Services for older people

Locations inspected

Name of CQC registeredlocation

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

Postcodeofservice(ward/unit/team)

Airedale General Hospital TADY6 Ward 24 BD20 6TD

BDCT Headquarters, New Mill TADHQ Older people’s communitymental health teams BD18 3LD

Airedale Centre for Mental Health TAD54 Bracken Ward BD20 6TA

This report describes our judgement of the quality of care provided within this core service by Bradford District NHSTrust. 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 Bradford District Care Trust and these are broughttogether to inform our overall judgement of Bradford District Care Trust.

Bradford District Care Trust

SerServicviceses fforor olderolder peoplepeopleQuality Report

New MillVictoria Road, SaltaireShipleyWest YorkshireBD18 3LDTel: 01274 228300Website: www.bdct.nhs.uk

Date of inspection visit: 17-19 June 2014Date of publication: 15 September 2014

Good –––

1 Services for older people Quality Report 15 September 2014

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 services for olderpeople Good –––

Are services for older people safe? Good –––

Are services for older people caring? Good –––

Are services for older people effective? Good –––

Are services for older people responsive? Good –––

Are services for older people well-led? Good –––

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 4

The five questions we ask about the service and what we found 5

Background to the service 7

Our inspection team 7

Why we carried out this inspection 7

How we carried out this inspection 7

What people who use the provider's services say 7

Good practice 8

Areas for improvement 9

Detailed findings from this inspectionLocations inspected 10

Mental Health Act responsibilities 10

Mental Capacity Act and Deprivation of Liberty Safeguards 10

Findings by our five questions 11

Summary of findings


Overall summaryBradford District Care Trust provides inpatient andcommunity services for older people with a functionalmental illness, such as depression, and organicconditions, such as dementia.

Services for older people were safe. Staff understood andimplemented safeguarding procedures well. In addition,community caseloads were well managed and there weregood systems in place to manage risk on a day-to-daybasis.

People’s care and treatment was planned effectively,which helped to achieve good outcomes. Older people’sneeds were also comprehensively assessed. Staffprovided person-centred care and treatment that was inline with people’s individual care plans. We also foundthat the way in which the multidisciplinary team workedtogether was excellent, and that information was sharedappropriately. Staff were supported well by managersand colleagues, and received appropriate training,supervision and professional development. This enabledthem to deliver safe and effective care.

Staff provided kind and compassionate care. Olderpeople and their carers were treated with respect, andtheir dignity and privacy were maintained. Although

carers were involved in the planning and delivery of care,this was not always recorded. Staff were, however,committed to providing good quality care and treatedpeople as individuals.

Services were responsive to older people’s and carers’needs. The teams understood people’s needs and wishes,and could respond to these. Services were planned anddelivered in a way that met the different needs of thelocal communities. For example, we saw a range ofservices provided that addressed the different culturalneeds of people using the service. In addition, the serviceprovided an extended seven-day service in thecommunity. This meant that they could respond moreeffectively to people’s needs. There also were goodarrangements in place to support effective working withother agencies.

Services for older people were joined-up and well-led.Managers were visible and accessible to people who usethe service, carers and staff. The trust encourageddevelopment of the service development and alsoinvolved people who use the service and their carers. Thetrust’s governance structure also supported the deliveryof the service.

Summary of findings


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

Are services safe?The service had a good track record on safety and provided a safeservice for older people. Staff understood and implementedsafeguarding procedures well. Community staff caseloads were alsowell-managed. This helped staff to deliver safe and effective careand treatment. In addition, there were good systems in place tomanage risk on a day-to-day basis and make sure that lessons werelearnt from any incidents.

Good –––

Are services effective?People’s care and treatment was planned effectively, which helpedto achieve good outcomes. Older people’s needs were alsocomprehensively assessed. Staff delivered care that was in line withpeople’s care plans, and that reflected people’s individual needs.Staff received training, supervision, support and professionaldevelopment that enabled them to deliver effective care. We alsofound that the way in which the multidisciplinary team workedtogether was excellent, and that information was sharedappropriately.

Good –––

Are services caring?Staff provided kind and compassionate care and support to olderpeople and their carers. They responded calmly and sensitively topeople in distress and respected people’s dignity and privacy. Staffprovided person-centred care and there was clear evidence thatcarers were also involved. We found that the services wereinterested in the people they cared for as individuals, and that staffwere committed to providing good quality care.

Good –––

Are services responsive to people's needs?Services for older people were responsive to people’s needs. Therewere clear care pathways in place, and the teams understoodpeople’s needs and wishes and could respond to these. Serviceswere also planned and delivered in a way that met the differentneeds of the local communities. In addition, there was an extendedcommunity service, which operated seven days week and ensuredthat services were responsive.

Good –––

Are services well-led?The trust’s vision and direction was communicated effectively tostaff. The governance structure in place also supported the deliveryof the service. Services for older people were joined-up and well-led,

Good –––

Summary of findings


and managers were visible and accessible to people who use theservice, carers and staff. The trust encouraged development of theservice and also involved people who use the service and theircarers.

Summary of findings


Background to the serviceBradford District Care Trust provides inpatient andcommunity services for older people with a functionalmental illness, such as depression, and organicconditions, such as dementia.

Ward 24 is an inpatient ward for older people with organicconditions. It has 19 beds and is based at AiredaleGeneral Hospital. Bracken Ward provides services forolder people with functional conditions and is based atAiredale Mental Health Centre.

The service has four community mental health teams(CMHTs) that provide a specialised service to olderpeople. In addition, the service provides memoryassessment and treatment services and day services.

We inspected Airedale Mental Health Centre and Ward 24in July 2013. We found that the service was compliantwith the regulations.

Our inspection teamOur inspection team was led by:

Chair: Angela Greatley, Chair, The Tavistock and PortmanNHS Foundation Trust

Team Leader: Jenny Wilkes, Head of Inspection –Hospitals Directorate (Mental Health), Care QualityCommission (CQC)

The team included CQC inspectors and a variety ofspecialists: a consultant psychiatrist, a specialistdementia nurse, a care home manager, an occupationaltherapist (clinical lead), a social worker, a Mental HealthAct commissioner, and an Expert by Experience, who hadexperience of care.

Why we carried out this inspectionWe inspected this core service as part of our Wave 2 pilotmental 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?

We carried out announced visits to Bradford District CareTrust’s older people’s services on 17, 18 and 19 June 2014.

We also carried out a further short-notice, announcedvisit to Bracken Ward on 3 July 2014. Before visiting, wereviewed a range of information we held about the coreservice and asked other organisations to share what theyknew. During the visits, we held focus groups with a rangeof staff who worked within the service, including nurses,consultant psychiatrists and therapists. We talked withpeople who use services, their carers and/or familymembers. We observed how people were being cared forand reviewed their care or treatment.

What people who use the provider's services sayBefore our inspection, we held listening events, includingone at the Airedale Centre for Mental Health. Patients

with experience of older people’s services wereexceptionally complementary about the care they

Summary of findings


received and the environment of Bracken Ward. They alsocomplemented the staff on how well managed the moveof Bracken Ward from Lynfield Mount Hospital to theAiredale Centre had been. However, carers told us thatthey felt that they had not been listened to fully as part ofthe consultation about the move.

We spoke with people and carers on Ward 24, BrackenWard and those using community mental health servicesfor older people. In addition, we spoke with peopleduring home visits, when we accompanied communitypsychiatric nurses. We also spoke with people in amemory assessment and treatment service clinic, andday centre.

People using the service and their carers told us that stafftreated them well and with respect, and that they feltsupported. Everyone told us they felt safe on the ward.One person we visited in the community told us theywere very happy with the service they received from theircommunity psychiatric nurse. Others told us that theyenjoyed visits from the community team. This was typicalof what people and carers told us about the services forolder people.

People using the memory assessment and treatmentservice were very enthusiastic and positive about theservice they received from the team.

As several people on Ward 24 and Bracken Ward wereunable to speak with us directly, we observed people’sexperiences on the ward using the short observationalframework for inspection (SOFI 2).

We observed staff interacting with people in a caring andcompassionate way. They also responded to people indistress in a calm, gentle and respectful manner. Staffappeared to be interested in people and anticipated theirneeds. During our observations on Ward 24, we saw manyexamples where staff treated people in a kind, caring andsensitive manner. Care was person-centred and peoplereceived care and support based on their individualneeds.

All the interactions we observed between staff andpeople using the service were positive, and showedwarmth and real engagement. The atmosphere on Ward24 was calm and people appeared relaxed in thecompany of staff. One person who wished to walk aroundthe ward was often accompanied by staff and thisappeared to reassure them.

Good practice• The design of Ward 24 was carefully considered. The

team had worked hard to identify the best evidence interms of designing a safe and therapeutic environmentfor older people with dementia.

• Some local integration meetings, which involvedcommunity psychiatric nurses, GPs, district nurses andothers, were working particularly well. There was goodcommunication and partnership working, which madesure that older people’s needs were being met.

• There was a high level of investment in staff trainingand development across the service. This benefittedthe service, people using the service and their carers.

• The service had successfully integrated the ChiefNursing Officer’s 6Cs of nursing (care, compassion,

competence, communication, courage andcommitment) into the delivery of care on Ward 24. The6Cs had been clearly explained to staff in the contextof the care environment. This meant that they couldbe implemented effectively, which benefitted peopleand their carers.

• Staff at the memory assessment and treatment serviceclinic we visited provided excellent person-centredcare to people and families who were attending for anassessment and diagnosis of memory impairment.The service was aware of, and responsive to, the needsof local communities and staff showed exceptionalskill and sensitivity in the way they communicatedwith people.

Summary of findings


Areas for improvementAction the provider MUST or SHOULD take toimprove

• The service should ensure that all duplicate andmultiple electronic records held about the sameperson using the service are removed from the system.

• The trust should improve the recording of people’sviews in care plan documents to show fully theparticipation of people in their care and recovery.

• The trust should provide people detained under theMental Health Act 1983 with copies of section 17 leavemore consistently.

• The trust should provide people seen at home by thecommunity mental health team staff with informationon how to make a complaint, or how to contact thepatient advice and liaison service (PALS), as a matter ofroutine.

• The trust should offer people access to psychologyservices more consistently. Some community mentalhealth teams for older people reported difficulty inaccessing a psychologist, while others had apsychologist in the team, which was reported to bevery beneficial to people using the service.

