Combat Stress/Audley Court · • Combat Stress/Audley Court provided a safe and clean environment...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

CombCombatat StrStress/ess/AAudleudleyy CourtCourtQuality Report

Audley AvenueNewportShropshireTF10 7BPTel:01952 822 722Website:https://www.combatstress.org.uk/get-help/how-we-help/treatment-centres

Date of inspection visit: 9th July 2019Date of publication: 30/08/2019

1 Combat Stress/Audley Court Quality Report 30/08/2019

Overall summary

We rated Combat Stress/Audley Court, Specialistcommunity-based mental health services for adults ofworking age as good because:

• The provider had a high standard of managerial,medical and clinical leadership and made effective useof multi-disciplinary team working.

• Clinical governance at Combat Stress/Audley Courtwas well established and linked to local and nationalquality improvement initiatives, research and audit.

• Risk assessment and care planning were of a highstandard and helped clinicians and therapists providesafe care.

• The services provided were responsive to the needs ofpatients and based on the existing and emergingevidence for effective treatment.

• Combat Stress/Audley Court had been through asuccessful period of organisational change andredesign and developed a model of service thatpatients told them they found helpful and of highquality.

However;

• Patient feedback indicated that patients needed morehelp managing their physical health and accessingcommunity activities

• Some staff thought that the provider had noteffectively communicated the implications oforganisational change for themselves and the service.

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Community-basedmental healthservices for adultsof working age

Good –––

Summary of findings


Contents

PageSummary of this inspectionBackground to Combat Stress/Audley Court 6

Our inspection team 6

Why we carried out this inspection 6

How we carried out this inspection 7

What people who use the service say 7

The five questions we ask about services and what we found 8

Detailed findings from this inspectionMental Health Act responsibilities 12

Mental Capacity Act and Deprivation of Liberty Safeguards 12

Outstanding practice 21

Areas for improvement 21

Summary of findings


Combat Stress/Audley Court

Services we looked atSpecialist community-based mental health services for adults of working age

Good –––


Background to Combat Stress/Audley Court

Combat Stress is a national charity providing clinicaltreatment for veterans and reservists of the Royal Navy,Army, Royal Air Force, merchant navy and other alliedservices who suffer from mental health problems,including psychological trauma, attributable to orassociated with their service. It delivers therapeuticservices regionally in Scotland, Northern Ireland, CentralEngland and Wales and the South of England. The hub atAudley Court, and its satellite venues and home visitingservices serve Wales and the Central England catchmentarea.

Combat Stress/Audley Court is registered with the CQC toprovide the regulated activity of the treatment of disease,disorder or injury. It provides a range of specialisttreatment, for men and women, discharged from thearmed forces who experience mental health problemsassociated with their time in and/or transition frommilitary service. All patients accepted for treatment areassessed as low risk. Treatments and services includecommunity mental health nursing, trauma focussedcognitive behavioural therapy, psychotherapeuticeducation and mindfulness programmes, occupationaland art therapy, structured activities and peer support.Patients receive both individual and group-basedtreatments. Combat Stress/Audley Court’s specialist

community mental health services are distinct and timelimited. Where mental health services beyond the scopeof the service are required, patients are referred to NHSand independent sector mental health services.

At the time of inspection, a senior manager at CombatStress/Audley Court was in the process of applying tobecome registered manager.

Prior to 2011 Combat Stress/Audley Court provided aresidential respite service for patients. This consisted oftwo weeks of residential care, often several times a year.The service then moved to providing a mixture ofresidential and mental health welfare services beforefinally settling on its current community based model ofcare in 2017. These changes had provoked concerns frompatients who had previously found the respite model tobe of benefit. The provider had addressed those concernsthrough their complaints procedure but not to thesatisfaction of all their previous patients.

There have been a total of four inspections carried out atAudley Court and it was last inspected in 2015 when itreceived a rating of good. Residential respite is stillprovided at Christmas at other Combat Stress treatmentcentres and the provider works with the Royal BritishLegion to provide recovery breaks twice a year at RoyalBritish Legion Premises.

