Community-based mental health services for older people

Locations inspected

Name of CQC registeredlocation

Location ID Name of service (e.g. ward/unit/team)

Postcodeofservice(ward/unit/team)

Hellesdon

RMY01

The Julian HospitalDementia and Complexity inLater Life TeamDementia Intensive SupportTeam

NR2 3TD

HellesdonRMY01

Gateway HouseDementia and Complexity inLater Life Team

NR18 0WF

HellesdonRMY01

Carlton CourtDementia and Complexity inLater Life Team

NR33 8AG

Norfolk and Suffolk NHS Foundation Trust

Community-bCommunity-basedased mentmentalalhehealthalth serservicviceses fforor olderolderpeople.people.Quality Report

Hellesdon HospitalDrayton High RoadNorwichNR6 5BETel:01603 421421Website: www.nsft.nhs.uk

Date of inspection visit: 21 - 23 October 2014Date of publication: February 2015

Requires Improvement –––

1 Community-based mental health services for older people. Quality Report February 2015

Dementia Intensive SupportTeam

Hellesdon

RMY01

Chatterton HouseDementia and Complexity inLater Life TeamDementia Intensive SupportTeam

PE30 5PD

HellesdonRMY01

Woodlands UnitDementia Intensive SupportTeam

IP4 5PD

HellesdonRMY01

Main SiteDementia Intensive SupportTeam

IP33 3NR

This report describes our judgement of the quality of care provided within this core service by Norfolk and Suffolk NHSFoundation Trust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘IntelligentMonitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Norfolk and Suffolk NHS Foundation Trust andthese are brought together to inform our overall judgement of Norfolk and Suffolk NHS Foundation Trust.

Summary of findings


RatingsWe are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings willalways be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring dataand local information from the provider and other organisations. We will award them on a four-point scale: outstanding;good; requires improvement; or inadequate.

Overall rating for Community-basedmental health services for older people Requires Improvement –––

Are Community-based mental health servicesfor older people safe? Requires Improvement –––

Are Community-based mental health servicesfor older people effective? Good –––

Are Community-based mental health servicesfor older people caring? Good –––

Are Community-based mental health servicesfor older people responsive? Inadequate –––

Are Community-based mental health servicesfor older people well-led? Requires Improvement –––

Mental Health Act responsibilities and MentalCapacity Act / Deprivation of Liberty SafeguardsWe include our assessment of the provider’s compliancewith the Mental Health Act and Mental Capacity Act in ouroverall inspection of the core service.

We do not give a rating for Mental Health Act or MentalCapacity Act; however we do use our findings todetermine the overall rating for the service.

Further information about findings in relation to theMental Health Act and Mental Capacity Act can be foundlater in this report.

Summary of findings


Contents

PageSummary of this inspectionOverall summary 5

The five questions we ask about the service and what we found 6

Background to the service 8

Our inspection team 8

Why we carried out this inspection 8

How we carried out this inspection 8

What people who use the provider's services say 9

Good practice 9

Areas for improvement 9

Detailed findings from this inspectionLocations inspected 10

Mental Health Act responsibilities 10

Mental Capacity Act and Deprivation of Liberty Safeguards 11

Findings by our five questions 12

Summary of findings


Overall summaryWe rated the mental health community services for olderpeople as ‘requires improvement' because:

• There were no clear procedures in place to managerisks to people and staff safety at all times. Themanagement approaches used to respond tofluctuations in people’s mental state were not safe.

• People’s medicines were not routinely monitored toensure that they were always stored at the safetemperature for them to be effective.

• People over the age of 65 with dementia had noaccess to 24 hour crisis team in some areas. Thismeant they had no access to specialist services andremained at risk.

• Staff lacked a clear understanding of the vision andvalues of the organisation.

• Staff told us that the morale was low as the seniormanagement did not listen to their concerns.

• Quality was inconsistently monitored at local levelswhich meant that trends were not fully analysed inorder to make improvements to the service.

However:

• People were treated in line with current legislation andnational guidance. The physical health needs ofpeople who used the service were assessed andmonitored to ensure people’s health and wellbeing.

• Staff were polite, kind and treated people with respectand dignity. Care was delivered in a caring andcompassionate way.

• People told us they were involved in their care.Relatives were involved in care planning and theirinformation was used to develop people’s care plans..

Summary of findings


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

Are services safe?We rated the mental health community services for older people as‘requires improvement' because:

• There were no clear procedures in place to manage risks topeople and staff safety at all times. The managementapproaches used to respond to fluctuations in people’s mentalstate were not safe.

• Routine checks were not always carried out to ensure thatmedicines were kept at the safe temperature for optimumeffectiveness.

• There were staff shortages in other areas which resulted in staffhaving high caseloads. This could affect people’s safety andtreatment.

However:

• Staff received training in how to safeguard people who used theservice from harm and demonstrated that they knew how to dothis


Are services effective?We rated the mental health community services for older people as‘good' because:

• People’s mental capacity was assessed and where peoplelacked the mental capacity to make decisions about their careand treatment, decisions were made in their best interests.

• People were treated in line with current legislation and nationalguidance. The physical health needs of people who used theservice were assessed and monitored to ensure people’s healthand wellbeing.

• Staff worked well as a multi-disciplinary team and took aperson-centred approach. However, we saw that there waslimited input from occupational therapy services.

• There was a range of treatment approaches available to meetpeople’s needs. Staff were well trained and had access totraining and development opportunities.

However

• There were inconsistencies in providing regular supervisionand appraisals.

Good –––

Are services caring?We rated the mental health community services for older people as‘good' because:

Good –––

Summary of findings


• Staff were polite, kind and treated people with respect anddignity. Care was delivered in a caring and compassionate way.

• People told us they were involved in their care. Relatives wereinvolved in care planning and their information was used todevelop people’s care plans.

• Staff demonstrated a high level of emotional support topatients on an individual level and took time to supportpatients in a sensitive manner.

Are services responsive to people's needs?We rated the mental health community services for older people as‘inadequate' because:

• People over the age of 65 with dementia had no access to 24hour crisis team in some areas. This meant they had no accessto specialist services and remained at risk.

• Information about services provided was not very clear andcould affect effect delivery of care.

However:

• Complaints were taken seriously, investigated, responded topromptly and lessons learnt.

• We saw that there was a system to respond to urgent referralsusing the single point of access.

Inadequate –––

Are services well-led?We rated the mental health community services for older people as‘requires improvement' because:

• Staff lacked a clear understanding of the vision and values ofthe organisation.

• Staff told us that the morale was low as the senior managementdid not listen to their concerns.

• Quality was inconsistently monitored at local levels whichmeant that trends were not fully analysed in order to makeimprovements to the service.

• Staff felt a disconnect with senior management

However:

• Staff showed passion for their work despite feeling undervaluedby senior management.


Summary of findings


Background to the service• The older people community service provides mental

health services across Norfolk, Suffolk and GreatYarmouth and Waveney for people experiencingdementia and complexity in later life. The offices andclinics are situated around the counties and provideaccess to care within clinics and people’s own home.The service is provided by two teams, DementiaIntensive Support team (DIST) and Dementia andComplexity in Later Life (DCLL).

• DIST teams in Norfolk offers assessment, interventionand intensive support to adults with age related needsincluding established or suspected dementiadiagnoses, severe and enduring mental healthproblems such as anxiety, depression and relatedbehavioural problems. However, the DIST teams inSuffolk cared for people with dementia related issuesonly.

• DCLL services offer assessment diagnosis andtreatment for adults experiencing memory problems,

cognitive impairment, dementia, and other mentalhealth issues associated with later life. The DCLL alsooffers a memory treatment service that providesassessment and monitoring of patients who wereprescribed one of the drugs that have been licensedfor the treatment of mild to moderate Alzheimer’sdementia.

• The operational times for all DIST teams includedweekends but varied across the trust depending onthe population served. The DCLL teams operated from9am to 5pm Monday to Friday. None of the teamsprovided 24 hours service.

• A single point of access for referrals was operatedwithin all teams in Norfolk and Great Yarmouth andWaveney, known as the Access and Assessment Team(ATT) which triage all referrals. These services have notbeen inspected before.

Our inspection teamOur inspection team was led by:

Chair: Joe Rafferty, Chief Executive Officer,Merseycare NHS Trust

Team Leader: Julie Meikle, Head of HospitalInspection (mental health), CQC

Inspection Manager: Lyn Critchley, InspectionManager, CQC

The team included CQC managers, inspection managers,inspectors and support staff and a variety of specialistand experts by experience that had personal experienceof using or caring for someone who uses the type ofservices we were inspecting.

Why we carried out this inspectionWe inspected this trust as part of our on-goingcomprehensive mental health inspection programme.

How we carried out this inspectionTo get to the heart of people who use services’ experienceof care, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?

• Is it responsive to people’s needs?• Is it well-led?

Before visiting, we reviewed a range of information wehold about Norfolk and Suffolk NHS Foundation Trust

Summary of findings


and asked other organisations to share what they knew.We carried out an announced visit between 21 Octoberand 23 October. Unannounced inspections were alsocarried out on the late evening of 06 November 2014.