Summary of findings


Locations inspected

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

Ward 24 Airedale General Hospital

Older people’s community mental health teams BDCT Headquarters, New Mill

Bracken Ward Airedale Centre for Mental Health

Mental Health Act responsibilitiesThe use of the Mental Health Act (MHA) 1983 was generallygood in Ward 24 and Bracken Ward, the older people’sinpatient wards. Statutory duties under the Act were beingfulfilled and the MHA documentation we reviewed on the

wards was up-to-date and reflected the lawful detention ofpeople. Care plans and risk assessments were documentedalthough there was little formal record of people’s andcarers involvement in care planning.

Mental Capacity Act and Deprivation of Liberty SafeguardsThe mental capacity of people using the service wasassessed and discussed routinely in multi-disciplinaryreviews of care. Staff demonstrated a clear understandingof the Mental Capacity Act 2005 and documentation wascompleted by the multidisciplinary team. Care plans were

in place for some people using the service that explicitlyaddressed issues of capacity and consent. There was norecorded use of Deprivation of Liberty Safeguards (DoLS)on Ward 24 or Bracken Ward in the last six months.

Bradford District Care Trust

SerServicviceses fforor olderolder peoplepeopleDetailed findings


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

Summary of findingsThe service had a good track record on safety andprovided a safe service for older people. Staffunderstood and implemented safeguarding procedureswell. Community staff caseloads were also well-managed. This helped staff to deliver safe and effectivecare and treatment. In addition, there were goodsystems in place to manage risk on a day-to-day basisand make sure that lessons were learnt from anyincidents.

Our findingsAiredale General Hospital

Track record on safetyWard 24 had a good track record on safety. There was aclear system for the reporting of incidents. Staff were ableto explain the process to us and described how theyreported incidents via the trust’s electronic reportingsystem. Staff knew the type of incident they were requiredto report and how to report them. All incidents werereviewed by the ward manager and the governance teamwho maintained oversight.

Information on safety was collected from different sourcesand used to monitor performance. A range of performanceindicators were monitored every month and reportedcentrally. Information was collected on all incidents,including the number of falls that occurred on the ward.The ward manager told us that falls were the mostfrequently occurring incident and described action taken toreduce falls, which often related to a specific individual.The majority of falls had usually resulted in minimal or noharm to people. The overall reporting of incidents fromApril 2013 to March 2014 in the service for older people, asa whole, was low.

The governance and quality committee met monthly andreviewed all compliments, complaints, serious incidentsand progress on action plans as well as risk registers.

Learning from incidents and improving safetystandardsThe ward manager maintained an overview of all incidentsreported on the ward. Incidents were investigated and theoutcome shared with staff on the ward and more widely atlocality governance meetings. Staff told us incidents werediscussed in team meetings and changes were made to thecare of people as a result of any learning identified.

The manager provided us with examples of changes thathad been made to services as a result of learning fromincidents. Falls were the most frequently occurring incidentand investigation of these had included a mapping ofwhere falls had occurred to determine whether there wereany common factors in the ward environment thatincreased or decreased the likelihood of falls. However, noclear pattern had emerged. All reviews of falls involved areview of the person’s medicines and we saw a post-fallprotocol on display on the staff office

When safety alerts were issued by the trust, these wereshared with staff by the ward manager at team meetingsand through individual supervision.

Reliable systems, processes and practices to keeppeople safe and safeguarded from abuseWe spoke with people using the service and carers we meton Ward 24. Everyone told us they felt confident in relationto the safety of people on the ward.

Staff had received training in safeguarding vulnerableadults and staff we spoke with knew how to recognise asafeguarding concern. Safeguarding was discussed at wardteam meetings and during individual supervision to ensurestaff had sufficient awareness and understanding ofsafeguarding procedures. Staff we spoke with were awareof the trust’s safeguarding policy. They knew who to informif they had safeguarding concerns. Staff provided examplesof safeguarding referrals that had been made.

There was good, clear information available for staff andvisitors to the ward with a dedicated noticeboard forsafeguarding information. Some staff had completed trainthe trainer training in recognising and responding to abuseallegations.

We found that people’s medicines were being managedsafely. For example, when we checked the medicine

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

Good –––


management arrangements on Ward 24 we found allmedicines stored in locked clinic room and the medicinecupboards and refrigerators were locked. The medicinekeys were held by a nurse. Fridge temperatures weremonitored to ensure that medicines requiring cold storageremained effective. We noted all recorded temperatureswere within the required range.

Staff were aware of the trust’s whistleblowing policy andtold us they felt able to raise any concerns they had aboutthe care and treatment of people who use the service withsenior managers. Some staff gave us examples of whenthey had raised about concerns or suggestions forimprovements in the care of people and said this had beenreceived positively by senior staff.

Assessing and monitoring safety and riskStaff were aware of the needs of people using the serviceand were able to explain how they were supporting them.Appropriate nursing handover took place between shifts.We observed a handover on Ward 24. The meetingincluded detailed discussion of people’s needs, includingany potential risks to their safety and how these should bemanaged or mitigated.

Staffing levels on the ward were sufficient to meet theneeds of people using the service. The ward manager toldus they were able to obtain additional staff when the needsof people changed and more staff were required to ensuretheir safety. The few staff vacancies were being activelyrecruited to. A new occupational therapist (OT) was due tostart as a replacement for the OT who had recently left.

Bank and agency staff were used to cover any shortfalls instaffing. Regular ‘bank’ staff were used wherever possibleso that care and treatment was provided by staff who werefamiliar with the ward routines and people’s needs. Bankand agency staff were given a brief induction to the ward,which included orientation to the layout of the ward, anintroduction to trust policies and procedures and where toaccess them and records management.

There were seven different consultant psychiatristsproviding care and treatment to people on the ward. Themanager told us that consultants contacted the wardeveryday which enabled discussion of any concerns aboutpeople’s care and treatment.

Staff told us current staffing levels were safe but they werenot clear how the established staffing levels on each shifthad been determined particularly in relation to skill mix of

qualified and unqualified staff. Staff told us that nightswere particularly challenging as there was no coverprovided for the qualified nurse to take a break. Action wasbeing taken by senior managers to assess the optimalstaffing needs of the ward using a clustering tool tomeasure the acuity and needs of people using the service.

Training records showed that most staff had been trainedin how to restrain people safely. Training included the useof breakaway techniques and how to physically restrain aperson. Staff told us they rarely needed to restrain peoplebut sometimes used ‘safe holds’. This was confirmed bytrust records which showed there had been two records ofincidents of use of restraint in the last six months.Supportive or safe holding of people had been reported onmore than 30 occasions within the same time period. Therewas written guidance for staff on the use of restraint. Thishelped ensure the practice was lawful, carried out safelyand was not excessive.

There was a policy in place addressing the covertadministration of medicines which staff told us theyoccasionally needed to follow. However, we noted that thepolicy had been due for review in 2011 but this had nottaken place.

We saw that individual risk assessments had beenconducted in respect of people using the service. Staff toldus that where particular risks were identified measureswere put in place to ensure the risk was managed.Individual risk assessments we reviewed took account ofpeople’s previous history as well as their current mentalstate. Most risk assessments had been updated recently.

When a person was admitted to the ward a number ofassessments of risk were conducted. For example, risks inrespect of nutrition, skin integrity and falls were assessed.Where a risk was identified plans were put in place tosupport the person and minimise the risk.

We observed a staff handover between shifts at lunchtimeon the ward. Communication about people’s individualneeds was clear and the handover included discussion ofindividual risks to people including any additional safetychecks needed.

The ward manager was aware of the risks entered on therisk register for the ward and confirmed they were beingmanaged effectively.


Good –––


Understanding and management of foreseeablerisksRegular environmental safety checks were carried out onWard 24. This helped identify the need for any repairs andprotect people from general risks in the ward environment.A ligature risk assessment was conducted annually.Modifications had been made to the ward to make it safer,such as collapsible curtain rails. The ward manager told usthere was a balance between managing existing ligaturerisks and having an environment that was helpful andappropriate for people with dementia.

There were good systems in place for infection preventionand control. The infection prevention and control leadnurse paid regular visits to the ward. All staff uniforms werelaundered on site to ensure they were cleaned at thecorrect temperature. Senior managers maintainedoversight of housekeeping staff. There were audits ofinfection control and prevention and staff hand hygiene toensure that people who use the service and staff wereprotected against the risks of infection.

We saw that the ward was clean and people and carers toldus that standards of cleanliness were usually good. Theward was well-maintained and the corridors were clear andclutter free. Staff disposed of sharp objects such as usedneedles and syringes appropriately in yellow bins. We sawthese were not over-filled. People were provided withhygienic wipes to clean their hands prior to eating theirmeals which helped minimise the risk of infection.

Emergency equipment, including automated externaldefibrillators and oxygen, was in place and checkedregularly to ensure it was fit for purpose and could be usedeffectively in an emergency. Medical devices were alsochecked regularly to ensure they were working correctly.Staff had undertaken training in life support techniquesand this was due to be updated the day after our visit to theward.

Regular fire risk assessments and fire tests were carried outincluding practice evacuations of the ward. This helpedprotect people from the risk of harm.

When staffing shortages needed to be filled, this wasgenerally done through the use of bank staff. This was wellmanaged on the ward, and regular staff, who were familiar

with the ward, were used to cover shift vacancies wherepossible. This meant most staff had knowledge of the wardand people using the service and were able to understandand manage foreseeable risks as a result.

Older people’s community mental health teams

Track record on safetyThe service for older people had a clear system in place forthe reporting of incidents. Staff we spoke with clearlyexplained the process for reporting incidents through theelectronic reporting system. Staff were confident in beingable to report incidents appropriately. Information onsafety was collected from a range of sources to monitorperformance, this included information on incidents andtrends were identified. The service had a good track recordon safety. The overall reporting of incidents from April 2013to March 2014, in the service for older people as a whole,was low.

Learning from incidents and improving safetystandardsStaff told us that reporting incidents was encouraged.Incidents were investigated and the outcome shared withstaff and more widely at local governance meetings. Stafftold us that presentations of learning from serious incidentinvestigations were delivered in culture of openness.Incidents were discussed in team meetings and changeswere made to the care of people as a result of any learningidentified. We found that both learning within and acrossteams took place. Staff told us, and we observed, thatsafety and risk was always discussed in team meetings.

