Information about how to give feedback was displayed in the communal areas on all the wards,
including access to advocacy.
Involvement of families and carers
The service implemented the ‘triangle of care’ across all wards. The triangle of care principles
ensure all carers receive consistent information and support so that they feel included and can
support the person they care for better. It encourages partnership working with carers and ensures
they are involved in care and support planning and that they are offered the information and
support they need to care safely and effectively.
Carers were invited to multi-disciplinary team meetings. They were included in plans for discharge
and were invited to attend occupational therapy home assessments. Staff gave them information
about the carer’s assessment and support groups in the community. Care plans described carers’
involvement and records documented the support offered to them.
All the wards held monthly carers’ meetings, but attendance was low. The managers were
considering how this could be improved.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 341
Is the service responsive? Between 1 August 2017 to 31 July 2018, there were a number of patients who moved wards a
number of times after the initial admission for this core service, as outlined in the table below.
During the last 12 months – YR 1 (2018)
During the previous 12 months – YR2 (2017)
Ward name
Number of ward moves
Number of patients
How many were at 'end
of life'*
%-share of all patients
Number of patients
How many were at 'end
of life'*
%-share of all patients
Boothroyd 0 83 0 80% 92 0 84%
1 12 0 12% 12 0 11%
2 8 0 8% 4 0 4%
3 0 0 0% 1 0 1%
4+ 1 0 1% 1 0 1%
Total 104 0 100% 110 0 100%
Irwell 0 49 0 84% 21 0 95%
1 8 0 14% 1 0 5%
2 1 0 2% 0 0 0%
3 0 0 0% 0 0 0%
4+ 0 0 0% 0 0 0%
Total 58 0 100% 22 0 100%
Acorn 1 Ward MHH
0 46 0 77% 47 0 85%
1 12 0 20% 7 0 13%
2 0 0 0% 1 0 2%
3 2 0 3% 0 0 0%
4+ 0 0 0% 0 0 0%
Total 60 0 100% 55 0 100%
Oak 1 Ward MHH
0 71 0 84% 80 0 87%
1 12 0 14% 11 0 12%
2 1 0 1% 1 0 1%
3 0 0 0% 0 0 0%
4+ 1 0 1% 0 0 0%
Total 85 0 100% 92 0 100%
Heys Court
0 11 0 100% 0 0 0%
1 0 0 0% 0 0 0%
2 0 0 0% 0 0 0%
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 342
During the last 12 months – YR 1 (2018)
During the previous 12 months – YR2 (2017)
3 0 0 0% 0 0 0%
4+ 0 0 0% 0 0 0%
Total 11 0 100% 43 0 100%
Access and discharge
People could access the service closest to their home when they needed it. Waiting times from
referral to treatment and arrangements to admit, treat and discharge patients were in line with
good practice. When patients were moved or discharged, this happened at an appropriate time of
day.
Staff planned for patients’ discharge on admission. They formulated a discharge/leaving hospital
care plan that included the family’s wishes for the patient’s future care. They liaised with social
care professionals, care co-ordinators, other health and care professionals and other care
providers to facilitate discharge.
Bed management
The trust provided information regarding average bed occupancies for five wards in this core
service between 1 August 2017 and 31 July 2018.
Four of the wards within this core service reported average bed occupancies ranging above the
nationally recommended minimum benchmark of 85% over this period. There were beds available
for patients returning form overnight leave.
We are unable to compare the average bed occupancy data to the previous inspection due to
differences in the way we asked for the data and the period that was covered.
At the time of the inspection bed management was operating effectively as on the day of our visit
Boothroyd ward was discharging a patient as well as having a vacant bed. On the day of our visit
to Irwell ward, this ward had seven vacant beds. If wards had elevated levels of 1:1 observation
then they would not accept further admissions until the risk had reduced.
Ward name Average bed occupancy range (1 August 2017 – 31
July 2018) (average last 12 months)
Acorn1 Ward MHH 63.4% - 97.0% (83.4%)
Boothroyd 75.7% - 98.5% (90.9%)
Irwell 72.5% - 95.3% (85.7%)
Oak1 Ward MHH 87.7% - 100.8% (94.5%)
Heys Court 81.2% - 93.8% (88%)
The trust provided information for average length of stay for the period 1 August 2017 to 31 July
2018.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 343
We are unable to compare the average length of stay data to the previous inspection due to
differences in the way we asked for the data and the period that was covered.
Ward name Average length of stay range in days (1 August 2017 –
31 July 2018) (average last 12 months)
Acorn1 Ward MHH 37.7 – 77.3 (58.0)
Boothroyd 43.6 – 74.6 (56.4)
Irwell 46.7 – 94.0 (67.9)
Oak1 Ward MHH 48.5 – 101.4 (71.2)
Heys Court 761 – 2661 (1556)
This core service reported no out area placements between 1 August 2017 and 31 July 2018.