During the visit we held focus groups with a range of staffwho worked within the service, such as nurses, doctors,

therapists. We talked with people who use services. Weobserved how people were being cared for and talkedwith carers and/or family members and reviewed care ortreatment records of people who use services. We metwith people who use services and carers, who sharedtheir views and experiences of the core service.

What people who use the provider's services sayDuring the inspection, we spoke with eight people whoused the service. They were pleased with the careprovided. We found that people were positive about theirexperiences of care and we observed polite, warm andpatient interaction with people. People told us that staff

were very supportive, included them in their careplanning and gave them information that helped them tomake choices about their care. People told us that theyfelt staff treated them with respect and dignity andlistened to them.

Good practice• The DIST team had introduced an innovative helpline

to offer support and advice to carers and care homes.• Despite the pressures of workload the staff we

observed were dedicated, caring and compassionate.

• The DCLL had integrated its collaborative working withGPs and social workers to increase outcomes forpatients.

Areas for improvementAction the provider MUST or SHOULD take toimproveAction the provider MUST or SHOULD take toimprove

• The trust must ensure that there are robust policiesand procedures that keep staff and patients safe in thecommunity.

• The trust must ensure that people receive the rightcare at the right time by placing them in suitableplacements that meet their needs and have access to24 hour crisis team.

• The trust must ensure that all risk assessments andcare plans are updated consistently in line with multi-disciplinary reviews.

• The trust must ensure that they provide people withthe right information about services.

• The trust must ensure that there are systems in placeto monitor quality and performance of the teams.

• The trust must improve staff engagement as manystaff in mental health community teams felt“disconnected” from senior managers and theleadership of the Trust.

• The trust must ensure that health and safety checksare carried out consistently.

• The trust must ensure that temperatures for medicinesstored are regularly monitored in line with medicinesmanagement guidelines.

• The trust must ensure that all staff receive regularsupervision and appraisal.

• The trust must ensure that the teams are adequatelystaffed including junior medical staff.

Summary of findings


Locations inspected

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

The Julian Hospital HQ: Hellesdon

Gateway House HQ: Hellesdon

Carlton Court HQ: Hellesdon

Chatterton House HQ: Hellesdon

Woodlands Unit HQ: Hellesdon

Main Site HQ: Hellesdon

Mental Health Act responsibilitiesWe do not rate responsibilities under the MentalHealth Act 1983. We use our findings as a determinerin reaching an overall judgement about the Provider.

The teams adhered to the Mental Health Act legislationappropriately where it was applicable.

Norfolk and Suffolk NHS Foundation Trust

Community-bCommunity-basedased mentmentalalhehealthalth serservicviceses fforor olderolderpeople.people.Detailed findings


Mental Capacity Act and Deprivation of Liberty SafeguardsWe found that the community staff had an understandingof the Mental Capacity Act (MCA) and had attended trainingto ensure that they had the required knowledge. Thistraining was completed as part of the mandatory trusttraining.

Detailed findings


* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatoryabuse

Summary of findingsWe rated the mental health community services forolder people as ‘requires improvement' because:

• There were no clear procedures in place to managerisks to people and staff safety at all times. Themanagement approaches used to respond tofluctuations in people’s mental state were not safe.

• Routine checks were not always carried out to ensurethat medicines were kept at the safe temperature foroptimum effectiveness.

• There were staff shortages in other areas whichresulted in staff having high caseloads. This couldaffect people’s safety and treatment.

However:

• Staff received training in how to safeguard peoplewho used the service from harm and demonstratedthat they knew how to do this

Our findingsJulian Hospital and Gateway House - CentralNorfolkSafe and clean environment

We saw that the environment was clean and staff practicedgood infection control procedures. The environment wasused solely by staff. We saw that security procedures werefollowed.

Safe staffingThe teams used the traffic light monitoring system toassess the level of staffing required according the size ofcaseloads held within the teams. Caseloads wereconstantly reviewed in the supervision sessions. Bothteams consisted of band six and five nurses and band foursupport workers. Staffing levels and grades were clearlyidentified with band six nurses responsible for carrying outassessments in people’s homes. The band five

nurses carried out follow ups and were supported by seniornurses. The band four workers were responsible forobservations of care, personal care and support in carehomes.

The DIST team had medical support from two consultantswho provided two sessions a week and one full timespeciality doctor.

Assessing and managing risk to patients and staffRisk assessments were carried out for all visits to people toensure that all staff were safe. Where the risk was deemedhigh, staff saw people in pairs.

All staff were aware of the lone working policy and told usthat they followed it. Staff had established systems forensuring staff whereabouts were known and logged and asystem was in place for ensuring staff had returned safelyfollowing community visits.

Patient's risks were assessed prior to care and treatmentstarting. Risk assessments and management plansmatched the identified needs. However the records we sawcontained patient information that wasmisfiled. Information for different patients was mixed inclinical records file so that information was not availablewhen needed.

All staff spoken with demonstrated that they knew how toidentify and report any abuse to ensure that people whoused the service were safeguarded from harm.

At Gateway house we saw that portable appliance test wasnot carried out for the equipment used in the offices.Equipment was not maintained and checked regularly toensure it continued to be safe to use. The equipment wasnot clearly labelled indicating when it was next due forservice.

There was no routine monitoring of the temperature ofstored medicines to ensure they were kept within rangesrecommended by the manufacturers. This meant theireffectiveness was potentially compromised.

Are services safe?By safe, we mean that people are protected from abuse* and avoidable harm

Requires improvement –––


Reporting incidents and learning from whenthings go wrong

We saw that there was an effective system to recordincidents and near misses. We saw that incidents werereported and investigated. Staff told us that they receivedfeedback following incidents through meetings andinformation was circulated within the team.

We saw evidence that learning from incidents took placeand that specific changes to practice was made as a resultof incidents. This meant that the trust was able to identify,investigate and learn from incidents.

Chatterton House - West NorfolkSafe and clean environment

The environment was clean and staff practiced goodinfection control procedures. The environment wasoccasionally visited by patients and relatives. We saw thatsecurity procedures were followed. However the lightingwas poor and not working in some rooms.

Safe staffingKings Lynn teams felt stretched, the teams had caseloadsabove the anticipated numbers. For example DIST had 39instead of 25. Agency nurses were used to supplement theteam numbers. The clinical leads told us that the teamswere on risk register for low staffing levels. Low staffinglevels had an impact on care and treatment as well as safedischarge in a timely manner. Staffing rotas showed thatsome nurses were working long hours and consecutivedays. This indicated that the service was struggling to staffthe service to deliver safe care.

Teams monitored staffing levels against required activity.The teams used the traffic light monitoring system toassess the level of staffing required according the numberof caseload held within the team. The manager told us thatthey were mostly amber. There was an escalation plan forlocal teams to follow for amber and red status. A review ofsafer staffing in the community had commenced and staffwere recording the complexity as well as number ofpatients in case loads and this would feed into reportingand workforce planning.

The teams had a locum consultant psychiatrist and werestruggling to recruit a permanent consultant. There wasmedical cover from a speciality doctor and a junior doctor.

Assessing and managing risk to patients and staffRisk assessments were carried out for all visits to people toensure that all staff were safe. Where the risk wasconsidered high, staff visited in pairs.

All staff were aware of the lone working policy and told usthat they followed it. Staff had established systems forensuring staff whereabouts were known and logged and asystem was in place for ensuring staff had returned safelyfollowing community visits.

People’s risks were assessed prior to care and treatmentstarting. There were good examples of completed riskassessments and management plans that matched theidentified needs. There were risk assessment andmanagement plans in place that stated how staff shouldsupport people safely.

There were thorough policies and procedures in place inrespect of safeguarding to support staff to respondappropriately to concerns. All staff spoken with proved thatthey knew how to recognise and report any abuse toensure that people who used the service were protectedfrom harm.

All notes were in paper format and reasonably wellmaintained. The patient records we examined were writtenlegibly and assessments were comprehensive andcomplete, with associated action plans and dates. Recordswere kept safely in lockable cabinets and confidentialitywas maintained.

Routine checks were not always carried out to ensure thatmedicines were kept at the safe temperature for optimumeffectiveness.


There was an effective mechanism to capture incidents,near misses and never events. Incidents were reported viaan electronic incident reporting form. Staff told us theyknew how to report incidents and were encouraged to usethe reporting system. Staff were able to explain howlearning from incidents and complaints was cascaded to allstaff. Learning from incidents was discussed in staffmeetings.

Carlton Court – Great Yarmouth & WaveneySafe and clean environment

We saw that the environment was clean and staff practicedgood infection control procedures. The environment was




occasionally visited by patients and relatives for clinics.Security procedures were followed. The environment wasmaintained to ensure the safety of staff and people whoused the service.

Safe staffingStaffing levels for community nurses varied across thedifferent localities. Some of the localities were satisfactorilystaffed. Lowestoft community team, particularly DIST, feltheavily stretched and staff had been working over theircontracted hours. Lowe staffing levels had an impact onreferrals and patient care was not always undertaken in atimely manner. The teams used the traffic light monitoringsystem to assess the level of staffing required according thenumber of caseload held within the teams. Caseloads wereconstantly reviewed in the supervision sessions. However,issues reported in regard to inadequate staffing levels inthe DIST team had not been taken into account. This meantthat key risks and actions to mitigate any impact uponeffective care delivery were not prioritised.