Our inspection team

The team that inspected the service comprised one CQCinspector and one Inspection manager.

Why we carried out this inspection

We inspected this service as part of our ongoingcomprehensive mental health inspection programme.

Summaryofthisinspection

Summary of this inspection


How we carried out this inspection

To fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider:

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

Before the inspection visit, we reviewed information thatwe held about the location and asked a range of otherorganisations for information.

During the inspection visit, the inspection team:

• visited the Audley Court premises

• spoke with the manager applying to become theregistered manager, before the inspection, and withthe interim director of operations and the newlyappointed director of operations at the time ofinspection.

• spoke with seven other staff members; including thelead doctor, nurse, occupational therapist, arttherapist, cognitive behavioural therapist and handyperson/gardener.

• received feedback about the service fromHealthwatch;

• collected feedback from eight patients using commentcards;

• spoke to two patients over the telephone• looked at eight care and treatment records of patients:• looked at a range of policies, procedures and other

documents relating to the running of the service

What people who use the service say

The provider conducted its own survey of patients fromMay 2018 to April 2019 and found patients to be satisfiedwith services overall. The inspection team also receivedcomment cards from patients and spoke with two otherpatients. All patients who provided CQC with feedbackwere in treatment at the time of the inspection.

Patients were complimentary about all staff at CombatStress/Audley Court and described them as professional,caring and pleasant. They said that the therapy and

education provided by clinicians had helped them copebetter with their trauma and supported the improvementof their relationships in civilian life both at home and atwork.

Patients described the services delivered by CombatStress/Audley Court as an asset to the community and asclinically excellent. The majority of those in treatmentsaid they had a better quality of life and that staff hadhelped give them hope for the future.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated Safe as good because:

• Combat Stress/Audley Court provided a safe and cleanenvironment for its community patients. All clinical areas wereclean and the building itself was very well maintained.

• Therapeutic services were provided to patients by a qualifiedstaff team, experienced in the issues faced by combat veteransand allied service personnel experienced in civilian life. Aconsultant psychiatrist led the team of psychologists,community mental health nurses, occupational therapists andcognitive behavioural therapists.

• Clinical managers supported staff to manage their caseloadsand ensured patient safety over a large geographical area. Allstaff participated in a mandatory training in safeguarding andbasic life support to ensure the care and safety of patients.

• Staff completed detailed risk assessments for patients andthese were up to date. Staff made safeguarding referrals andknew how to recognise forms of abuse their patients might beexperiencing.

• Serious incidents were investigated thoroughly, and staff weretransparent in their discussions with patients when somethingwent wrong.

Good –––

Are services effective?We rated Effective as good because:

• Staff made holistic assessments of patients that focussed onthe specific mental health problems patients faced whendealing with trauma. Patients’ were effectively triaged to ensurethey had the capacity to participate in the provider’stherapeutic program.

• Care records we reviewed on the organisations electronicpatient record system identified the needs of patients. Theserecords provided detailed information on the care beingplanned for patients and staff were working hard to improvethese further by using redesigned forms.

• All therapeutic interventions provided by staff at CombatStress/Audley Court was evidence based and complied withNational Institute for Health and Care Excellence guidance. Staffalso participated in a comprehensive audit program.

Good –––




• Combat Stress/Audley Court staff had the necessary skills to dotheir job and were regularly supervised, appraised andsupported in their continued professional development. Thisensured staff maintained and updated their skills to care forpatients safely.

• All staff worked well as a multidisciplinary team to ensure thedelivery of care was tailored to the individual needs of patients.

Are services caring?We rated caring as good because:

• Service user feedback from patient satisfaction surveysconfirmed the inspection team’s finding that staff were caringand compassionate towards their patients. Patients also fedback that they felt involved in their care

• The organisation made good use of local peer support andcarer organisations and supported staff in their dealings withother health and social care providers.