Reliable systems, processes and practices to keeppeople safe and safeguarded from abuseStaff had received training in safeguarding vulnerableadults. Staff we spoke with had excellent knowledge ofsafeguarding issues and knew how to recognise asafeguarding concern. Safeguarding was discussed at teammeetings and during individual supervision to ensure staffhad sufficient awareness and understanding ofsafeguarding procedures. Staff were aware of the trust’ssafeguarding policy. They provided examples ofsafeguarding referrals that had been made and weobserved discussion of safeguarding concerns in acommunity team meeting. Caseload managementdiscussions covered areas of risk such as child protectionand adult safeguarding. Flow charts of safeguardingprocedures were available to support staff and contained alist of important contacts in different local agencies.


Good –––


Protocols were in place for the safe transfer of people fromadult services to older people’s services.

Staff were aware of the trust’s whistleblowing policy andtold us they felt able to raise any concerns they had aboutthe care and treatment of people who use the service withsenior managers.

When reviewing people’s health care records we foundexamples of where duplicate or multiple electronic recordshad been created for the same person. In most cases thishad been identified and the duplicate records had beenclosed. However, in one community team we noted that aperson had multiple records in their name. This could havecaused confusion for staff about the current care plannedfor the person, particularly those staff unfamiliar with theservice and individuals using the service.

Assessing and monitoring safety and riskStaffing in the community teams was sufficient to meet theneeds of people using the service. The community teamshad effective systems in place to manage caseloads.Community staff told us that caseloads were generallybetween 20 and 25 people although some staff told us theyhad less than 20. Individual caseloads were based onpeople’s level of needs rather than being a specific number.Team members were supportive of each other and sharednew referrals to ensure that staff were able to manage theirwork load safely and effectively. Staff told us howallocations of people using the service were sometimeschanged depending upon the person’s needs and who wasbest able to support them. Staff normally assessed newpeople to the service in pairs.

Staff were aware of the needs of people using the serviceand were able to explain to us how they were supportingpeople. We saw that individual risk assessments had beenconducted in respect of people. Staff told us that whereparticular risks were identified measures were put in placeto ensure the risk was managed. Individual riskassessments we reviewed took account of people’sprevious history as well as their current mental state. Mostrisk assessments had been updated recently, although wenoted in one community team that a few risk assessmentswere not completed or were out of date. We observed adiscussion of a new referral to a community team and sawthat discussion of current and historical risk factors formeda prominent part of the overall assessment process.

Acute liaison team staff, who were part of the communitymental health teams for older people, prioritised referralsbased upon risk.

Community team staff were confident in risk managementand used positive risk management in the community inorder to prevent unnecessary admissions to hospital and tosupport people’s wishes to be cared for and treated athome where this was possible and safe.

Community mental health team managers monitored thequality of risk assessments and addressed any shortfallsdirectly with individual staff. Community staff were awareof the risks entered on the risk register for their team. Weobserved a discussion of a new risk that had beenidentified in the team and systems put in place to prevent areoccurrence of the situation.

Understanding and management of foreseeablerisksSystems were in place to maintain staff safety. The servicehad good lone working practices in the form of a buddysystem, where staff informed another identified staffmember of their whereabouts at all times and checked inwith them at the end of the day. If there were any concernsabout risk two staff carried out visits together.

We observed good discussion and consideration of risk andsafety in the day to day management of people’s care.

Airedale Centre for Mental Health

Track record on safetyBracken ward had a good track record on safety. Staff weretrained in safeguarding vulnerable adults and children.Staff we spoke with were knowledgeable about theirresponsibilities in regards to the safeguarding process.They described the process for referring any identifiedpotential or actual concerns to the relevant department.Staff reported that ordinarily they would undertake thisprocess via the support of their manager. The trust’ssafeguarding policy and procedure was available on thetrust’s intranet site and was easily accessible. Staff wereable to provide appropriate examples of the type ofsafeguarding concerns they would report and describedthe process for completing this. Staff said they wereencouraged to be open and transparent. They feltconfident that if they raised a concern it would be listenedto and dealt with appropriately.


Good –––


There was a clear system for reporting incidents. Both themanager and ward staff were able to explain the process tous and described how they reported incidents via thetrust’s electronic reporting system. Staff were aware of thetypes of incident they were required to report and theprocess for reporting it. The ward manager maintainedoversight of all reported incidents and received a monthlyreport from the risk management team. We found a rangeof performance indicators were monitored every monthand reported centrally. The manager was aware of anypatterns and emerging themes for the ward, and we sawaction plans in place to address these. The overallreporting of incidents in the service for older people as awhole was low between the period from April 2013 toMarch 2014.

Learning from incidents and improving safetystandardsThe trust’s serious incident data demonstrated that trust-wide learning from serious incidents had been reviewed bythe governance team and shared with staff throughout thetrust. The manager informed us that learning fromincidents was shared by the senior management team anddisseminated via email. This was then forwarded to wardstaff and/or discussed at team meetings whereappropriate. Staff reported that incidents were discussed atteam meetings and we saw minutes that confirmed this. Ifany leaning had been identified, this was then reflected inchanges made to people’s care. Staff told us that reportingof incidents was encouraged.

We found evidence of learning taking place at a local level.For example, the ward identified gaps in information inregards to people’s diet and fluid intake. In order to addressthis, Bracken Ward implemented protected meal times,whereby all staff attended the dining area at meal times inorder to assist and support people who used the service.We observed this process on the day of our inspection andnoted staff were available and responsive to people’sneeds. The manager reported that since introducing thisnew way of working the recording of diet and fluid intakehad improved and this has had a consequent positiveimpact for the health of people who used the service.

Reliable systems, processes and practices to keeppeople safe and safeguarded from abuseWe found appropriate systems in place for the safe receipt,storage, handling and disposal of medication. Medicineswere stored within locked cupboards in a secure clinic

room. The fridge in the clinic room contained certainmedications. We found these medications were in date andthat fridge temperatures were being maintained within therequired range. We noted in the preceding three monthsthere were a number of days when the fridge temperaturehad not been monitored. This oversight had been capturedby an audit and we saw the issue had been discussed at ateam meeting. We looked at a sample of medicationadministration records and found that these had beencompleted appropriately and corresponded with themedication stock levels.

We found evidence of reliable systems, processes andoperating procedures in place for infection prevention andcontrol. Training in this area was a mandatory requirement.We reviewed the policy and procedure in place and found itcontained detailed guidance for staff to be able to follow.The trust has a 24-hour contact number for an infectioncontrol nurse should any member of staff have anemergency situation they needed guidance and advice on.Recently, the ward had a norovirus and all procedures werefollowed in relation to the outbreak and management ofthe virus to minimise the risks of spreading further.Measures put in place included: closing communal toilets;informing relatives; additional cleaning; and closing theward to all but essential visits.

Staff had received training in safeguarding adults and staffwe spoke with knew how to recognise a safeguardingconcern. Staff were aware that some people may struggleto communicate concerns and needed to be mindful ofmore subtle evidence of abuse having potentially takenplace. This included noting changes in behaviour, anexample provided was a person becoming morewithdrawn. Staff were aware of the trust’s whistleblowingpolicy. They told us they felt confident to raise any concernsthey had about the care and treatment of people who usedthe service with senior managers. Staff also confirmed thatthey would challenge poor practice at a local level withcolleagues and broach any concerns with their managerwhere appropriate to do so.

People we spoke with told us they felt safe on the ward andwere happy to discuss any concerns they had with staffshould the need have arisen. Information on how to reportabuse was on display in communal areas of the ward.

Assessing and monitoring safety and riskStaffing levels on the ward were sufficient to meet theneeds of the people who used the service. We observed


Good –––


that while staff were kept busy, they responded quickly toindividual requests from people. When providing one-to-one support, people were not rushed and staff spent timesupporting people at relaxed pace in order to ensurepeople were fully understood what was happening. Theward manager told us they were able to secure additionalstaff when the needs of people changed and more staffwere required to ensure their safety. Staff told us that if aperson needed increased observation, additional staffingwould be arranged. This was usually accommodated byregular bank staff who had a working knowledge of theward and understood the needs of the patient group. Staffconfirmed that bank staff were appropriately inducted andorientated to the ward.

Bracken Ward operated staffing levels of five staff duringthe day (two qualified nurses and three healthcare supportworkers) and four staff at night (one qualified nurse andthree healthcare support workers). Appropriate staffinglevels for the ward were clearly displayed on a wall in thecommunal area and had the appearance of a traffic lightsystem. We observed that staffing levels had remained‘green’ since the opening of Bracken Ward approximatelyeight weeks before our inspection, indicating thatappropriate and safe staffing levels had been maintained.

We found evidence of the service assessing and respondingto individual risk. Risk assessments had been undertakenfor each person who used the service. Where a risk wasidentified, a plan was put in place to ensure the risk wasmanaged. Risk assessments took account of the currentpresentation as well as historical risk factors. Riskassessments were reviewed regularly and we foundevidence of this in care records. The RIO electronic recordssystem allowed for multiple teams to be involved inpeople’s care via access to a central system. This meantthat assessments undertaken in the community wereaccessible by ward staff and vice versa. This allowed for thetimely transfer of information and ensured that risk issueswere communicated in real time to the people that neededto know.

We observed a staff handover between shifts after lunch onthe ward. The handover was comprehensive and includedan overview of each patient’s progress as well as anychanges in terms of risk management. Staff had a good

understanding of each patient and used the meeting as afrank and open exchange to discuss progress what neededto be improved. Risk was considered more globally and notjust in terms of how each person was presenting in theward environment. Staff were aware of the individual socialcircumstances of each person discussed and used thisinformation to inform discussions about dischargeplanning and any associated risks at home.

Understanding and management of foreseeablerisksWe found evidence of regular environmental safety checksbeing carried on Bracken Ward. This included a monthly‘walk around’ by the estates department to identify theneed for any repairs and protect people from general risksin the ward environment. Estates and facilities staffundertook a Health and Safety assessment on 1 July 2014.This outlined areas of work still to be completed followingthe move to the Airedale site. The manager informed usthat due to the building being new there had been anumber of minor issues in regards to the fabric of thebuilding and electronic systems that needed attention.These repairs and modifications had been undertakenswiftly in order to maintain safety and ensure the smoothrunning of the ward.

The moving of the ward to a new geographical area hadcaused some initial disruption to staffing levels, with eightstaffing members having left due to the logistical difficultyof getting to the new unit. In order to manage and maintainappropriate staffing levels and to ensure safety, new staffwere recruited and regular agency staff utilised to fillshortfalls in the interim.

Bracken Ward had a business continuity plan to managethe ward in a number of emergency situations. Thisincluded changes in demand as well as seasonal weatherchanges.