There were no junior medical staff in DIST and anyassessments had to be done through the GP. There was alack of medical input from the team to ensure that thosepatients with high and complex needs, such as patientswaiting for the availability of a bed, received the requiredmedical care to meet their needs.

Staffing rotas showed that some nurses and supportworkers were working a number of excessive consecutiveshifts. This indicated that the service was struggling tomaintain adequate staffing. Staff told us that the service isnot adequately staffed. The clinical lead for DIST told usthat the team had a large geographical area to cover andstaff spent a great deal of time travelling. There were twovacancies for band six nurses.

Assessing and managing risk to patients and staffThe AAT team triaged all the referrals and this helped toidentify patients who were at immediate risk. Staff wereable to prioritise and refer these patients appropriately tothe relevant teams. Patients’ needs were assessed prior tocare and treatment being commenced and we sawexamples of completed needs assessments and careplanning. The handovers and meetings within the teamswere effectively used to identify patients in the communitywith escalating needs.

There were no clear policies and procedures in place toidentify and manage risks to people and staff safety in

urgent cases where people required continuous support orwere waiting for a bed. Staff undertook night sitting inpatient's home without appropriate arrangements inplace to ensure that both staff and patients were safe. Stafftold us that they did not feel safe working out of hours inthe community especially as it was the less experiencedand skilled staff that were working on out of hours duty.Staff were not aware of how to access immediate supportin case of emergency.

The trust had a lone working policy and staff were aware ofit, however this was not followed when working out ofhours.

All staff had a good understanding of how to identify andreport any abuse to ensure that people who used theservice were safeguarded from harm. All staff spoken withknew the designated lead for safeguarding who wasavailable to provide support and guidance. Informationwas readily available to inform people who used theservice and staff on how to report abuse.

Records within the team were managed appropriatelyusing a paper filing system. Records were well organisedand different team members could access people’s recordswhen needed.

Medicines stored by the service were not routinelymonitored to ensure that there were always stored at thesafe temperature for them to be effective.


There was an effective mechanism to capture incidents,near misses and never events. Incidents were reported viaan electronic incident reporting form. Staff told us theyknew how to report incidents and were encouraged to usethe reporting system.

Incidents reviewed during our visit demonstrated thatthorough investigations and root cause analysis took place,with clear action plans for staff that were shared within theteam.

Woodlands Unit - East SuffolkSafe and clean environment

The environment was very clean, in a modern building andwell decorated; there was an immediate and positiveimpression of a caring environment. The security




procedures were followed and staff practiced infectioncontrol procedures. Regular health and safety checks werecompleted of the place and identified risks were put rightto ensure the safety of people using the service and staff.

Safe staffingThe teams used the traffic light monitoring system toassess the level of staffing required according the numberof caseload held within the teams. Caseloads wereconstantly reviewed in the supervision sessions.

The team consisted of two band five nurses, three band sixnurses with one vacancy which was being recruited for.There were one and half OTs, two band four assistantpractitioners and three band three support workers. Theteam got one day a week psychologist input with nomedical input and the team was regarded as a nurse ledservice. Medical input was accessed through DCLL.

Staff told us that they worked long hours and at timeswithout breaks but were able to claim back their timeowed. Every patient was reviewed daily and the team wasable to respond to the referrals within specified targetsincluding urgent referrals. The caseload for each nurse waseleven and at times could go as high as 14. There was nowaiting list in the team. Staff told us that they felt thecaseload was manageable but pressure came from theintegrated delivery service which had a waiting list of six toeight weeks.

Assessing and managing risk to patients and staffThere were procedures in place to identify and managerisks to people. We observed that staff discussed risksrelated to patients in staff hand-over and multi-disciplinarymeetings. Patient safety was taken into account in the waycare and treatment was planned and links to communityother teams were discussed.

Risk assessments were carried out for all visits to people toensure that all staff were safe. People’s needs were clearlyassessed prior to care and treatment starting. There weregood examples of completed needs assessment anddetailed care plans that matched the identified needs.There were risk assessment and management plans inplace that expressed how staff should support peoplesafely.

All staff were aware of the lone working policy and told usthat they followed it.

All staff we spoke with had a good understanding of how toidentify and report any abuse to ensure that people whoused the service were safeguarded from harm. All staffspoken with knew the designated lead for safeguardingwho was available to provide support and guidance. Wesaw that information was readily available to inform peoplewho used the service and staff on how to report abuse.

Records were held in electronic system called EPEX andalso in paper formats. Patient records were generally wellmaintained and well completed with clear dates, times anddesignation of the person documenting. Records were keptsafely in lockable cabinets and confidentiality wasmaintained.

No medicines were kept on site during our visit.


There was a trust wide electronic incident reportingprocess which all staff we spoke with were aware of. Staffhad good knowledge and understanding of incidents thatshould be reported and they told us they were reportingincidents. We saw that incidents were reported andinvestigated. Staff told us that they received feedbackfollowing incidents through meetings and information wasdistributed within the team.

Main Site - West SuffolkSafe and clean environment

We saw that the environment was clean but wasdiscoloured and not well maintained. Staff practiced goodinfection control procedures. We saw that securityprocedures were followed. Health and safety checks werecarried out to ensure the safety of staff.

Safe StaffingThe teams used the traffic light monitoring system toassess the level of staffing required according the numberof caseload held within the teams. Caseloads wereconstantly reviewed in the supervision sessions.

The team was led by a band seven nurse and consisted offour band five nurses, one band six nurse with one vacancyfor band six and two for band five. The clinical lead told usthat there were delays with recruitment taking up to threemonths to appoint staff internally. There were three OTs,one social worker and four band three support workers.Medical input was accessed through DCLL.




Staff told us that there were pressures due to staffshortages and this was impacting on the effective deliveryof care. Every patient was reviewed daily and the team wasable to respond to the referrals within specified targetsincluding urgent referrals. The team was well organisedand had a clear operational policy on how to meet theirtargets. There was no waiting list in the team. Staff told usthat the felt that the caseload was manageable butpressure would come from the integrated delivery servicewhich was a new initiative.

Assessing and managing risk to patients and staffRisk assessments were carried out for all visits to people toensure that all staff were safe. Where the risk was deemedhigh, staff saw people in pairs. There were risk assessmentand management plans in place that expressed how staffshould support people safely.

All staff were aware of the lone working policy and told usthat they followed it.

All staff spoken had a good understanding of how toidentify and report any abuse to ensure that people whoused the service were safeguarded from harm. All staffspoken with knew the designated lead for safeguardingwho was available to provide support and guidance. Wesaw that information was readily available to inform peoplewho used the service and staff on how to report abuse.

Records within the team were managed appropriatelyusing electronic and paper file systems. We saw that therecords were well organised and different team memberscould access people’s records when needed.


Incidents were reported and investigated. Staff told us thatthey received feedback following incidents throughmeetings and information was circulated within the team.

Learning from incidents took place. Specific changes topractice were made as a result of incidents.




Summary of findingsWe rated the mental health community services forolder people as ‘good' because:

• People’s mental capacity was assessed and wherepeople lacked the mental capacity to make decisionsabout their care and treatment, decisions were madein their best interests.

• People were treated in line with current legislationand national guidance. The physical health needs ofpeople who used the service were assessed andmonitored to ensure people’s health and wellbeing.

• Staff worked well as a multi-disciplinary team andtook a person-centred approach. However, we sawthat there was limited input from occupationaltherapy services.

• There was a range of treatment approaches availableto meet people’s needs. Staff were well trained andhad access to training and developmentopportunities.

However

• There were inconsistencies in providing regularsupervision and appraisals.

Our findingsJulian Hospital and Gateway House - CentralNorfolk

Assessment of needs and planning of careRecords sampled showed that comprehensiveassessments had been completed on initial contact whichcovered all aspects of care as part of a holistic assessment.However there were inconsistencies in updating care plansto reflect discussions held within the multidisciplinarymeetings.

There was evidence of physical health monitoring inrecords and staff confirmed these checks were undertaken.We saw that physical health was discussed and furtherassessment of these needs had been offered. This meantthat patients’ physical health and wellbeing as part of aholistic approach was monitored.

Best practice in treatment and careNational Institute for Health and Care Excellence (NICE)guidelines were followed in respect of medicationprescribed and in delivering psychological therapies,particularly around memory - services. The teams hadestablished a therapeutic base for interventions. Staffshowed us evidence of clinics held, which includedcognitive behavioural therapy (CBT). The teams consistedof staff trained in CBT. The nature of the issues peoplepresented with often led to referral on for psychologicaltherapies following assessment. People were assessed by aspecialist to determine a diagnosis of dementia. The teamsworked closely with GP surgeries and held monthlymeetings with their allocated nurse. Links were alsomaintained with Norwich and Norfolk hospital for anyreferrals.

Information on patients subject to the Care ProgrammeApproach (CPA) and section 117 after care was readilyaccessible to both health and social work staff via securecomputer access. This meant that the assessing andcoordinating of care for people with complex needs wasshared with external professionals.