This core service reported 11 readmissions within 28 days between 1 August 2017 and 31 July
2018.
Nine readmissions (82%) were readmissions to the same ward as discharge.
The average of days between discharge and readmission was 10 days. There were no instances
whereby patients were readmitted on the same day as being discharged but there was one
instance where a patient was readmitted the day after being discharged.
Ward name Number of
readmissions
(to any ward)
within 28 days
Number of
readmissions
(to the same
ward) within 28
days
% readmissions
to the same
ward
Range of days
between
discharge and
readmission
Average days
between
discharge and
readmission
Irwell 2 2 100% 3-11 7
Acorn 1 Ward MHH
1 1 100% 2 2
Oak 1 Ward MHH
3 1 33% 3-26 16
Boothroyd 5 5 100% 1-19 9
Core service Total
11 9 82% 1-26 10
Discharge and transfers of care
Between 1 August 2017 and 31 July 2018, there were 297 discharges within this core service.
This amounts to 8% of the total discharges from the trust overall (3784).
Caveat: Acorn ward reported more delayed discharges than there were actual discharges for
months August 2017 and May 2018.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 344
The graph below shows the trend of delayed discharges across the 12-month period.
The graph suggests a spike in February 2018.
Discharge from hospital was delayed by local authority funding for care homes and availability of
suitable care home placements.
A discharge coordinator was employed on Boothroyd ward. This role ensured patients records
were fully up to date prior to discharge planning meetings. There was a process to notify GP’s and
refer to community teams in a timely manner.
There is no data pertinent to this core service in relation to patients lost to follow up.
The trust has identified the services in the table below as measured on ‘referral to initial
assessment’ and ‘assessment to treatment’.
The core service met the referral to assessment target in five of the six teams.
The assessment to treatment times ranged from 1.5 days to 21 days across the six teams. No
target was provided.
Name of hospital site or
location
Name of in-patient ward
or unit
Please state
service type.
Days from referral to initial assessment
Days from referral to treatment
Comments,
clarification
Target Is this target national or
local?
Actual (media
n)
Targe
t
Is this target national or
local?
Actual (media
n)
Mossley Hill
Acorn Ward Complex Care
30 Days
Local 2.5
6
Boothroyd Boothroyd Ward
Complex Care
30 Days
Local 7
11
Clock View
Irwell Ward Complex Care
30 Days
Local 1.5
1.5
Mossley Hill
Oak Ward Complex Care
30 Days
Local 13.5
21
8 8
6
5
6
8
10
6 6
8
6
8
0
2
4
6
8
10
12
Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18
Number of delayed discharges
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 345
Facilities that promote comfort, dignity and privacy
Patients had their own areas/rooms where they could keep personal belongings safely. There were
quiet areas for privacy and where patients could be independent of staff. Patients could personalise
their bedrooms.
Irwell ward and Heys Court provided patients with their own bedrooms. Only Irwell ward had en-
suite toilets with a shower. Otherwise patients were expected to sleep in shared bedrooms or bed
bays of 2, 3 or 4 patients. This did not promote dignity or privacy. Shared bedrooms had curtains
separating each bed area to increase privacy.
The trust’s estates strategy prioritised the replacement of ward environments that were not fit for
purpose. The trust was building a new hospital, Hartley Hospital, in Southport to replace the
Hesketh Centre (Boothroyd ward). The build was due to be completed in October 2019. The trust
was also undertaking a feasibility study of potential sites for a new hospital to replace wards at
Broadoak, with a view to submitting a business case in the near future. The trust told us that they
hoped to be able to open this new hospital in Liverpool within the next three years.
Staff and patients had access to the full range of rooms and equipment to support their care and
treatment, which included clinic room to examine patients, activity and therapy rooms.
All beds were furnished with a graded mattress as standard unless a patient needed an air flow
replacement one.
The accommodation was all ground floor and accessible for those with reduced mobility, with
accessible toilets and bathrooms available for patients on and all wards.
Patients could make a phone call in private or had their own mobile telephones they could use in
private.
Patients had access to outside level space, some with non-slip floor covering.
The provision of safe secure storage varied across the core service were facilities varied from lockable
furniture containing a lockable digital safe or draw, or the option of valuable items being placed in on
site secure storage. Patients had keys to their bedrooms and safe storage if they chose to and or there
was no risk identified.
Staff ensured that patients had access to appropriate spiritual support. On Irwell ward we saw the
Church of England vicar visiting patients, chatting to and having a drink with them.
Patients had a choice of food to meet the dietary requirements of religious and ethnic groups. The
food was of a good quality with a trust average food quality score of 95.4% from patient-led
assessments of the care environment. Patients could make hot drinks and snacks whenever they
liked.