Staff were aware of what to do in a fire drill and wherepeople should assemble. We did not see any personalemergency evacuation plans (PEEPs) in place for peoplewho used the service. This was discussed with the wardmanager who informed us they would amend theadmission documentation to include this.


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Summary of findingsPeople’s care and treatment was planned effectively,which helped to achieve good outcomes. Older people’sneeds were also comprehensively assessed. Staffdelivered care that was in line with people’s care plans,and that reflected people’s individual needs. Staffreceived training, supervision, support and professionaldevelopment that enabled them to deliver effectivecare. We also found that the way in which themultidisciplinary team worked together was excellent,and that information was shared appropriately.


Assessment and delivery of care and treatmentAppropriate arrangements were in place to managepeople’s medicines effectively. We reviewed the medicineadministration records of several people on the ward. Mosthad been completed appropriately and explained why anyparticular dose had been omitted. There was a regularaudit of medicine records to ensure recording ofadministration was complete. The majority of medicineswere administered as prescribed. Staff told us thepharmacist frequently reviewed medicine administrationrecords to ensure that prescriptions and administration ofanti-psychotic medicines were appropriate and not over-used.

People’s needs were assessed and care was delivered inline with their individual care plans. Assessments includeda review of the person’s physical health with specificassessments of infection risks, skin integrity, and risk of fallsand nutritional risks. Where physical health concerns hadbeen identified care plans were put in place to ensure theperson’s needs were met. Records showed that risks tophysical health were identified and managed effectively.We reviewed several care plans on the ward and theseshowed that individual plans were in place whichaddressed people’s assessed needs. We saw that most ofthese were reviewed on a regular basis and updated ordiscontinued as appropriate.

When falls had occurred we saw that this was recorded inpeople’s care records with reference to the incident reportnumber. There was a falls protocol in place and evidence ofmedical assessment following falls.

Staff undertook training in the Mental Capacity Act 2005and Deprivation of Liberty Safeguards (DoLS) every twoyears. Staff we spoke with demonstrated goodunderstanding of the Mental Capacity Act. They were awareof recent legal decisions in respect of the Mental CapacityAct 2005. The legal status of the admission of people usingthe services had been reviewed as a result and action hadbeen taken based on the legal advice obtained. There wasno record of DoLS being used on Ward 24 in the last sixmonths.

When we reviewed people’s care records we saw thatcapacity assessments were discussed in multidisciplinaryteam meetings and documented, sometimes with gooddetail. Care plans were in place for some people using theservice that explicitly addressed issues of capacity andconsent.

Mealtimes on Ward 24 were protected, which meant thatpeople were able to concentrate on eating and drinkingwithout being disturbed by visitors including clinicians.They were able to eat and drink at any time and the wardkept stocks of tinned food and sandwich fillers in caseanyone wanted a snack. This helped ensure people’snutritional needs were met. We saw that adapted cutleryhad been provided to help people eat by themselves and abright yellow plate was used by a person with a visualimpairment as the contrast in colour allowed them to seetheir food more clearly.

The service responded promptly to ensure people’sphysical health needs were met. Ward 24 was locatedwithin an acute general hospital which facilitated access tophysical health care services.

Outcomes for people using servicesStaff provided care to people based on national guidance,such as National Institute for Clinical Excellence (NICE)guidelines, and were aware of recent changes in guidance.We saw evidence of discussion on NICE guidelines inpeople’s health care notes.

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.

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Ward staff carried out regular audits as a way of ensuringhigh quality care was provided to people. For example, wesaw audits of people’s care plans had been undertaken anddetailed feedback provided to nurses to enableimprovements.

The inpatient service was not formally benchmarked inrelation to other services and no formal accreditation forthe ward had been sought. However, the ward managerhad visited other services, was aware of current research inthe field of dementia care and actively sought toimplement improvements in care and practice based onupon robust evidence.

Staff, equipment and facilitiesStaff received appropriate training, supervision andprofessional development. Staff told us they hadundertaken training pertinent to their role including insafeguarding vulnerable adults, fire safety and life supporttechniques. Records showed that most staff were up-to-date with statutory and mandatory training requirementsand the training matrix was on display near the entrance tothe ward. In addition, most staff had undertaken specialisttraining in dementia care. For example, several staff hadattended training in ‘Cornerstones of Person-CentredDementia Care’ at Bradford University and health caresupport workers had completed national vocationalqualifications at levels two or three, following the dementiastrand of the course. Health care support workers had beensupported to develop competencies in physical health care

New staff undertook a period of induction before beingincluded in the staffing numbers. Ward managers hadaccess the electronic staff records which allowed them tomaintain oversight of staff progress in respect of trainingcompletion. The training provided helped ensure staff wereable to deliver care to people safely and to an appropriatestandard.

All staff told us they had undergone a performanceappraisal within the last year which confirmed performancefigures on display in the ward. Individual supervisionmeetings took place every two months although formalrecords of the meetings were not kept. Most staff told usthat supervision usually took place as planned although itwas sometimes cancelled if the ward was particularly busy.

Equipment was checked regularly and monitored to ensureit was fit for purpose. Equipment was cleaned betweenuses, and labelled to show when it had last been cleaned.Service checks of equipment were carried out.

A range of meaningful activities were provided on the ward.We observed people taking part in group and one to oneactivities with staff. This included individual discussionsabout people’s life histories and their likes and dislikeswhich were recorded in their own ‘living well’ folder. Wealso saw reminiscence work with people and quizzes andgames where staff made active attempts to includeeveryone.

Multidisciplinary workingAssessments of people were multidisciplinary in approach,with involvement from medical, nursing and occupationaltherapists. There was evidence of effectivemultidisciplinary team (MDT) working in people’s records.People who use the service had access to a range ofprofessionals with specialist skills where needed. We sawthat care plans included advice and input from differentprofessionals involved in people`s care. We observed athorough discussion of a person’s needs involving medicaland nursing staff. Nursing staff described psychiatrists as“responsive and proactive”.

Staff described good working relationships withcommunity mental health teams and told us systemsworked well in terms of effective discharge planning, careprogramme approach and seven-day follow-up postdischarge.

Mental Health Act (MHA) 1983Information on the rights of people who were detained wasdisplayed in wards and independent mental healthadvocacy services were readily available to support people.Staff were aware of the need to explain people’s rights tothem. There was a leaflet providing information for peoplewho were informally admitted to the ward about their legalrights, although we noted that this had not been updatedfor some time.

The use of the MHA was mostly good on the ward and wefound people were being legally detained. Mental healthdocumentation reviewed was generally found to becompliant with the Act and the Code of Practice in thedetained patients’ files we reviewed.


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We noted that although all section 17 leave was recordedin people’s electronic records copies were not routinelyprovided to people who use the service. This practice didnot comply with the MHA Code of Practice.


Assessment and delivery of care and treatmentWe noted during home visits that community psychiatricnurses routinely provided information to people abouttheir medicines and potential side-effects.

The community teams used a duty system to ensure thatcalls to the teams could be responded to quickly. We notedthat staff on duty were knowledgeable about the peoplebeing supported and cared for by the team and were ableto respond effectively to enquiries from the police andother agencies. Staff on duty knew about on-going risksand how they were being managed.

People’s needs were assessed and care was delivered inline with their individual care plans. A range of tools andscales were used to make assessments of people’s mentalhealth needs, such as, Becks Depression Inventory and theYoung Schema Questionnaire. When we reviewed people’shealth care records we found detailed descriptions ofpeople’s issues with clear management plans in place.Comprehensive summaries of people’s care were availableand we saw evidence to show that people’s physical healthneeds were assessed and responded to.

There were individual relapse/crisis plans in place tosupport people using the service in case they were needed.

Staff had undertaken training in the Mental Capacity Act(MCA) 2005 and Deprivation of Liberty Safeguards (DoLS),which was updated every two years. Staff we spoke withdemonstrated good understanding of the MCA. They wereaware of recent legal decisions in respect of the MCA andhow this affected their practice.

When reviewing people’s health care records we notedsome good examples of very detailed and specificassessments of people’s mental capacity, whereas someothers lacked detail.

The promotion of good physical and mental health wasevident in case discussions we observed in a communitymental health team meeting. Staff had good knowledge ofthe physical as well as mental health needs of olderpeople.

Outcomes for people using servicesStaff provided care to people based on national guidance,such as National Institute for Clinical Excellence (NICE)guidelines, and were aware of recent changes in guidance.For example, a staff member told us about the NICEguidelines for delirium and how these were reflected intheir practice.

The community mental health teams were using a numberof measures to evaluate the effectiveness of the service forolder people. Health of the nation outcome scales (HoNOS)and patient-reported outcome measures (PROMS) wereused to measure clinical outcomes for people using theolder people’s service. Record keeping audits and audits ofcare planning were carried out regularly. Performancetargets included a target of 12 months for conducting careprogramme approach (CPA) reviews and follow-up withinseven days of people discharged from older people’sinpatient services. A team manager told us the seven-dayfollow-up target was routinely met, although targets inrespect of completion of carers’ assessments were not. Thiswas being addressed with staff in order to bring aboutimprovement.

Staff, equipment and facilitiesStaff received appropriate training, supervision andprofessional development. Staff told us they hadundertaken training pertinent to their role including insafeguarding vulnerable adults and that the trust was verysupportive in respect of staff training and development.Records showed that most staff were up to date withstatutory and mandatory training requirements.

Staff were well supported to attend additional specialisttraining and development opportunities. For example, staffin one community team were to attend a course in usingMontessori principles to work creatively with people withdementia. Another community team were due toundertake training on physical health care during the weekof our visit and specific dementia training was beingorganised for those staff that needed it.

All staff told us they had undergone a performanceappraisal within the last year. Appraisals were used toidentify staff learning and development needs. Staffreceived regular managerial and clinical supervision.

Multidisciplinary workingAssessments of people were multidisciplinary in approach,with involvement from medical, nursing and occupational


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therapy. There was evidence of effective multidisciplinaryteam (MDT) working in people’s records. People who usethe service had access to a range of professionals withspecialist skills, such as speech and language therapists,where needed. We saw that care plans included advice andinput from different professionals involved in people`scare. In some community teams we found that staff valuedthe different disciplines in the team and workedexceptionally well together.

Specific services, such as the memory assessment andtreatment service clinics and day hospitals, had beendeveloped to provide specialist assessment and care.