Skilled staff to deliver careStaff we spoke with understood their aims and objectivesin regard to performance and learning. This wasreviewed at their annual appraisal. These objectives werebeing revisited and reviewed on a monthly basisthroughout the year in supervision. Staff told us andrecords we looked at showed that regular caseload or linemanagement supervision had been taking place regularly.

We saw that staff received the training they needed andwhere updates were required, this was monitored througha system that highlighted specific needs.

Staff told us that they received further training in differentareas of their specialities that benefited and addressed theneeds of people who used the service. The team hadnurses specialising in areas such as nurse prescriber, CBTand cognitive stimulation group. At Gateway House therewas a lead nurse for onset dementia. Support workers wereseconded to have training in mental health foundationdegree to become assistant practitioners. This meant staffwere appropriately qualified and skilled in their job role.

The team consisted of nurses, consultants, specialitydoctors, psychologists, occupational therapists (OT), socialworkers and support workers.

Are services effective?By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.

Good –––


Multi-disciplinary and inter-agency team workIn all teams we visited staff described positive relationshipswith other services and the multi-disciplinary approach tocare and treatment was optimal. We saw evidence ofworking with others including internal and externalpartnership working, such as multi-disciplinary workingwith GPs, hospitals, other community mental health teams,independent sector and local authority.

Staff spoke of good relationships with other teams andtransfer between teams involved working in partnershipand where possible undertaking joint visits. Other teamswe met with during our visit described effectivecollaborative working with DIST and DCLL staff.

The DCCL team held monthly Integrated Care Meetings atGP practices attended by GPs, palliative nurses, districtnurses, social workers and any other professionalsinvolved.

Transfer of care between teams and shared care withinteams was effectively managed. This enabled smoothtransition between teams for the patient as part of their on-going recovery. Staff were clear about the lines ofaccountability and who to escalate any concerns to.

Staff told us and we saw that they attended their reviewmeetings. We found that there was not enough input fromOT services, the OT only worked part time.

Adherence to the MHA and the MHA Code ofPractice

Staff received training and updates in regard to the MentalHealth Act.

We saw records for people subject to section 117 after carethese were reviewed and updated appropriately.

Staff told us that social workers and approved mentalhealth professionals (AMHP) in the teams providedguidance on the Mental Health Act to support compliance.

Good practice in applying the MCACapacity to consent to care and treatment was addressedas part of the assessment routine and this wasdocumented. The relevant legislation and the assessmentof mental capacity had been used appropriately to ensurethat people’s rights were respected and exercised controlover their lives. We saw that people had access to anindependent mental health advocate (IMHA). All staff hadreceived training in the Mental Capacity Act (MCA).

Chatterton House - West NorfolkAssessment of needs and planning of care

Records sampled showed that comprehensiveassessments had been completed on initial contact whichcovered all aspects of care as part of a holistic assessment.Care plans and risk assessments were updated to reflectdiscussions held within the multidisciplinary meetings.

There was evidence of physical health monitoring inrecords. Staff told us that physical health checks wereundertaken. We saw that physical health was discussedand further assessment of these needs had been offered.This meant that patients’ physical health and wellbeing aspart of a holistic approach was monitored.

Best practice in treatment and careStaff were aware of the most recent, relevant NICEguidance. Information about up to date clinical researchand policy was shared amongst the team.

Staff showed us evidence of clinics held, which includedCBT. The teams consisted of staff trained in CBT. The natureof the issues people presented with often led to referral onfor psychological therapies following assessment. Peoplewere assessed by a specialist to determine a diagnosis ofdementia.

The Health of the Nation Outcome Scales (HoNOS) werethe mostly widely used routine clinical outcome measuresas is recommended by National Service Framework forMental Health. The scales aid the assessment process andcan determine through its evaluation the progress oftherapeutic intervention. Addenbrooke’s CognitiveExamination (ACE-R) was also used to assess the cognitivedomains. These were completed by practitioners who hadreceived training in how to undertake this.

Skilled staff to deliver careStaff understood their aims and objectives in regard toperformance and learning. This was reviewed insupervision. However, these objectives were not beingrevisited and reviewed on a regular basis throughout theyear due to infrequent meaningful supervision. Recordsshowed that some staff had not had supervision for over sixmonths. Staff told us that they received annual appraisals.Appraisals were now monitored through the electronicsystem where staff would receive an email when theirappraisal was due.


Good –––


All new and agency staff were provided with an inductionperiod in which they shadowed experienced staff to ensurethat they knew how to support patients safely. An agencymember of staff confirmed that they had undertaken aperiod of induction on starting with the trust.

We saw that staff received the training they needed andwhere updates were required, this was monitored througha system that highlighted it. Staff told us that there weredelays in getting some of the training as the places werelimited or it would be very far away from Kings Lynn.

Staff told us that they received further training in differentareas of their specialities that benefited and addressed theneeds of people who used the service. The team hadnurses specialising in areas such as nurse prescriber, CBTand cognitive stimulation group.

We noted a good skill mix of staff in all teams to supportevidence based care.

The team consisted of nurses, consultants, specialitydoctors, junior doctors, psychologists, occupationaltherapists, social workers and support workers. Staff told usand we saw that they attended their review meetings. Wefound that there was not enough input fromoccupational therapy services as there was only a part timepost.

Multi-disciplinary working and working withothers

We observed good collaborative working within the multi-disciplinary teams. This was supported in all areas weinspected. We found that staff worked well together andthe healthcare professionals valued and respected eachother’s contribution into the planning and delivery ofpatient’s care.

We saw examples of linking with GPs, hospitals,ambulance, district nursing, community support teams andsocial care. We observed effective communication,appropriate information sharing and decision-makingabout a patient’s care. The information was shared acrossdifferent types of services involving both internal andexternal to the organisation. However, we noted one casewhere a follow-up with the GP was not pursued when onepatient had gone over one year without blood tests whenpresenting with risk factors for delirium. The patient was

referred to GP and no blood tests were carried out. Thismeant that the patient at risk of delirium was not furtherassessed for indicators of delirium. This appeared to be anisolated case.

The community teams had developed strong links with GPpractices and the local care homes to implement acommon vision for timely, flexible and responsive careservices.



We saw records for people subject to section 117 after care.These were reviewed and updated appropriately.

Staff told us that social workers and AMHPs in the teamsprovided guidance on the Mental Health Act to supportcompliance.

Good practice in applying the MCACapacity to consent to care and treatment was addressedas part of the assessment routine and this wasdocumented. The legislation and the assessment of mentalcapacity had been used appropriately to ensure thatpeople’s rights were respected and that they exercisedcontrol over their lives. We saw that people had access toan IMHA. All staff had received training in the MCA.

Carlton Court – Great Yarmouth & WaveneyAssessment of needs and planning of care

There was a comprehensive assessment of people’s needson initial contact which covered all aspects of care as partof a holistic assessment. Care plans showed regularupdates to reflect progress in achieving aims.

There was evidence of physical health monitoring inrecords. Staff told us that physical health checks wereundertaken. We saw that physical health was discussedinitially and further assessment of these needs had beenoffered.

Best practice in treatment and careNICE guidelines were followed in respect to medicationprescribed and in delivering psychological therapies,particularly around memory treatment service. The teamshad established a therapeutic base for interventions. Staffshowed us evidence of clinics held, which included CBT.The teams had all staff trained in CBT. The nature of the


Good –––


issues people presented with often led to referral on forpsychological therapies following assessment. People wereassessed by a specialist to determine a diagnosis ofdementia. The teams worked closely with the GP surgeries.

A dementia pathway was in place and patients had an ACE-R examination so any intervention could be made. If theassessment showed they were at risk of cognitiveimpairment, they were referred to the psychiatrists andmemory team where appropriate. There were effectivehandovers between services.

Information on patients subject to the CPA and section 117after care was readily accessible to both health and socialwork staff on secure computer data. This meant that theassessing and coordinating of care for people with complexneeds was shared with external professionals.

Skilled staff to deliver careStaff we spoke with understood their aims and objectivesin regard to performance and learning. These objectiveswere being revisited and reviewed on a monthly basisthroughout the year in supervision sessions. We sawrecords and staff told us that regular caseload or linemanagement supervision took place regularly.

We saw that staff received the training they needed andwhere updates were required, this was monitored throughan IT training system that highlighted needs.

Staff told us that they received further training in differentareas of their specialities that benefited and addressed theneeds of people who used the service. The team hadnurses specialising in areas such as nurse prescriber,safeguarding lead, lead and research champion. Supportworkers were seconded to have training in mental healthfoundation degree to become assistant practitioners.

The team consisted of nurses, consultants, junior doctors,psychologists, OT, social workers and support workers. Stafftold us and we saw that they attended their reviewmeetings.

Multi-disciplinary and inter-agency team workWe saw evidence of effective multi-disciplinary workingwith social workers in the teams and proactive referral todistrict nurses for physical health issues. Patient notesselected at random demonstrated the input of varioustherapists and referrals to GPs, hospitals, other communitymental health teams, independent sector and localauthority.