The 2017 patient-led assessments of the care environment (PLACE) score for ward food at the
locations scored the same or higher than similar trusts.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 346
Feedback from patients was that the food was of good quality. We saw pictorial menus in use on
Irwell ward to assist patients with decision making. Menus include information about whether
meals were gluten free, vegan or vegetarian.
Site name Core service(s) provided Ward food
HEYS COURT, GARSTON Caring for adults over 65 yrs
Caring for people whose rights are restricted under
the Mental Health Act
Mental health conditions
91.5%
CLOCK VIEW HOSPITAL
Acute wards for adults of working age and psychiatric
intensive care units
Wards for older people with mental health problems
Community based mental health services for adults of
working age
100.0%
LIVERPOOL EMI (MOSSLEY HILL
HOSPITAL)
Wards for older people with mental health problems
Community based mental health services for older
people
95.5%
BOOTHROYD WARD
Wards for older people with mental health problems
Community based mental health services for older
people
98.6%
Trust overall 95.4%
England average (mental health and learning disabilities) 91.5%
Patients’ engagement with the wider community
Staff supported patients with activities outside the service, such as work, education and family
relationships.
Families were signposted to carer networks groups in the community and some wards had monthly
carer meetings.
Patients on Boothroyd ward had access to the gym at the nearby Hesketh Centre.
Patients care records contained information about their accommodation needs after discharge for
example if they needed alternative or care home accommodation or adaptations made to their
homes to support their mobility. Patients were involved in and agreed with the decisions about
their accommodation needs.
When patients were having section 17 leave in the community these contained details of where
the patients were visiting, whether staff support was needed and a contact number for the patient
in case of an emergency.
On some wards there were walking groups in the local community as part of the ward based
activities programme.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 347
Meeting the needs of all people who use the service
The service was accessible to all who needed it and took account of patients’ individual needs. Staff
helped patients with communication, advocacy and cultural support.
On or soon after admission patients were provided with a welcome pack containing information
about the individual ward they were admitted to. This included information about the facilities, meal
and visiting times on the wards There was also a ‘getting it right’ information booklet for families,
used for obtaining specific information about meeting patients’ needs and informing patient care
plans.
The wards provided dementia friendly surroundings although they were restricted by the physical
environment. Signage was mostly pictorial, with clear signage indicating the purpose for which the
living space was used for. In toilets and bathrooms there were contrasting colours, for example,
blue toilet seats and hand rails. Each ward had an assisted bath or shower.
Lounges and bedrooms had clocks which indicated the day, date and time to orientate patients
their surroundings. Bedrooms and bays had digital calendar clocks, indicating the period of the
day, for example morning or afternoon.
The trust assessed wards using the Patient-led assessments of the care environment (PLACE)
NHS Improvement standard for a dementia friendly environment. Of the wards we visited only
Clock View Hospital received a score worse than other similar trusts for dementia friendly, scoring
79.9% compared to 84.8% nationally.
There were quiet spaces and areas where patients could meet visitors, with views onto the
enclosed garden area or outside. Flooring was non-reflective and non-slip and seating was
traditional. Boothroyd ward had family room with comfortable soft furnishings.
Listening to and learning from concerns and complaints
The service treated concerns and complaints seriously, investigated them and learned lessons from
the results, and shared these with all staff.
Wards used a weekly community meeting to discuss the ward activities, patients’ satisfaction and any
concerns they had about the service they received. Community meetings were led by staff form the
ward or occupational therapy. Agenda items and minutes from the previous meetings discussed and
feedback on progress was shared as well as any new business for discussion.
There was information displayed and information leaflets available about the Patient Advocacy Liaison
Service (PALS) to support patients who wanted to make a formal complaint about their care or
treatment. On Acorn ward patients raised concern about the soft diets provided as well as the odour of
the fish in a meal. Both concerns were rectified. On Boothroyd ward the staff used a handheld
electronic device to gain feedback from patients on their views of the service they received.
This core service received three complaints between 1 August 2017 and 31 July 2018. One of
these was partially upheld and one was not upheld. Neither were referred to the Parliamentary and
Health Services Ombudsman. The third was still under investigation.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 348
Ward
name
Total
Complaints
Fully
upheld
Partially
upheld
Not
upheld
Under
Investigation
Referred to
Ombudsman
Upheld by
Ombudsman
Boothroyd
Ward 2 0 1 0 1 0 0
Oak Ward 1 0 0 1 0 0 0
Total 3 0 1 1 1 0 0
This core service received no compliments during the last 12 months from 1 August 2017 and 31
July 2018.
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 349
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. Ward managers demonstrated effective leadership and had a good
understanding of their service and how to improve it. Leadership training was available and
managers were encouraged to attend. Staff described ward managers and senior managers as
approachable and accessible.