Information sharing between inpatient mental healthwards and community services was effective and staff toldus they worked well together. However, staff reported thatcommunication about the discharge of people using theolder people’s service from acute hospital wards was poor.This was despite repeated reminders to acute hospital staffto inform the community mental health team when theperson was discharged.

The community teams did not have social workersembedded within the team. This was a recent developmentfor some teams although others told us there had neverbeen a social worker in the particular community mentalhealth team for older people. If social services involvementwas required appropriate referrals were made. Staff told usthis often resulted in a delay to people receiving socialworker involvement. One manager described “struggling”to get social work input.

Community mental health teams for older peopledemonstrated good inter-agency working with otherorganisations. For example, the Alzheimer’s societyundertook some joint sessions with the teams at the dayhospitals. Joint visits were undertaken with district nurseswhen relevant to the person’s care. The care home liaisonteams and acute liaison teams worked well with otherservices. The care home liaison team worked closely withcommunity matrons and delivered support to people andstaff in care homes. We observed a community psychiatricnurse give a clear and detailed handover of information tocare home staff about a person they had assessed.

Local integrated care meetings took place, which involvedcommunity psychiatric nurses, GPs, district nurses andothers. Some integrated care meetings were workingparticularly effectively to ensure older people’s

comprehensive needs were being met through goodcommunication and partnership working. Multidisciplinarycare plans were produced with a focus on people most atrisk of admission to hospital. Services were being designedaround the individual rather than services.


Assessment and delivery of care and treatmentWe reviewed records and found that staff had carried outcomprehensive assessments of people admitted to theward which covered both health and social care needs.These assessments informed the content of individualisedcare plans. Where physical and mental health care needshad been identified, care plans were put in place to ensurethe person’s needs were met. We observed care beingdelivered to people in line with their care plans. People wespoke with described feeling optimistic about their futureand that the care and treatment they received gave themhope. One person commented, “Staff are working with meto get me home, I am holding on to that.”

Records demonstrated that appropriate risk assessmentshad been undertaken and were reviewed regularly. Wereviewed several risk assessments and found these werecomprehensive and updated to take account of anychanges in people’s presentation and associated risks tothemselves or others. Risk assessments were clearly set outand maintained a balance between the rights of people tomake choices whilst appreciating the need to minimise riskand keep people safe.

We found that the provider was providing evidence-basedassessment, care and treatment in line with recognisedguidance, standards of best practice and legislation.Overall we observed good compliance with both theMental Health Act 1983 and the Mental Capacity Act (MCA)2005. We saw evidence of the staff team working withinNICE (National Institute for Health and Care Excellence)guidelines. For example, ‘CG178 Psychosis andschizophrenia in adults: treatment and management’. Thisincluded practices whereby staff listened to people andtook account of wishes and preferences. We also saw staffwho were competent in assessing people from diverseethnic and cultural backgrounds. The multi-disciplinaryteam were aware of cultural and ethnic differences intreatment expectations and adherence to agreedtreatment options. We observed plans put in place toaddress identified cultural needs which included liaisingwith specialist community-based services.


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We observed people being supported to make choices andinformed decisions about their care and treatment.Mechanisms were in place to seek consent, and to recordand keep under review consent decisions. We reviewedcare records and found that capacity assessments werediscussed in multi-disciplinary team meetings and this wasclearly recorded in care files. Staff were aware of and hadundertaken training in the MCA and Deprivation of LibertySafeguards (DoLS). They were able to tell us thecircumstances in which they would seek assessment of aperson’s mental capacity. Staff were aware that mentalcapacity was issue and time specific and that irrespectiveof the outcome of the assessment, this would not precludeinvolvement by the person in decisions about their careand treatment.

Outcomes for people using servicesWe looked at how the delivery of care and treatmentachieved positive outcomes for people who used theservice. We saw that people’s progress and needs wereassessed daily and communicated effectively via staffhandovers. These handovers covered significant issues aswell as progress to agreed goals for each individual.Progress and outcomes were also discussed at wardrounds.

Bracken Ward was currently in the process of introducingPROMs (patient-reported outcome measures). This willinvolve collecting survey data from people who use theservice in order to measure and understand the quality ofthe services that were being delivered and whether peoplewere achieving positive outcomes. Staff were aware of theorganisational change which promoted the plannedintroduction of PROMs and were able to understand thedirect link between funding that the service receivedthrough their work to deliver high quality care and toachieve good outcomes.

We found evidence of patient feedback being collected andused to improve service provision. The ward were using afeedback form with 12 questions relating to patientexperience on the ward. The information collected wascommunicated to the trust centrally and the ward was thengiven feedback on necessary improvements.

Staff equipment and facilitiesStaff described feeling competent and confident to fulfiltheir role and meet the needs of people who used theservice. Staff told us they had undertaken training relevantto their role. This included additional role specific training

outside of the mandatory training program. Records wereviewed showed that most staff were up-to-date with theirmandatory training and the ward manager had oversight ofwho had completed what and when on an electronicmatrix. New staff and staff who had missed training due toabsence for example were clearly identified on this matrixand plans were in place for the necessary training to beundertaken.

New staff undertook a period of induction before beingincluded in the staffing numbers and were given aninduction pack covering trust systems, policies andprocedures. Staff described a process of ‘shadowing’whereby new staff shadow an experienced worker in orderto gain confidence and skills before providing any directcare and support.

All staff told us they had received an annual performanceappraisal and we saw records which confirmed this. Staffdescribed good support from their manager as well as peersupport from the team. Staff reported that if they had aparticular issue relating to their practice or were unsureabout something they would broach this with theirmanager, who would make themselves available. Staffdescribed a process of ad-hoc/informal supervision. Wefound limited evidence of regular planned clinicalsupervision or records which would support this. Wediscussed this with the manager and they confirmed thatthis had been given a lower priority in the context of thebusy period due to the recent move to a new location. Themanager assured us that plans were in place torecommence regular planned supervision.

There was a range of meaningful activities provided on theward and a time-table was on display in the communalarea. This included creative art groups as well as quizzesand bingo. Patients we spoke with described enjoying theactivities on offer and said that staff encouraged them toget involved.

We found that equipment was checked regularly andmonitored to check it was fit for purpose. Facilities on theward were good and there was ample space both insideand outside the building for people to partake in variousactivities. Numerous rooms were available and weobserved how these were utilised to support people tohave private time with their families. The ward had accessto an adapted kitchen and we were told how this was usedto help people rebuild their skills and confidence as part oftheir recovery focused discharge planning. We saw in


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electronic records how this important work was followedup in the community and evidence of occupationaltherapists from the ward having undertaken assessmentsof people at home. People spoke positively about the newbuilding and facilities. Comments included. “Nice to havemy own bathroom” and “The rooms are nice, there havebeen some problems with it being a new build but they getit sorted quickly.”

Multidisciplinary workingThe staff team on Bracken Ward was multidisciplinary andcomprised occupational therapists, nursing and medicalstaff. We found evidence of effective multidisciplinaryworking in people’s records and observed a healthyworking culture between the various professionals duringmeetings, ward reviews and staff handovers. Assessmentsgenerally involved the whole team, with each disciplinecontributing to each person’s individual care plan.Information on patients subject to the Care ProgrammeApproach was shared on the electronic system which allthe different professions could access.

Staff described working within a cohesive team which hadrespect for each other’s skills and respective background.We found positive links between the ward and communityservices and that communication between all the teamsinvolved in an individual’s care was good. We observed award review which was attended by a representative fromthe community mental health team (CMHT) as well as stafffrom Bracken Ward. We found that when people wereadmitted to the ward there was close liaison with thecommunity team. This continued throughout theadmission as well as when planning for discharge. Themultidisciplinary working and coordination withcommunity teams ensured a smooth transition betweenservices and minimised any unnecessary blocks to thepatient pathway. One person we spoke with commented,“They are sending me home next week and my CPN(community psychiatric nurse) will then take over.”

Mental Health Act (MHA) 1983On the day of our inspection to the ward, there were twopeople who were detained under the MHA. We found thatthese individuals had been lawfully detained and that theirdetention was founded on the required two medicalrecommendations as well as an application by theapproved mental health professional (AMHP). People toldus they had been informed of their legal rights when theywere admitted to the ward and we found this recorded incare records. Staff were aware of the need to explainpeople’s rights to them. There were leaflets availableproviding information to people who had been admittedinformally as well as those people who had been detainedunder the MHA. These leaflets were available in multiplelanguages in order to meet the diverse population the wardserves.

We looked at leave granted under section 17 of the MHA.We found that this was recorded in people’s electronicrecords. At our MHA monitoring visit in April 2014, we foundthat conditions were not being specified on leave forms.During this inspection the two leave forms we reviewedcontained conditions which were clearly recorded.However, we found that copies of leave forms were notroutinely provided to people who used the service which isnot in line with the MHA Code of Practice.

We found evidence of assessments of capacity to consentto care and treatment. These were clearly recorded inelectronic records.

We saw some good practice in regards to compliance withthe MHA. Staff were well aware as to the guiding principlesof the MHA Code of Practice such as ‘participation’ and‘least restriction’ principles. We observed creative careplanning which was person-centred, allowed for positiverisk-taking and minimised the restrictions imposed onpeople’s liberty.


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Summary of findingsStaff provided kind and compassionate care andsupport to older people and their carers. Theyresponded calmly and sensitively to people in distressand respected people’s dignity and privacy. Staffprovided person-centred care and there was clearevidence that carers were also involved. We found thatthe services were interested in the people they cared foras individuals, and that staff were committed toproviding good quality care.


Kindness, dignity and respectPeople`s privacy and dignity were respected. People whouse the service and carers told us staff treated them withrespect. We observed staff interacting with people in acaring and compassionate way. Staff responded to peoplein distress in a calm, gentle and respectful manner. Theyappeared interested and engaged in providing good qualitycare to people and anticipated people’s needs.

People using the service and carers told us they weretreated well and supported by staff. For example, onerelative told us “I have been fully supported by staff andinvolved in my relatives care.” Staff were described and“always helpful” and “amazing.”

As several people on Ward 24 were unable to speak with usdirectly about their experience of care we carried outseveral periods of observation in the lounge including oneperiod where we used the short observational frameworkfor inspection (SOFI 2) to help us understand people’sexperiences on the ward. During our observation we notedmany examples of kind, caring and sensitive interactionsbetween staff and people using the service. People wereencouraged to take fluids regularly and assisted to sitcomfortably in their chairs. Staff asked people how theywere feeling. Staff positioned themselves at the sameheight as people using the service and used touchappropriately to gain and maintain people’s attention.Those people who required help eating and drinking weregiven one to one assistance. Staff worked with people in aperson-centred way.