Staff spoke of good relationships with other teams and toldus how transfer between teams involved working inpartnership and where possible undertaking joint visits.Other teams we met with during our visit describedeffective collaborative working with DIST and DCLL staff.

Transfer of care between teams and shared care withinteams was effectively managed. This enabled smoothtransition between teams for the patient as part of their on-going recovery. Staff were clear about the lines ofaccountability and who to escalate any concerns to.

There were integrated pathways with independent care.The DIST team worked in partnership with externalagencies. Staff told us that they had worked closely with acare home that had six beds and was used as alternative tohospital admission. However these beds were now closedas a result of the care home being unable to safely managepatients who were placed there.




Staff told us that social workers and AMHP in the teamsprovided guidance on the Mental Health Act to supportcompliance.

Good practice in applying the MCACapacity to consent to care and treatment was addressedas part of the assessment routine and this wasdocumented. The relevant legislation and the assessmentof mental capacity had been used appropriately to ensurethat people’s rights were respected and exercised controlover their lives. We saw that people had access to an IMHA.All staff had received training in the MCA.

Woodlands Unit - East SuffolkAssessment of needs and planning of care

Records sampled showed that comprehensiveassessments had been completed of the patient’s needsand risks at initial contact with the team. Care plans andrisk assessments were comprehensive, personalised andregularly reviewed and updated. They showed that peopleand their families, where appropriate, had been involved indeveloping the care plans.


Good –––


There was evidence of physical health monitoring inrecords. We saw that physical health checks were carriedout and discussed. Where further assessment of theseneeds had been identified as required patients werereferred to specialists.

Best practice in treatment and careStaff were aware of the most recent, relevant NICEguidance. Information about up to date clinical researchand policy was shared amongst the team. Riskassessments in care records reflected NICE guidelines inpractice including care for dementia, nutrition and falls riskassessments.

The HoNOS were the mostly widely used routine clinicaloutcome measures as is recommended by National ServiceFramework for Mental Health. The scales aid theassessment process and can determine through itsevaluation the progress of therapeutic intervention. ACE-Rwas also used to assess the cognitive domains. These werecompleted by practitioners who had received training inhow to undertake this.

We saw evidence that progress was monitored in nurserecords and that team recorded data on progress towardsagreed goals in each patient’s notes.

Information on patients was easily accessed by both healthand social care teams on shared secure computer systems.Mood scales and risk assessments were part of both teams.This meant that the assessing and coordinating of care forpeople with complex needs was shared with socialworkers.

Skilled staff to deliver careStaff received the training they needed and hadopportunities for continuing professional development forareas that benefited and addressed the needs of peoplewho used the service. For example, some of the staff hadattended training in nurse prescribing and had started afoundation degree in mental health. Staff we spoke withwere appropriately qualified and competent in their jobrole. We noted a good skill mix of staff in the team tosupport evidence-based care.

All staff spoken with told us that they received regularsupervision and had an annual appraisal where theirpersonal and professional development goals were set.

There was effective monthly caseload and linemanagement supervision for all staff. Incorporated into thiswas a review of each staff member’s objectives and aims aspart of their own professional development.

All new staff were provided with an induction period inwhich they undertook mandatory training. All staff hadreceived mandatory training and where there were gapsdates were already booked for staff to attend.

The team was nurse led and did not include medical staffas part of the team. There was limited input fromoccupational therapy services.

Multi-disciplinary and inter-agency team workWe observed good collaborative working within the multi-disciplinary team. We found that staff worked well togetherand the healthcare professionals valued and respectedeach other’s contribution into the planning and delivery ofpatient’s care.

We saw an excellent example of MDT working. There was astrong link between hospital, ambulance, GPs, districtnursing, multi-disciplinary community team, hometreatment team, crisis team and social care through a callcentre. We observed effective communication, appropriateinformation sharing and decision-making about a patient’scare. The information was shared across different types ofservices involving both internal and external to theorganisation.

We observed detailed and timely multi-disciplinarydiscussions and handovers to ensure patients’ care andtreatment was coordinated and the expected outcomeswere achieved. A patient’s changing needs were discussedin team handover and referrals were made to thecommunity psychiatry liaison team to ensure continuity ofcare.

Care pathways of patients on the caseloads of thedementia team were shared with GPs and social workers.This had led to integrated care between GP and mentalhealth team and social care services.


Staff received training and updates in regard to the MentalHealth Act. We saw records for people subject to section117 after care these were reviewed and updatedappropriately.


Good –––


Good practice in applying the MCACapacity to consent to care and treatment was addressedas part of the assessment routine and this wasdocumented. The legislation and the assessment of mentalcapacity had been used appropriately to ensure thatpeople’s rights were respected and exercised control overtheir lives. The social workers in the team led on capacityassessments. We saw that people had access to an IMHA.All staff had received training in the MCA.

Main Site - West SuffolkAssessment of needs and planning of care

The physical health needs of people were routinelyassessed and monitored. The team worked closely withGPs and secondary health care services to ensure that theidentified needs were met during people’s care with theteam. For example, we saw that analgesia was prescribedthrough GP pain clinics. We found that care plans were upto date and risk assessments were fully completed.

Best practice in treatment and careStaff were aware of the most recent, relevant NICEguidance. Information about up to date clinical researchand policy was shared amongst the team.

The HoNOS were the mostly widely used routine clinicaloutcome measures as is recommended by National ServiceFramework for Mental Health. The scales aid theassessment process and can determine through itsevaluation the progress of therapeutic intervention. ACE-Rwas also used to assess the cognitive domains.

There was no evidence of clinical staff actively involved inclinical audit.

Skilled staff to deliver careStaff we spoke with understood their aims and objectivesin regard to performance and learning, through theirannual appraisal. These objectives were being revisitedand reviewed on a four to six weekly basis throughout theyear in supervision sessions. We saw records and staff toldus that regular caseload or line management supervisiontook place regularly.

We saw that staff received the training they needed andwhere updates were required, this was monitored througha system that highlighted when training was due.

Staff told us that they received further training in differentareas of their specialities that benefited and addressed theneeds of people who used the service. Staff had access toexternal training such as dementia academy and assistantpractitioner course. However, staff told us that due to staffshortages time was limited to attend external training.

The team consisted of nurses, psychologists, OT, socialworkers and support workers. Medical input was accessedthrough DCLL. Staff told us and we saw that they attendedtheir review meetings.

Multi-disciplinary and inter-agency team workWe observed good collaborative working within the multi-disciplinary team. We found that staff worked well togetherwith other healthcare professionals and external agencies.The team adopted a multi-disciplinary approach to careand treatment when addressing people’s needs.

There were good links with other services within the trustwhich ensured that information was shared. Staff also toldus that they have built good working relationships withmany GPs, care homes and voluntary sector in the area inwhich they work.

There were excellent links to the voluntary service whichprovided day time activities. Staff spoke positively aboutthe staff in the voluntary services and told us they workedin partnership to achieve positive outcomes for people.




Staff told us that social workers in the teams providedguidance on the Mental Health Act to support compliance.

Good practice in applying the MCACapacity to consent to care and treatment was addressedas part of the assessment routine and this wasdocumented. The legislation and the assessment of mentalcapacity had been used appropriately to ensure thatpeople’s rights were respected and exercised control overtheir lives. We saw that people had access to an IMHA. Allstaff had received training in the MCA.


Good –––


Summary of findingsWe rated the community services for older people withmental health problems as ‘good' because:

• Staff were polite, kind and treated people withrespect and dignity. Care was delivered in a caringand compassionate way.

• People told us they were involved in their care.Relatives were involved in care planning and theirinformation was used to develop people’s care plans.

• Staff demonstrated a high level of emotional supportto patients on an individual level and took time tosupport patients in a sensitive manner.


Kindness, dignity, respect and supportPeople were complimentary about the support theyreceived from the teams and felt they get the help theyneeded. People told us and we saw that they had beentreated with respect and dignity and staff were polite,friendly and willing to help.

We observed interactions between staff and people usingthe service both over the phone and also face to face. Thelanguage used was compassionate, clear and simple anddemonstrated positive engagement and willingness tohelp.

The involvement of people in the care theyreceive

People told us that they were involved in their care reviewsand were free to air their views. Records of MDT meetingswe sampled showed that people’s and their familymembers’ views were taken into account and they weresupported to make informed choices.

Staff told us that people’s carers were involved in theassessment and care planning where appropriate. Weobserved that one relative called to discuss the care planwith the team and their views were taken into account.

Chatterton House - West NorfolkKindness, dignity, respect and support

People were happy about the support they received fromthe teams and felt they get the help they needed. Peopletold us and we saw that they had been treated with respectand dignity and staff were courteous, pleasant and willingto help.

We observed interactions between staff and people usingthe service both over the phone and also face to face. Thecommunication used was compassionate, clear and simpleand demonstrated positive commitment with willingnessto help.

The involvement of people in the care theyreceive.

People told us that they were involved in their care reviewsand were free to air their views. Records of MDT meetingswe sampled showed that patients and their familymembers’ views were taken into account and they weresupported to make informed choices. Staff told us thatpeople’s carers were involved in the assessment and careplanning where appropriate.