Vision and strategy
The trust 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 trust values were embedded within policies and procedures. Staff spoke about aiming for
perfect care and a just culture. Staff were consulted regarding changes to the service and their
views considered and acted upon.
Culture
Managers across the trust promoted a positive culture that supported and valued staff, creating a
sense of common purpose based on shared values. Staff felt respected, supported and valued.
They told us they were supported by their colleagues and managers, including senior managers.
Managers dealt with poor staff performance when needed. Ward managers described using staff
discipline processes to good effect. Staff on Irwell ward and Heys Court reflected that morale had
improved since new managers were appointed. Staff felt assured that they could raise concerns
and that managers would be supportive of them. Staff were recognised for their achievements. A
staff member had been nominated for an award on Oak ward.
During the reporting period, there were two cases where staff had been either suspended, placed
under supervision or were moved to a different ward. One staff member had been suspended and
one was moved to a different ward.
Of the two cases, one involved Band 2 staff group and the other Band 3 staff group.
Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these
should be noted.
Ward name Suspended Under supervision Ward move Total
Irwell Ward 0 0 1 1
Oak Ward 1 0 0 1
Core service total 1 0 1 2
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 350
Governance
The trust used a systematic approach to continually improve the quality of its services and
safeguarding high standards of care by creating an environment in which excellence in clinical
care would flourish. Managers had access to effective governance systems that enabled them to
have oversight of the service.
There was an electronic dashboard which provided ward managers with up to date data on staff
training, supervision and appraisal compliance, bed occupancy rates and staffing levels.
There was an electronic incident reporting system that staff were confident to use. Information
from incidents was analysed and themes addressed.
There was a system for auditing Mental Health Act and Mental Capacity Act procedures. There
was a central Mental Health Act administrator.
The trust had identified issues on Irwell ward and Heys Court. Managers had acted on these
concerns and made improvements. Ward managers had been particularly effective in improving
the culture and performance of the wards. Comprehensive action plans had been created and
implemented. This included meeting targets for supervision, training and a reduction in staff
sickness rates. New staff had been recruited and staff on both wards described a positive and
professional atmosphere.
Management of risk, issues and performance
The trust had effective systems for identifying risks, planning to eliminate or reduce them, and
coping with both foreseeable and unforeseeable risks. We saw evidence of action plans being
implemented to improve the performance of the service. There was a trust wide risk register to
monitor and improve risks. The Trust had an up to date major incident action plan for serious
unplanned events. Dysphagia training had been identified on the risk register. Actions had been
implemented and a programme of staff training had been undertaken. Staff were able to raise
issues directly with ward managers or other senior staff. There was a whistleblowing process that
staff were aware of and knew how to access. There was a freedom to speak up guardian.
Information management
The trust collected, analysed, managed and used information well to support all its activities, using
secure systems with security safeguards. A new electronic recording system had been in place for
approximately four months. Staff described having some initial difficulties but the system was now
working well and embedded into the service. A quality dashboard was available at ward and
service level to monitor and support improvements. Staff made notifications to external bodies as
needed.
Engagement
Staff, patients and carers had access to up-to-date information about the services they used and
about the trust, for example, through the intranet, bulletins, newsletters. The trust displayed all
their policies on the public website for anyone to access. A booklet had been developed that
described the services provided by the trust. All wards, with the exception of Oak ward had
Mersey Care NHS Foundation Trust evidence appendix: wards for older people with mental health problems Page 351
developed their own welcome packs to help orientate patients to the ward. Oak ward was in the
process of reviewing their welcome pack.
Patients and carers had opportunities to give feedback on the service they received in a manner
that reflected their individual needs. Each ward held regular patient and carer meetings. Patient
meetings were held weekly on each ward. Carer meeting were held on a monthly basis but
attendance was poor. Ward managers were considering different ways to improve carer
engagement.
Managers and staff had access to feedback from patients, carers and staff and used it to make
improvements. We saw evidence that patient feedback was acted upon from patient meetings.
Complaints from carers were considered and acted upon where necessary. Staff were consulted
regarding changes to the service. Staff had input into the design of the new ward being built at
Boothroyd ward. Staff were also consulted regarding a proposed move of Oak and Acorn wards to
another location.
Patients and staff could meet with members of the provider’s senior leadership team to give
feedback. Senior leaders regularly visited each service.
Learning, continuous improvement and innovation
Staff were given the time and support to consider opportunities for improvements and innovation
and this led to changes. This included the development of the “getting it right” document that
supported staff and carers to discuss the needs of patients. It included personalised information to
help support patients whilst they were an inpatient and any future care placement. The information
was added to care plans and risk assessments and shared with new providers.
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 provided services within which have been awarded an accreditation together with the
relevant dates of accreditation. However, there was no information pertaining to this core service.