All interactions we observed were positive and showed realengagement with people. The ward atmosphere was calmand people appeared relaxed in the company of staff. Aperson who wished to walk around the ward was oftenaccompanied by staff and this appeared to reassure them.It was evident that staff had adopted the Chief NursingOfficer’s ‘6Cs of nursing’ and implemented them in theirpractice.

People were asked for their consent before observationswere carried out. For example, we saw a nurse ask a personfor their consent to taking a blood sample.

People using services involvementStaff told us that they involved people and their carers inpeople’s care as much as possible although there were noformal arrangements for this. Staff asked carers aboutpeople’s likes and dislikes so as to be able to provide careappropriately. These were recorded in ‘living well’ foldersalthough we found that the information in some people’sfolders was quite minimal. There was little recorded inpeople’s care records to suggest that they or their relativeshad been involved in developing the care plan.

Staff showed understanding of carers’ needs and offeredsupport as well as signposting them to local voluntarysector organisations for additional support. Carers wereinvited to care programme approach meetings and wardrounds to discuss people’s care and progress.

Emotional support for care and treatmentStaff provided good emotional support to people on theward at an individual level. We observed staff taking time toexplain and support people in a sensitive manner. Theyresponded to the needs of relatives and carers and tooktime to explain care and treatment and address anyconcerns.

Staff promoted self-care and people’s independence.People were supported to maintain social contact throughflexible visiting and the provision of regular social activitieson the ward.

A productive wards initiative had led to the development ofa carers information pack. Carers we spoke with confirmedthey had received a pack and found it useful.


Kindness, dignity and respectWe accompanied several community staff on visits topeople, with their permission, and met with people and

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

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carers at a day centre and memory assessment andtreatment service clinic. People we spoke with were verypositive about the older people’s service. For example, oneperson said, “I can’t fault the service,” and anotherdescribed it as a “first class service.” People told us theywere always treated with respect.

A person we visited in the community told us they werevery happy with the service they received from theircommunity psychiatric nurse. Another person saidcommunity staff were “uplifting” and “got me out of a hole.”This was typical of feedback we received from people usingthe service and carers.

When we observed staff interactions with people using theservice, we saw they were kind, compassionate andrespectful to people. They demonstrated a caring andunderstanding attitude. When people were discussedduring referral and allocation meetings this was donerespectfully and staff showed real empathy for the peoplethey spoke about and worked with. Staff demonstratedrespect for people’s cultural beliefs.

People using services involvementPeople were involved in their care. People’s choices wererespected and we saw examples of when care had beenrefused and this had been respected. When people hadasked for a change of consultant or allocated communitypsychiatric nurse the request had been accommodatedand a different nurse or consultant assigned. However, wefound little information in people’s care records about howthey were being involved in care planning.

Day services for older people were developing aprogramme of activities in conjunction with people whoused the day services, which included older people.

Emotional support for care and treatmentCommunity staff told us that they involved people andtheir carers in people’s care as much as possible. Theysupported carers directly and signposted them to otherorganisations for additional support. Managers and staffacknowledged that formal carer assessments did notalways take place and we observed this issue beingdiscussed in one community team meeting.

We observed considerable emotional support provided tocarers and people who use the service by staff. Staff werecommitted to working towards people’s recovery.

Staff in the memory assessment and treatment serviceclinic we visited were sensitive to people’s need forinformation on their diagnosis. People were asked beforethe assessment how much they wanted to know abouttheir memory problems and whether they would like adiagnosis. Written information about diagnoses was givento people and carers to take away.

People’s pets were included in their care plans when thesewere important to them. This reflected community teamstaff’s understanding of people’s individual needs.


Kindness, dignity and respectPeople who used the service told us that staff were kindand treated them with respect. We observed positiveinteractions between staff and patients on the ward. Whenresponding to people in distress, staff spoke softly andwere both patient and calm. Staff were skilled at using keyreference points individual to the patients that helpedpromote good communication and reduce levels of anxietyand distress. When responding to individuals in distress,staff respected privacy and dignity by encouraging peopleto walk with them to a quieter area of the ward. This wasalso the case when staff were planning and discussingaspects of their care with the individual concerned.

People told us that they had good relationships with thestaff. For example, one person told us “The staff areexcellent, second to none and nothing is too muchtrouble.” Other comments included; “The staff got me welland cared for me” and “They know me well, I have knownthe staff a long time, they understand me when I amunwell.”

Before people were provided with care and support theirconsent was sought. We noted that this consent wasrevisited throughout the care and support task. Thisdemonstrated to us that staff were aware that consent isongoing and can be withdrawn by the person at any time.

A number of people on Bracken Ward were unable to speakwith us directly about their experience of care andtreatment. To help us understand their individualexperiences we used the Short Observational Frameworkfor Inspection (SOFI 2). During our observation we notedthat staff were warm and engaging in their manner. Theydemonstrated genuine affection and used touchappropriately to enhance interactions. We saw evidence ofenabling practice whereby people were recognised and


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encouraged to be active participants in their care andsupport. Furthermore, we observed appropriate self-disclosure by staff to encourage people to engage in talkingabout their families and wider social networks. Staff had aclear understanding of the care and support needs of thepeople who used the service as well as knowledge aboutpeople’s circumstances in the community.

People using services involvementPeople were involved in their care. We saw examples ofstaff working in partnership with people to formulate theircare plan. People’s choices were respected. We observedtwo multidisciplinary reviews on Bracken Ward. On eachoccasion the person was fully involved in decisions abouttheir care and was actively encouraged to set out theirpersonal wishes and goals. Staff had effectivecommunication skills and conflicts of opinion werehandled sensitively. When formulating plans for leave fromthe ward, there were open and frank discussions about thevarious options and choices available, as well as theassociated risks and benefits of each option. One personwe spoke with told us “I get involved with decisions aboutmy care, they always ask my opinion.”

While we found good evidence of involving people indecisions about their care, this was not reflected in careplan documents. We reviewed the records of six peoplewho used the service and found that the ‘service user view’section of the care plan was blank in three of them. Thethree that had been completed were brief and containedlimited meaningful information in regards to the views ofthe person and how they wished to be supported.

People were supported to make informed decisions abouttheir care. Where appropriate, the staff had sought theviews of family and arranged interpreters for people whosefirst language was not English. We saw that staff supportedpeople to access advocacy services and the servicesavailable were clearly displayed in communal areas. Staffwere aware of and provided necessary support to peoplewho appeared to require advocacy service but struggled tomake appropriate arrangements for themselves.

Staff had a good understanding of the Mental Capacity Act(2005) and the fundamental principles of ‘assumedcapacity’ and making decisions in people’s ‘best interest’for individuals deemed to lack capacity to make certaindecisions. We saw documentary evidence of capacityassessments having been undertaken. Records of thesewere contained in individual care files.

Emotional support for care and treatmentStaff provided good emotional support to people onBracken Ward. We observed staff encouraging people to getactively involved in caring for themselves. There was agood balance between the promotion of self-care and staffproviding assistance where appropriate. This meant thatpeople were supported to be as independent as possibleand people’s skills and attributes were maintained duringtheir admission to the ward. When providing care orsupport staff did not rush people and took their time toexplain what was happening in the context of each person’sindividual care plan.

We found evidence of staff supporting people to keep incontact with their family and social networks. During areview on the ward we observed staff supporting anindividual who was struggling emotionally with theiradmission. The person was concerned about who wascaring for his family whilst they were away from home. Staffworked closely with this patient to keep in contact with hisfamily, provide reassurance and to develop a plan inpartnership to facilitate their discharge home. Staffunderstood the cultural context of these concerns in termsof the temporary loss of role in respect of this person’sposition in the family.

Visitors to the ward were encouraged and supported withvisiting times and we saw that meetings involving family forexample were arranged at times to accommodate people’sfamily and work commitments.


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Summary of findingsServices for older people were responsive to people’sneeds. There were clear care pathways in place, and theteams understood people’s needs and wishes and couldrespond to these. Services were also planned anddelivered in a way that met the different needs of thelocal communities. In addition, there was an extendedcommunity service, which operated seven days weekand ensured that services were responsive.


Planning and delivering servicesInformation from the trust showed there had been a meanbed occupancy rate of 74% on Ward 24 over the last sixmonths. As a result people who needed to be admitted toan inpatient bed could do so in a timely way. On the day ofour visit to Ward 24, we noted there were 12 peopleadmitted to the 19-bed ward. There was an average lengthof stay of six to eight weeks on the ward.

Male and female sleeping areas were separate on the wardand there were separate bath/shower and toilet facilities.

Right care at the right timeCare was delivered in the ward by a multidisciplinary team.Most admissions to the ward came via a consultantpsychiatrist or the older people’s community mental healthteams. The aim of the service was to discharge people oncethey had reached an optimal level of functioning.Occupational therapists carried out home assessments andwere able to ensure necessary arrangements were in placebefore people were discharged. Staff told us that dischargefrom the ward was sometimes delayed while a package ofcare for the person was agreed or when a person needed agreater level of support than they had been receivingbefore admission. Data we received from the trust showedthat there had been 23 delayed discharges in the last sixmonths.

Staff described the discharge process to us for a personwho had been on the ward for an extended period of time.

The discharge plan in place aimed to achieve a smoothtransition of care from the ward to a care home. Theperson’s specific individual needs had been consideredand planned for by the multidisciplinary team.

A target of seven-day follow-up post-discharge bycommunity staff was in place and mostly achieved.Discharge summaries were sent to people’s GPs by theward administrator to ensure they were kept informed ofthe person’s progress and on-going needs, includingmedicines prescribed. There had been no recordedreadmissions to the service within 90 days of discharge.

Ward staff reported that people’s care co-ordinators wereinvited to care programme approach (CPA) meetings andusually attended.

Care pathwayThere were clear care pathways in evidence. The clinicalmanager for the service reported that meetings had beenheld with commissioners and others to develop a smootherpathway and facilitate discharges for people with complexneeds, particularly where funding of care needed to beagreed.

Care was delivered in the inpatient service by amultidisciplinary team. In addition, there was input fromspecialist teams, such as physical healthcare teams, whenrequired.

People’s diversity and human rights were respected.Attempts were made to meet people’s individual needsincluding cultural, language and religious needs. Contactdetails for representatives from different faiths wereprovided and local faith representatives visited people onthe ward.