Carlton Court – Great Yarmouth & WaveneyKindness, dignity, respect and support

We spoke with two people using the services. People werevery complimentary about the care and treatment theyreceived. They told us they felt listened to and included ineach stage of the care they received.

We observed interactions between staff and people usingthe service both over the phone and also face to face. Thelanguage used demonstrated kindness, respect, supportand was clear and simple. Staff demonstrated clearcompassion, warmth and positive engagement withpeople.


People were involved in their care reviews and were free toair their views. Records of MDT meetings showed that theviews of people and their family members were taken intoaccount and they were supported to make informedchoices.

Staff told us that people’s carers were involved in theassessment and care planning where applicable.

Are services caring?By caring, we mean that staff involve and treat people with compassion,kindness, dignity and respect.

Good –––


Woodlands Unit - East SuffolkKindness, dignity, respect and support

All the staff we spoke with demonstrated a clearunderstanding of how to treat people with respect anddignity. The staff were polite, kind and passionate abouttheir role in providing therapy to people.


People had a variety of care plans which wereindividualised and showed evidence of risk assessments.Review meetings were used to involve people andincorporate their views within the care planning process.We found some evidence of people’s and their relatives’views being included within the care plans.

Main Site - West SuffolkKindness, dignity, respect and support

All the staff we spoke with demonstrated a clearunderstanding of how to treat people with respect anddignity. The staff were polite, kind and passionate abouttheir role in providing therapy to people.


Review meetings were used to involve people and theirviews within the care planning process. We found someevidence of people’s views being included within the careplanning. Staff told us that people’s carers were involved inthe assessment and care planning where appropriate.

Are services caring?By caring, we mean that staff involve and treat people with compassion,kindness, dignity and respect.

Good –––


Summary of findingsWe rated the mental health community services forolder people as ‘inadequate' because:

• People over the age of 65 with dementia had noaccess to 24 hour crisis team in some areas. Thismeant they had no access to specialist services andremained at risk.

• Information about services provided was not veryclear and could affect effect delivery of care.

However:

• Complaints were taken seriously, investigated,responded to promptly and lessons learnt.

• We saw that there was a system to respond to urgentreferrals using the single point of access.


Access and dischargeStaff told us there were not enough mental health hospitalbeds to meet demand. They said they often experienceddelays due to lack of beds. This meant that bed availabilitywas impacting upon patient care and safety in thecommunity. The manager for DIST told us that they utilisedalternative to admission (ATA) beds that were available incare homes that they worked closely with.

Bed shortages caused people to be placed out areamaking liaison difficult and some patients were dischargedearly from wards before they were ready. Staff told us ofsituations where people were discharged straight tospecialist elderly mental health care homes without theDCLL involved. They felt that these care homes were notable to provide adequate support. In most cases, bothteams were involved in joint working with the wards fordischarge and admission.

Staff told us that they were ‘stretched’ and on occasionsstruggled to cope with their caseloads although it wasmanageable. We saw that the teams did not have a waiting

list and attended to people on time. The only team thathad a waiting list was the memory assessment team. Theirwaiting time of four to six weeks was considered to be goodcompared to the national average waiting time.

Referrals to the teams came from the access andassessment Team (AAT) following a triage which prioritisedreferrals according to risk and identified need. The referralpathways were clearly outlined and set out clear lines ofresponsibilities, time frames and actions to be taken. Theteams operated a duty worker system during working hoursand were responsible for appointments to carry outassessments. The DIST had met all its targets of respondingwithin four hours to urgent referrals and 72 hours to routinereferrals. The DCLL met its targets of responding within 28days.

Staff told us that caseloads were high but they had nowaiting lists and were managing to cope without pressureto discharge patients from caseloads. In the DIST staff hadup to three to four people per member of staff. In the DCLLstaff had up to 25 to 30 people per member of staff.

Caseload supervision within both teams was consistentand structured. These meant caseloads were reviewedregularly to ensure that people were being supportedtowards recovery and planned discharge.

Pathways for care and discharge were flexible to ensurethat services worked together to meet people’s changingneeds. Some of the people on existing caseloads from DISTwere discharged to DCLL or care homes where their needscould be met. The DIST operated a help line during workinghours to provide assistance to all care homes and carriedsome visits when deemed appropriate. There was noservice out of hours meaning During out of hours peoplehad to contact the emergency duty team (EDT) at socialservices. Some people were able to access the working agecrisis team if it was part of their care plan, but this did notinclude people with dementia.

We saw information in the assessment pack that had thenumbers to call if people needed a response to animmediate crisis. People had access to services to meettheir immediate needs, either through services provided bythe trust or from a variety of local or national supportservices. The teams were also able to refer people to otherservices when there is an identified need. For example,people were referred to Alzheimer’s Society, Age UK, andNorfolk Carers for advice and support.

Are services responsive to people’s needs?By responsive, we mean that services are organised so that they meet people’sneeds.



Meeting the needs of all people who use theservice

We saw that the teams had information leaflets for peopleregarding how the service works around DIST, DCLL andmemory treatment. However, we found that some of theinformation was misleading and not very clear and thiscould have a detrimental effect on other people. Forexample, DIST gave out leaflets which stated that it workswith people who have either dementia or suspecteddementia when it actually also worked with other peoplewith disorders other than dementia. The staff told us thatthe leaflets were given to all people who were referred toDIST.

The team liaised with the trust’s communicationsdepartment for written materials in other languages. Staffwe spoke with described clearly how to access interpretersthrough INTRAN, the trust’s interpreting services.

Staff were aware how to access advocacy services forpeople and leaflets given to people about the team alsocontained information about relevant local advocacycontacts.

Listening to and learning from concerns andcomplaints

Staff were aware of the trust’s complaints policy. Managerstold us that complaints went to and came through thecomplaints manager. Leaflets or information was routinelyprovided by the teams in regard to complaints. In theassessment pack we saw a number of leaflets used bypeople regarding how to make a complaint. People wespoke to had not needed to make a complaint but feltconfident about how to raise a complaint.

The complaints log showed that complaints wereinvestigated and documented what the outcomes andlearning were. The team manager shared the learning fromcomplaints through team meetings. We saw minutes ofthese meetings that included and discussed complaints.

Chatterton House - West NorfolkAccess and discharge

Staff told us that approved mental healthprofessionals(AMHPs) came to assess patients who neededinpatient service only if a bed has been identified. Wefound that people only had a mental health assessmentafter a bed has been identified. Staff told us that this was

the only way to get someone admitted swiftly even if thepatient was willing to go to hospital informally. This meantthat the mental health assessment was considered as theonly option for admission. This is not acceptable.

Referrals to the teams came from the AAT following a triagewhich prioritised referrals according to risk and identifiedneed. The referral pathways were clearly outlined and setout clear lines of responsibilities, time frames and actionsto be taken. The teams operated a duty worker systemduring their working hours and were responsible forappointments to carry out assessments. There was no 24hours service. This meant people had no access tospecialist services and remained at risk.

The DIST had a case load of 39 when it is supposed to have25; however there was no waiting list. Staff told us that thiswas putting pressure on meeting targets and providingtimely care. The DCLL has a waiting list for assessment anddiagnosis of 32.5 days where as the targets is 28 days. Stafftold us that caseloads were high and they had waiting listsand were finding it difficult to cope with the caseloads.

Some staff were travelling an average of 140 miles a day tocover the large geographical area. Staff reported it as fire-fighting, spending a great deal of time travelling rather thanhaving patient contact.

Pathways for care and discharge were flexible to ensurethat services worked together to meet people’s changingneeds. Some of the people on existing caseloads from DISTwere discharged to DCLL or care homes where their needscould be met. The DIST operated a help line during workinghours to provide assistance to all care homes and carriedsome visits where appropriate.

During out of hours there was no emergency response fromthe teams for older people and people with dementia theyhad to go through the accident and emergency (A&E). Thecrisis team was open and would only respond to adultsof working age. This meant that there was no emergencyresponse for older adults out of hours.

People were signposted to other services to meet theirimmediate needs either through services provided by thetrust or from a variety of local or national support services.The teams were also able to refer people to other serviceswhen there is an identified need. For example, people werereferred to Alzheimer’s Society, Age UK, and Norfolk Carersfor advice and support.





We saw that the teams had information leaflets for peopleregarding how the service works around DIST, DCLL andmemory treatment. However, we found that some of theinformation was misleading and not very clear and thiscould have a detrimental effect on other people. Forexample, DIST gave out leaflets which stated that it workedwith people who have either dementia or suspecteddementia when it actually also worked with people withdisorders other than dementia. The staff told us that theleaflets were given to all people who were referred to DIST.

The team liaised with the trust’s communicationsdepartment for written materials in other languages. Staffwe spoke with described clearly how to access interpretersthrough INTRAN, the trust’s interpreting services. We sawsome information leaflets written in Polish and Portuguese.



People told us that they could raise complaints when theywanted to and they were listened to and given feedbackfrom these. We saw that information on how to make acomplaint was easily accessible and included in theassessment pack.

Staff knew how to support people who used the serviceand their relatives to make a complaint. People wereprovided with information about the ways that they couldraise complaints and concerns regarding the service.

Carlton Court – Great Yarmouth & WaveneyAccess and discharge

Both teams offered community care to patients who weredeemed to require care and treatment in their own homes.The ATT team determined which patients were suitableand patients could also be referred to inpatient services.

Staff told us that AMHPs would only come to assesspatients who needed inpatient service only if a bed hasbeen identified. Staff told us that this was the only way toget someone admitted quickly even if the patient was

willing to go to hospital informally. This meant that themental health assessment was used as a way to get a bedfor patients who needed treatment in hospital. This isunacceptable practice.

The DIST had met all its targets of responding within fourhours to urgent referrals and 72 hours to routine referrals.The DCLL met its targets of responding within 28 days. Thememory treatment team had a waiting time of 21 days.

We observed that people’s needs were prioritised andnurses were able to respond to people urgently or within 28days. This ensured that there was some access to peoplewho had the highest needs and the service was able torespond accordingly to meet people’s needs. People hadaccess to all professionals within the team and werereferred to other services when there is an identified need.

The teams monitored the progress of patients on wardsawaiting discharge or transfers for example from DIST toDCLL when ready after intensive care. We found thatpatients with dementia were placed in care homes thatcould not adequately meet their needs. For example, as analternative to admission, patients with organic needs wereplaced in care homes that cared for people with functionalneeds resulting in people's needs not being met. Patientswere unable to get timely admission to inpatient servicesand were cared for in their own homes utilising the nightsitting staff.

There was not a 24 hour service. This meant people had noaccess to specialist services and remained at risk.


We saw that the teams had information leaflets forpeople explaining how the services work. However, wefound that some of the information was misleading andnot very clear and this could have a detrimental effect onother people. For example, DIST gave out leaflets whichstated that it works with people who have either dementiaor suspected dementia when it also worked with peoplewith disorders other than dementia. The staff told us thatthe leaflets were given to all people who were referred toDIST.

The team liaised with the trust’s communicationsdepartment for written materials in other languages. Staffwe spoke with described clearly how to access interpretersthrough INTRAN the trust’s interpreting services.




Staff were aware of how to access advocacy services forpeople and leaflets given to people about the team alsocontained information about relevant local advocacycontacts.


People were provided with information about the waysthat they could raise complaints and concerns regardingthe service.

Staff we spoke with were able to identify complaints whichhad been made in the service and explain how the servicehad learnt from them.

Woodlands Unit - East SuffolkAccess and discharge

Referrals to the service were accepted from self-referral,carers, GPs, ambulance service, A&E and other Health orSocial care professionals.

The team worked closely with the wards and psychiatricliaison to facilitate discharges. The team also worked withcare homes that did not have mental health nursing inputto support patients. The community nurse spent their timecoordinating care and supporting the person and staff.

The DIST team had a 12 week period to provide care andtreatment before the patients were discharged tocommunity mental health teams and integrated deliveryservice. The team told us that it varied all the time but allpeople were discharged within the target time.

The referral pathways were clearly outlined and set outclear lines of responsibilities, time frames and actions to betaken. The teams operated a duty worker system who waseither band six or seven during their working hours andwere responsible for appointments to carry outassessments. The DIST had met all its targets of respondingwithin four hours to urgent referrals and 72 hours to routinereferrals.

The team had been nominated for an award set up toprevent admission to general hospitals for dementia anddelirium patients only. It was set up as a result of dayservices closure.

The team provided care and treatment in a timely manner.The caseload and case allocations took place everymorning and were based on the needs of the patients.Urgent referrals were seen within four hours after receivingthe referral through the duty worker.

Staff told us that caseloads were manageable and had nowaiting lists. Discharges and referrals were clearly plannedwithout any pressure to reduce caseloads.

There was no service out of hours. This meant people hadno access to specialist services and remained at risk.

We saw information in the assessment pack that had thenumbers to call if people needed a response to animmediate crisis. People had access to services to meettheir immediate needs either through services provided bythe trust or from a variety of local or national supportservices. The teams were also able to refer people to otherservices or health professionals when there was anidentified need.


We found all staff were focused on the needs of theindividual patients and actively sought to minimise risks tothem. We saw evidence of referring patients with risks offalls to OT and discussion of goal settings.

There were a variety of comprehensive leaflets that weregiven to patients explaining their diagnosis and treatmentoptions that were relevant to patient group served by theteam.

People had access to advocacy services. There wasinformation available on how to access this service. Peoplewere able to access interpreting services to meet theirneeds if they did not speak English well enough to expresstheir needs.


Complaints were handled in line with trust policy. Staffshowed us that patients were given information on how tocomplain. We saw there was a clear complaints process inplace and that there was effective handling of complaints.

Complaints leaflets were available in the assessment packand these were given to patients on initial contact to keepin their homes for reference. Staff told us that any learningfrom complaint investigations was shared with the teamregularly in staff meetings.

Main Site - West SuffolkAccess and discharge

Referrals to the service were accepted from self-referral,carers, GPs, ambulance service, A&E and other health orsocial care professionals. The team worked closely with the




integrated delivery service and inpatient services for anyperson who required intensive care in the community orinpatient service. Joint working was encouraged betweenthe teams in order to facilitate smooth discharge.

We saw that staff worked with other community teams andinpatient services to plan for people’s discharge and nursesattended ward review meetings prior to their discharge.

The team had a12 week period to provide care andtreatment before the patients were discharged. The teamtold us that it varied all the time but all people weredischarged within the target time.

Referrals to the teams came from the AAT following a triagewhich prioritised referrals according to risk and identifiedneed. The referral pathways were clearly outlined and setout clear lines of responsibilities, time frames and actionsto be taken. The team did not operate a duty workersystem during their working hours. We saw that referralswere screened by the team leader and allocated to nursesaccording to their expertise as soon as they were received.

We observed that people’s needs were prioritised andnurses were able to respond to people urgently or within 24hours. This ensured that there was some access to peoplewho had the highest needs and the service was able torespond accordingly to meet people’s needs. People hadaccess to all professionals within the team and werereferred to other services when there is an identified need.

Staff told us that caseloads on books were approximately100. There was no waiting list within the team. Caseloadsupervision within the team was consistent and structured.These meant caseloads were reviewed regularly to ensurethat people were being supported towards recovery andplanned discharge.

People with complex needs had a contingency plan inplace which had details on what actions to take andservices to contact in case of an emergency. However therewas no 24 hour cover. This meant people had no access tospecialist services and remained at risk.


The team had a wide range of information available whichtold people how the services work and what to expect.

The team liaised with the trust’s communicationsdepartment for written materials in other languages. Staffwe spoke with described clearly how to access interpretersthrough INTRAN the trust’s interpreting services.



People were provided with information about the waysthat they could raise complaints and concerns regardingthe service.

Staff we spoke with were able to identify complaints whichhad been made in the service and explain how the servicehad learnt from them. For example, how the team hadmade improvements to enhance communication withfamilies and carers.




Summary of findingsWe rated the mental health community services forolder people as ‘requires improvement' because:

• Staff lacked a clear understanding of the vision andvalues of the organisation.

• Staff told us that the morale was low as the seniormanagement did not listen to their concerns.

• Quality was inconsistently monitored at local levelswhich meant that trends were not fully analysed inorder to make improvements to the service.

• Staff felt a disconnect with senior management

However:

• Staff showed passion for their work despite feelingundervalued by senior management


Vision and valuesStaff lacked a clear understanding of the vision and valuesof the organisation and felt that these values were notembedded into practice by senior management. Most ofthe staff spoken with were not aware of the vision andvalues of the trust. We saw that the vision and values of thetrust were not displayed in offices that we visited.

All staff spoken with demonstrated a good understandingof their team objectives but did not know how they fitted inwith the organisation’s values and objectives. The majorityof staff did not know who their senior managers were andtold us that they had never seen them at all.

Good governanceMost of the staff spoken with told us that the trust clinicalgovernance team analysed the risks within the organisationand this information was shared with all staff to reducerisks to safety. However they rarely received feedback onincidents in other areas so there was no learning fromthese incidents. All new policies, lessons from incidentsand complaints were identified and communicated to staffthrough staff meetings and emails. Most of the staff wespoke with confirmed to us that they received regularsupervision, appraisals and mandatory training. However,

medical staff told us that appraisals were not taking placeannually and other staff told us that training can take toolong to be facilitated as there will be no places available.However the trust's figures were low for supervision andappraisal.

Managers told us that the staffing levels were monitored ona daily basis using the green, amber and red system andthis information was send to governance team for review.However staffing levels were known to be a problem, butthis had not been acted upon.

Staff we spoke with were aware of internal and externalwhistleblowing policies and where to find them. All the staffwe spoke with told us that they would feel comfortableraising concerns with their managers.

Leadership, morale and staff engagementWe saw a supportive culture within teams. We were able toobserve teams working in collaboration and sawdocumentation of constructive working relationships.

Staff spoken with talked highly about their work, althoughmany told us workload and lack of support from seniormanagement was a serious issue for them. Theycommunicated clearly to us that staff supported each otherwithin teams but felt there is a huge disconnect with seniormanagement. They told us that the senior managementdid not listen to them or get them involved. This meantthey did not feel valued.