A choice of meals was available. A varied menu enabledpeople with particular dietary needs connected to theirreligion, and others with particular individual needs orpreferences, to access appropriate meals.

Staff told us that very few people from black and ethnicminority groups were admitted to the ward. Someconsideration of why this was the case had taken place.However, staff provided examples of how they had tried tomeet the particular needs of people admitted. There waswritten information available on the ward in several locallanguages and interpreters were accessible when needed.This included information on recognising dementia insouth Asian communities.

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

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Learning from concerns and complaintsThere was a system in place to learn from complaints. Wesaw information on how to make a complaint wasdisplayed in the ward. Information on the patient adviceand liaison service (PALS) and mental health advocacyservices for older people were also displayed. The carers’information pack also contained information on how tomake a complaint or raise concerns about care. Staffprovided examples of how changes had been implementedfollowing complaints including the development of aprotocol for admissions of people with functional healthproblems.

Staff told us they tried to address people’s and carers’concerns informally as they arose. Most carers we spokewith told us they felt they would be able to raise a concernshould they have one, and believed they would be listenedto by staff. Trust data on complaints showed that there hadbeen two formal complaints in relation to Ward 24 in thelast 12 months both of which had been upheld.


Planning and delivering servicesThe service provided support for older people withfunctional and organic conditions. A number of specialistservices had been developed to meet the needs of thesegroups. These included the memory assessment andtreatment service provided from a number of local clinics,the acute liaison teams and care home liaison teams.

The community teams provided care and treatment topeople via an extended service operating over seven days.This reduced the need for older people to access crisisservices and helped in preventing admission to hospital.The flexibility of the service allowed one person using theservice to receive their medicine by injection on a Sundayas they preferred.

Community staff told us that if an inpatient bed wasneeded for a person using the service this was nearlyalways available. They told us that access to inpatient bedscould be arranged for people in advance where there wereconcerns that they may not be able to maintain their safetyat home. People were well supported in the communitywhich reduced the need for inpatient beds. Staff describedseveral examples of good preventative work with peoplethat enabled them to remain at home and goodcontingency planning meant people rarely needed to usecrisis services.

The trust had recently introduced an administration hubwhich meant that all calls to the community teams wererouted via the hub, which then made contact with teammembers. Staff told us that this system was not workingparticularly well. People had complained about not beingable to get through on the telephone. Some referrals werereported to have been misdirected to other teams. Inaddition the hub was a Monday- to-Friday service. Atweekends, people could not access community mentalhealth teams via the administration hub. Staff in the acuteliaison team told us that referrals were generally faxedthrough to the team so the lack of administration hub atthe weekend did not affect referrals coming through to theteams. Teams operated a duty system which meant peopleusing the service and carers could contact teams directlyand did not have to always go through the administrationhub to contact staff.

Staff told us that the electronic records system wasunreliable and often froze or was slow to open, which led toconsiderable time being wasted. One staff memberdescribed the system as “slow and ineffective.” In ruralareas staff told us that connectivity was inconsistent andthis made communication via the telephone or intranetdifficult at times.

We noted that access to psychology services was patchyacross the community teams. Craven older people’scommunity mental health team had a psychologistembedded in the team which staff told us was very helpful.Other teams told us there was often a long wait for peopleto see a psychologist.

Right care at the right timeCare and treatment was delivered by multidisciplinaryteams. We observed a referrals meeting taking place andnoted that people were allocated to staff according to theirneeds.

Waiting times for services were monitored. None of theolder people’s community mental health teams reportedhaving a waiting list for services. The service was veryresponsive and able to provide timely assessments ofpeople’s needs. For example, the acute liaison team usuallyassessed people within 24 hours of receiving a referral.Acute liaison team staff were able to access people’s acutecare electronic records in order to monitor test results. Thishelped in the prioritisation of assessments as theinformation indicated the person’s level of medical fitness.


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There was a waiting list of several weeks for the memoryassessment and treatment service. A manager told us thiswas being addressed and the waiting time had beenreduced substantially from six months.

The community teams followed-up people promptly afterthey were discharged from the in-patient mental healthwards. They were good at meeting the target of follow-upwithin seven days and some teams told us they aimed tocomplete this within three days.

When we observed a community team allocations meetingwe noted that care was patient centred and responsive topeople’s individual needs.

Care pathwayClear care pathways were evident. The acute liaison teamworked closely with staff in acute hospitals andintermediate care and responded quickly to referrals forthe assessment of older people. We accompanied amember of the acute liaison team on a visit to an acutehospital ward to assess an older person’s mental healthneeds. The referral had just been received by the team andgiven a high priority.

Systems in place to ensure the effective transfer of peoplefrom acute adult teams were good. Discussions took placebetween services to ensure the person was placed with theteam that could best meet their needs. There was no strictage cut off for transition from one service to another.Decisions were based on the needs of the individual.

People’s diversity and human rights were respected. Staffhad undertaken training in equality and diversity althoughthis was in need of updating.

We found examples of culturally sensitive services beingprovided to older people using the service, such as a multi-cultural day at the therapeutic day centre. This wasprovided by multi-lingual staff. The memory assessmentand treatment service clinic we visited was provided in away that focused on the needs of the local community.Staff were deliberately recruited who spoke locallanguages. Assessment tools had also been adapted tomake them more effective with the population served. Thepsychologist at the clinic we spoke with was fluent in threelocal languages and conducted assessments in theperson’s preferred language where possible.

Community teams worked well with voluntary sectororganisations supporting local black and minority ethniccommunities. Voluntary organisations were seen as integralto people’s care.

Teams were diverse and many staff had additionallanguage skills which meant they could communicatedirectly with the diverse local population. Interpretingservices were accessible when needed.

Learning from concerns and complaintsThere was a system in place to learn from complaints. Wesaw information on how to make a complaint wasdisplayed in community team offices, day centre andmemory assessment and treatment service clinic.Information on the patient advice and liaison service (PALS)and independent mental health advocacy services for olderpeople was also available. However, people who were seenby community staff at home were not routinely providedwith information on how to make a complaint or contactthe patient advice and liaison service (PALS).

Staff told us they tried to address people’s and carers’concerns informally as they arose and provided examplesof changes made to people’s care as a result. Most peopleand carers we spoke with told us they felt they would beable to raise a concern should they have one, and believedthey would be listened to by staff. Trust data on complaintsshowed that there had been three formal complaints inrespect of the older people’s community mental healthteams in the last 12 months, one of which had beenupheld.


Planning and delivering servicesInformation from the trust showed for 2013/14, the numberof admissions was 74 and the number of discharges was 72.People who needed to be admitted to an inpatient bedcould do so in a timely way. On the day of our visit to theward we noted there were 10 people admitted to the22-bed ward. There was a year to date median length ofstay of 46.5 days from April 2013 to March 2014.

Male and female sleeping areas were separate on the wardwith all rooms having ensuite facilities.

The ward had a business continuity plan to manage theward in a number of emergency situations.


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We reviewed the medicine management policy andprocedure; we found this provided detailed guidance onhow to manage medicines, record administration ofmedication and manage controlled drugs.

People using the service on Bracken Ward did not havepersonal evacuation plans in place. This was discussedwith the manager who confirmed this is a recommendationfrom the trust’s fire officer and he will review the admissionprocess to include this within the care planningdocumentation.

Right care at the right timeWe reviewed the transfer and discharge policy andprocedure; this was comprehensive guidance on how todischarge or transfer a patient between mental healthservices or to the acute hospital at Bradford RoyalInfirmary. There was guidance on the minimumdocumentation which should be prepared and accompanythe patient during these stages of their care. This includedan emergency contact number should the family, patient orother professionals need further support. The dischargesummary in place aimed to achieve a smooth and timelytransfer of information to the patients GP; this wascompleted electronically on discharge from the ward.

Care pathwayCare was delivered in the inpatient service by amultidisciplinary team. In addition, there was input fromspecialist teams, such as physical healthcare teams andwhen required diabetic and dietetic services from theBradford Royal Infirmary were accessed.

People’s diversity and human rights were respected.Attempts were made to meet people’s individual needsincluding cultural, language and religious needs. We sawthat patient information leaflets on the Mental Health Actwere available in 26 different languages.

A choice of meals was available. A varied menu enabledpeople with particular dietary needs connected to theirreligion, and others with particular individual needs orpreferences, to access appropriate meals.

Listening and learning from complaintsWe reviewed the complaints policy and procedure andcould see evident that there was a system in place tomanage and learn from complaints. We saw informationleaflets on how to make a complaint was in the family roomfor access for visitors. Information on the patient adviceand liaison service (PALS) and mental health advocacyservices for older people were also displayed.

For the period April 2013 to March 2014 the ward had notreceived any formal complaints and there had been noserious incidents.


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Summary of findingsThe trust’s vision and direction was communicatedeffectively to staff. The governance structure in placealso supported the delivery of the service. Services forolder people were joined-up and well-led, andmanagers were visible and accessible to people whouse the service, carers and staff. The trust encourageddevelopment of the service and also involved peoplewho use the service and their carers.


Vision and strategyThe trust’s vision and strategies for the service were evidentand on display in the ward. Staff told us they understoodthe vision and direction of the trust and felt connected tosenior management and the trust board. Staff felt thatdementia care services were an increasingly high priorityfor the trust. Trust messages were cascaded via a regularnewsletter and in team meetings.

Responsible governanceThere was a clear governance structure in place thatsupported the safe delivery of the service. Lines ofcommunication from the board and senior managers tofrontline services were mostly effective, and staff wereaware of key messages, initiatives and the priorities of thetrust.

The ward manager had regular contact with the clinicalmanager and felt well supported. The clinical managerreceived a copy of all incidents reported on the ward andchecked that any resulting actions were followed through.They visited the ward daily and maintained oversight of thequality of care provided. The trust’s medical director hadvisited Ward 24 recently and assisted with the provision ofmeals to people using the service. Senior managers weresaid to be very responsive when approached.

Staff understood the management structure and where toseek additional support. For example, when we spoke withstaff about safeguarding processes, they all told us theywould seek advice from the ward manager or in theirabsence the safeguarding team for the trust if they neededto.

Data on performance was collected regularly. Informationon monthly performance was on display near the entranceto the ward where people who use the service, visitors andstaff could see it. Performance against these targets wasmonitored by senior managers to ensure any shortfallswere addressed.