Commitment to quality improvement andinnovation

We saw that in both teams there was lack of robust systemsto monitor quality of the service to ensure continuousimprovement. We saw that audits were not carried outwhich were able to measure standards in terms ofdevelopment and improvement within the service. Thismeant that performance of the service was not monitoredin order to drive improvement.

The managers told us that the audits were carried out attrust level. However there was no evidence to show thatthis information was given back to the teams to helpensure that areas that needed improvement werehighlighted. We did not see, for example, any detailedanalysis of information, of complaints trends, cancelledappointments, missed appointments, incident trends,produced at local level to be made available to people whoused the service, their families and staff.

Are services well-led?By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.



Chatterton House - West NorfolkVision and values

Most of the staff spoken with were not aware of the visionand values of the trust. We saw that the vision and values ofthe trust were not displayed in most offices that we visited.

All staff spoken were very clear about their team objectivesbut did not know how they fit in with the organisation’svalues and objectives. The majority of staff did not knowwho their most senior managers were and told us that theyhad never seen them at all.

Good governanceLocal team meetings were held to discuss information thathad been discussed within the governance meetings. Stafftold us team meetings were good for feedback and sharinglearning in regard to issues within and outside of the team.

The trust had a risk register which was reviewed on amonthly basis and updated by service managers. The riskregister for the trust had identified risks around staffing inKings Lynn. Senior managers raised issues that neededinclusion in the trust wide risk register and the managertold us that this was generally an effective tool forcapturing on-going concerns. However few actions weretaken as a result of this.

Staff told us that they were aware of the trust’swhistleblowing policy and that they felt able to reportincidents and raise concerns. Staff confirmed that theirimmediate manager was supportive and acted upon anyconcerns raised.

Leadership, morale and staff engagementStaff from both teams told us that they were well supportedby their line managers and were encouraged to accessclinical and professional development courses if thatbenefited to meet the needs of their patients. Staff weresupported to attend Norfolk Dementia Care Academy foradditional training in dementia and access to externaltraining from University of East Anglia.

We saw a supportive culture within teams. Staff told us thatall members of the team were valued and respectedregardless of profession or level of position. We were ableto observe teams working in collaboration and sawdocumentation of positive working relationships.

Staff spoken with talked highly about their work, althoughmany acknowledged capacity and lack of support fromsenior management were an issue for them. They told us

that the senior management did not listen to them andthey felt there was a disconnect between them. Staff toldus that the morale was low due to workload but theysupported each other as a team.


We saw that there were a number of audits which werecarried out which to measure standards in terms ofdevelopment and improvement within the service. Theseaudits included medication adherence and satisfaction,ethnic groups and records keeping. The consultantpsychiatrist led on research and we saw the most recentdata on understanding treatment and improvingcompliance. This meant that performance of the servicewas monitored in order to drive improvement.

We found that there was a system to monitor performance.We saw that an analysis of the team report was available towhich had details of admissions, discharges and referrals.However, there was no broad range of detailed analysis ofall key performance indicators and how this was sharedwith staff.

Carlton Court – Great Yarmouth & WaveneyVision and values

Staff lacked awareness or understanding of the vision andvalues of the organisation and felt that these values werenot rooted into practice by senior management. We sawthat the vision and values of the trust were not displayed inoffices that we visited.

All staff spoken with demonstrated a good understandingof their team objectives but did not know how they fitted inwith the organisation’s values and objectives. The majorityof staff did not know who their senior managers were andtold us that they had never seen them at all. The majority ofstaff told us that they were frustrated by unavailability ofbeds and lack of adequate staff and by the lack ofresolution.

Good governanceRegular team meetings were held with minutes of themeetings recorded. Areas of discussion included serviceupdates, risks, incidents, complaints, caseloads and anyissues of concern raised by staff. All staff we spoke withconfirmed to us that they received regular supervision,appraisals and mandatory training.




Staff were aware of the whistleblowing policy and told usthat it was available on the Trust’s intranet for staff to referto. One staff told us that they would not feel confident toreport and refer concerns if it was needed as there wouldbe no support from the senior management.

Leadership, morale and staff engagementThe majority of staff told us that they felt well supported bytheir line managers and peers. They felt that their linemanagers were approachable and encouraged openness.Two staff informed us that there was an element of bullyingand harassment from the management who were not opento new ideas. All of the staff told us that senior managerswere not accessible or approachable. Staff told us that themorale was low as the senior management did not listen totheir concerns.

Staff were very proud of the care they offered to patientsand how much this had developed. We saw a supportiveculture within teams and were passionate about their workand showed a genuine compassion for people. But theteam’s priorities of quality care for their patients werecompromised by other constraints within the trust. Staffexpressed loss of hope in reporting problems due to lack ofbeds and low staffing levels as they did not haveconfidence that action would be taken.


We found that in both teams there was lack of robustsystems to monitor quality of the service to ensurecontinuous improvement. We saw that audits were notcarried out which were able to measure standards in termsof development and improvement within the service. Thismeant that performance of the service was not monitoredin order to drive improvement.

We did not find evidence of regular audits of, for example,infection control, documentation or participation innational audits. The managers told us that the audits werecarried out at trust level. However there was no evidence toshow that this information was given back to the teams,analysed and trends formulated to ensure that areas thatneed improvement were highlighted. We saw that therewas no detailed analysis of information, for exampleconcerning complaints trends, cancelled appointments,missed appointments, or incident trends produced at locallevel which was made available to people who used theservice, their families and staff.

Woodlands Unit - East SuffolkVision and values

All staff spoken with had a good understanding of theirteam objectives. Staff told us that these objectives keptchanging due to re-structuring of the services. The majorityof staff did not know the managers above the servicemanager told us that they had only seen the previous chiefexecutive officer.

Most of the staff spoken with were not able to demonstratethe vision and values of the trust.

Good governanceRegular team meetings were held with minutes of themeetings recorded. Areas of discussion included serviceupdates, incidents, complaints, caseloads and any issuesof concern raised by staff. Most of the staff spoken with toldus the trust governance team analysed the risks within theorganisation and this information was shared with all staffto reduce risks to safety.

All new policies were identified and communicated to staffthrough staff meetings and emails. Staff confirmed to usthat they received regular communication from theirmanagers and were kept up to date with changes withinthe trust.

Staff were aware of the whistleblowing policy and that theywould feel confident to report and refer concerns if it wasneeded.

Leadership, morale and staff engagementThe service was led by the clinical team leader. All staffspoken with told us they felt that the management of theirteam was good and that they felt supported by their teammanager. However, they felt isolated from the seniormanagement and not engaged in trust developmentissues.

We observed a supportive and cohesive team thatbenefitted from a strong sense of purpose and clarity aboutthe service objectives, including regular supervision,appraisals, training and updates.

There was a sense of collective responsibility for teamperformance. Staff could demonstrate a clearunderstanding of their role, objectives and thecommunication processes within the team and wider trust.Staff confirmed that the team was cohesive with high staffmorale and benefited from an open and approachablemanager.





We saw that there was lack of systems to monitor quality ofthe service to ensure continuous improvement. We sawthat audits were not carried out which were able tomeasure standards in terms of development andimprovement within the service. This meant thatperformance of the service was not monitored in order todrive improvement.

The clinical lead told us that audits were not carried out.They were looking for the psychologist to start some auditssoon. The team carried out satisfaction survey for patientsand carers and were planning to do the same with GPs.

Main Site - West SuffolkVision and values

Most of the staff spoken with were not aware of the visionand values of the trust. We saw that the vision and values ofthe trust were not displayed in offices that we visited.

All staff spoken were very clear about their team objectivesbut did not know how they fit in with the organisation’svalues and objectives. The majority of staff did not knowwho their senior managers were and told us that they hadnever seen them at all.

Good governanceRegular team meetings were held with minutes of themeetings recorded. Areas of discussion included serviceupdates, incidents, complaints, caseloads and any issuesof concern raised by staff. All staff we spoke with confirmedto us that they received regular supervision, appraisals andmandatory training.

Staff were aware of the whistleblowing policy and that theywould feel confident to report and refer concerns if it wasneeded..

Leadership, morale and staff engagementThe service was led by the clinical lead. All staff spoken withtold us they felt that the management of their team wasgood and that they felt supported by their team manager.

Staff told us that the manager was very approachable, hadan open door policy and encouraged openness.

Staff felt that the unity within the team was very strong andthat helped them with focusing on quality and achievingpositive outcomes for people.

Staff spoken with talked highly about their work, althoughmany acknowledged staff capacity and lack of supportfrom senior management were an issue for them. Theycommunicated clearly to us that staff supported each otherwithin teams but felt there is a huge disconnect with seniormanagement. They told us that the senior managementdid not listen to them and was not supportive.


We saw that there was lack of systems to monitor quality ofthe service to ensure continuous improvement. We sawthat audits were not carried out which were able tomeasure standards in terms of development andimprovement within the service. This meant thatperformance of the service was not monitored in order todrive improvement.

We found that there was no information regarding analysisof key performance indicators to ensure that all areas ofperformance were kept under review.




Documents

Community-based mental health services for older people