Leadership and cultureWe found Ward 24 was well-led and there was evidence ofclear leadership at a local level. The ward manager wasvisible on the ward during the day-to-day provision of careand treatment to people, was accessible to staff andproactive in providing support to people. The culture onthe ward was open and encouraged staff to bring forwardideas for improvements in care. Staff told us they feltvalued and empowered to develop and improve theservice.

The service was proactive and anticipated and planned forchange.

Staff we spoke with were enthusiastic and engaged withward developments, including plans to move the ward toanother site in 2015. The ward manager had undertakenconsiderable research in respect of appropriateenvironments for people with dementia and hadcontributed to the design of the new facility. Estates andfacilities staff had been engaged in the process and hadaccompanied the ward manager on a visit to anotherservice for people with dementia which had a reputationfor excellence in design.

Staff told us they felt able to report incidents, raiseconcerns and make suggestions for improvements andwere confident they would be listened to by seniormanagers. Ward staff praised their manager. Performanceindicators were displayed near the ward entrance whichmeant information on ward performance was available topeople who use the service and visitors. This reflected theopen ward culture.

EngagementCare was person-centred. Ward staff encouraged theengagement and involvement of people on a day to daybasis.

A local carers’ action group was active in raising concernsabout the planned move of Ward 24 in 2015. The trust was

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.

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aware of concerns related to increased travel time andcosts for carers and visitors to the proposed new ward andhad agreed to finance increased transport costs for a fixedtime period in response to these concerns.

The service user and carer involvement group metregularly. Representatives from the group were involved ininterview panels for the recruitment of new staff and indesigning and reviewing written information prepared bythe trust to ensure it met people’s needs in terms of clarityand appropriateness.

Letters were sent to people recently discharged from theward and their carers requesting feedback about the careand treatment provided. The ward manager reported aresponse rate of 70% and said that most of the feedbackwas positive. Improvements had been made in response tofeedback received from people and carers. For example,improved signage had been introduced.

We spoke with staff at different levels on the ward. All staffreported feeling very supported by their manager. Staffwere kept up-to-date about developments in the trustthrough regular newsletters and emails. Staff on the wardhad the opportunity to meet weekly with the wardmanager to discuss the planned move of the service in2015 and were positive about this approach.

Performance improvementThe ward manager told us they had access to ongoingleadership training and development, which had been verybeneficial in terms of increasing skills and confidence.

Data on performance was collected monthly. Performancemeasures included completion of staff training andappraisal and clinical measures such as the number ofincidents and complaints reported. Performance againstthese targets was monitored by senior managers to ensureany shortfalls were addressed. Where performance did notmeet the expected standard, action plans were put in placeand implemented to improve performance.


Vision and strategyStaff told us they understood the vision and direction of thetrust and most felt connected to senior management andthe trust board. Trust messages were cascaded via a

regular newsletter and in team meetings. A consultantpsychiatrist told us they considered the trust board wasdriven by the “right values” and was easy to contact andspeak to.

Responsible governanceThere was a clear governance structure in place thatsupported the safe and effective delivery of the service.Lines of communication from the board and seniormanagers to the frontline services were mostly effective,and staff were aware of key messages, initiatives and thepriorities of the trust. Staff understood the managementstructure and where to seek additional support.

Leadership and cultureWe found the community mental health teams for olderpeople were well-led and there was evidence of clearleadership at a local level. Team managers were accessibleto staff. The culture of teams was open and staff wereencouraged to bring forward ideas for improvements incare. Most staff told us they felt valued and empowered todevelop and improve the service.

EngagementThere was a service user and care involvement group thatmet monthly. Representatives from the group wereinvolved in interview panels for the recruitment of new staffand in designing and reviewing written informationprepared by the trust to ensure it met people’s needs interms of clarity and appropriateness, such as the memoryassessment and treatment service leaflet. However, wefound limited evidence of attempts to gather feedbackfrom people using the service, about the service theyreceived, particularly people with cognitive impairment.

We spoke with staff at different levels in the communitymental health teams for older people. All staff reportedfeeling supported by their manager, with one managerbeing described as “inspiring”. Staff were kept up-to-dateabout developments in the trust through regularnewsletters and emails. The views of staff were collectedthrough supervision sessions and at team meetings. Moststaff told us they felt confident in being able to raiseconcerns. Teams had put in place action plans to addressstaff concerns identified through the annual staff survey.

At focus groups we organised, a number of community staffexpressed feeling disconnected from the senior


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management within the trust. Although they said they hadbeen consulted on changes taking place they felt that theirviews had not been listened to or taken on board by seniormanagement.

Performance improvementCommunity staff told us they had access to ongoingleadership training and development which had been verybeneficial in terms of increasing skills and confidence inmanaging teams and engaging with trust managers.

Data on performance was collected monthly. Performancemeasures included completion of staff training andappraisal and clinical measures such as the number ofincidents and complaints reported. Performance againstthese targets was monitored by senior managers to ensureany shortfalls were addressed. Where performance did notmeet the expected standard action plans were put in placeand implemented to improve performance.


Vision and strategyStaff were able to talk us through the vision and strategy forthe service and information about the future direction ofthe trust was on display on the ward. Staff reported thatthey felt very well engaged with their manager and thatthey had been supported well through the recent transitionto a new location. However, some staff said they had notbeen listened to as part of the consultation regarding themove. As a consequence a number of experienced staffwere finding it difficult to get to the new geographicallocation or had left their post due to struggling with newtravel arrangements. The staff we spoke with were of theopinion that the impact on staff in regards to travel was notfully appreciated in the planning or implementation.

Responsible governanceThere was limited performance data available which is notcurrently reviewed by the ward manager to identify risksand drive performance.

There was a clear governance structure in place thatsupported the safe delivery of the service. There wereappropriate lines of communication from the board andsenior managers to frontline services.

The ward manager attended a ward manager’s meeting,meeting notes for this were reviewed; we could see fromthe minutes that items discussed were around staffsickness, appraisals, training, safeguarding, recruitment,

transformation projects, complaints and care pathways.Information was disseminated from the ward managersmeeting to the ward staff by the manager in the form ofteam meetings.

The clinical manager received a copy of all incidentsreported on the ward and checked that any resultingactions were followed through. They visited the ward dailyand maintained oversight of the quality of care provided.

Staff understood the management structure and where toseek additional support. For example, when we spoke withstaff about safeguarding processes, they all told us theywould seek advice from the ward manager or in theirabsence the safeguarding team for the trust if they neededto.

We also reviewed the safeguarding policy and procedurewhich provided clear guidance on what the differing typesof abuse maybe, the signs to be aware of and how to reportany concerns or alerts. A flow chart was in place to supportthe understanding of the procedure.

Data on performance was collected via the RIO patientadministration system and used to contribute toward theMental Health Minimum Dataset. Information on monthlyperformance was not displayed near the entrance to theward where people who use the service, visitors and staffcould see it. We discussed this with the clinical servicemanager and the ward manager who agreed now the movehad been completed it was something they would address.

Leadership and cultureWe found Bracken ward was well-led and there wasevidence of clear leadership at a local level. The wardmanager was visible on the ward during the day-to-dayprovision of care and treatment to people, was accessibleto staff and proactive in providing support to people. Theculture on the ward was open and encouraged staff tobring forward ideas for improvements in care.

Staff we spoke with were enthusiastic and engaged withward developments, including plans to move the ward tothis site which had been completed approximately sevenweeks ago.

Estates and facilities staff had been engaged in the processand had undertaken a Health and Safety assessment on 1July 2014. This outlined areas of work still to be completedfollowing the move to the Airedale site.


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Staff told us they felt able to report incidents, raiseconcerns and make suggestions for improvements andwere confident they would be listened to by seniormanagers. Ward staff praised their manager.

EngagementThe PALS team also visited the ward every fortnight to askpatients for their input and feedback into the care andsupport they received while on the ward. Any items raisedto the PALS team are emailed to the ward manager foraction.

There was a facility called e-feedback on the ward; this wasan electronic feedback system where patients and theirfamilies can enter their answers to a series of questions.Based on data entered from November 2013 to April 2014 aselection of responses were, 100% answered the questionhow well did staff treat you with dignity and respect; 92%answered the question how well do you feel staff membershave explained your treatment to you; 83% answered thequestion how well did the different people caring for youwork together to give you the best possible care (forexample community staff, medical staff and nurses).

We spoke with staff at different levels on the ward. All staffreported feeling very supported by their manager. Staffwere kept up-to-date about developments in the trustthrough regular team meetings and emails.

At the engagement events we held and events facilitated byHealthWatch before the inspection, carers also reflectedthat they felt that they had not been listened to fully as partof the consultation regarding the move of Bracken ward.Some carers reported difficulty to get to the newgeographical location.

Performance improvementThe ward manager told us they had access to ongoingleadership training and development, which had been verybeneficial in terms of increasing skills and confidence.

The Electronic Staff Record (ESR) is a staff database whichallows the management of staff training and appraisals.The ward manager also held his own training matrix

(training record) for the staff on the ward; this showed themandatory training required, dates completed or dates duefor renewal. This assisted with the prompt booking oftraining as renewals became due. For the year endingMarch 2014, the ward achieved 95.4% for their mandatorytraining completeness.

The manager records in the ESR system the date that a staffmember’s appraisal has taken place; this is then held ontheir personal record as an audit trail for monitoringpurposes. On the day of the inspection we were unable toreview a completed appraisal form for a staff member.

Infection prevention and control was one of the mandatorytraining requirements. We reviewed the policy andprocedure in place and found it to be detailed guidance forstaff to be able to follow. The trust has 24-hour contactnumber for an infection control nurse should any memberof staff have an emergency situation they needed guidanceand advice. Recently the ward had a norovirus and allprocedures were followed in relation to the outbreak andmanagement of the virus to minimise the risks of spreadingfurther.

As part of the trust’s monitoring of infection control anannual cleanliness audit is completed this was lastundertaken in May 2014, where an overall score of 97.63%had been achieved.

Data on performance was collected monthly. Performancemeasures included completion of staff training andappraisal and clinical measures such as the number ofincidents and complaints reported. Performance againstthese targets was monitored by senior managers to ensureany shortfalls were addressed. For the period April 2013 toMarch 2014, the data showed that the ward had reported 3incidents; they had used an average of 11.3 whole timeequivalent per week of NHSP bookings (bank staff); 90% ofstaff had completed the information governance trainingand 100% had completed the fire training. Whereperformance did not meet the expected standard, actionplans were put in place and implemented to improveperformance.


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Documents

Services for older people