• The individual needs of patients were paramount in deliveringcare and staff were always mindful of the specific issues andchallenges facing patients.

• Care records demonstrated patient involvement in their careand encouragement to engage with wider civilian society.

• Patient satisfaction surveys confirmed that patients weresatisfied with the service they received. The provider wascommitted to building on this feedback to ensure thecontinuing improvement of services for veterans.

However;

• Patients said that they needed more support in managing theirphysical health and for taking part in community activities.

Good –––

Are services responsive?We rated Responsive as good because:

• After a period of consultation and redesign the service was clearabout its treatment program aims and offered clear criteria forthose patients wishing to access the service. Where patientsrequired interventions to help them prepare for treatment atCombat Stress/Audley court, staff liaised with other mentalhealth agencies to ensure patients received the help theyneeded.

Good –––




• The facilities provided at Combat Stress/Audley Courtpromoted recovery, comfort, dignity and confidentiality andincluded spacious and pleasant clinical and non-clinical areas.

• Staff focused on linking patients and their loved ones withsupport groups as an important part of the therapeuticprogram and ensured that patients had access to a range ofspecialist information.

• The provider managed complaints about its service efficientlyand made sure that lessons were learned after the complaintswere investigated fully by senior staff. Staff also receivedfeedback on the outcome of the investigation of complaintsthrough regular staff bulletins.

Are services well-led?We rated Well-led as good because:

• Leaders at Combat Stress/Audley Court had the skills,knowledge and experience to perform their roles andarticulated a good understanding of the challenges theirpatients faced and those of the organisation.

• Following extensive organisational change, services providedby Combat Stress/Audley court were delivered with a clearvision and a strong emphasis on all staff working to a commonset of shared values. Managers had also implemented effectivecontingency plans through a period of disruption over thewinter of 2018/9 and staff reflected positively on the wayprotests against the service were managed.

• Senior leaders consulted staff and patients regularly and staffsaid they felt supported in their work. They also told us they feltconfident to raise concerns with senior colleagues if they felt itwas necessary and without fear of retribution.

• The provider was fully engaged in quality improvement andinvolved staff wherever possible with service developmentsthrough regular local clinical governance meetings andcommunications.

• A risk register was held centrally, and risks identified by staffwere included on this. Managers had access to information tosupport them with their management role. The organisationhad a full range of policies and procedures which all stafffollowed.

Good –––




• Leadership encouraged and facilitated feedback from staff andpatients and instigated improvements after analysing thisfeedback. Combat Stress/Audley Court was also committed toresearch into the problems of veterans coping in civilian life.

However;

• Staff said that organisational change had not always beencommunicated effectively.




Mental Health Act responsibilities

We do not rate responsibilities under the Mental HealthAct 1983. We use our findings as a determiner in reachingan overall judgement about the Provider.

Combat Stress did not have responsibility for the MentalHealth Act 1983

Mental Capacity Act and Deprivation of Liberty Safeguards

The provider required all staff to complete MentalCapacity Act training as part of mandatory trainingrequirements.

Staff we spoke with demonstrated an understanding ofthe Mental Capacity Act and its five statutory principles.

Staff could apply this knowledge specifically to thepatients they worked with. Staff knew where to get advicefrom within the provider regarding the Mental CapacityAct.

Combat Stress/Audley Court was a community servicewith no facility for making use of DoLS

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Are community-based mental healthservices for adults of working age safe?

Good –––

Safe and clean environment

• Staff did regular assessments of the care environmentand this included a ligature risk assessment completedin June 2019. A ligature anchor point in a careenvironment is any type of object or room furniture thatcould be used for tying or binding a noose forattempting to commit suicide. All ligatures at CombatStress/Audley Court were deemed low or medium riskas most were in unused parts of the building,inaccessible to patients or in clinical areas wherepatients were never left unattended.

• Combat Stress/Audley Court had an alarm system in allpatient therapy rooms. The alarm sounded at receptionand all staff were trained to attend if staff used thealarm.

• The service kept an Automated External Defibrillatorand first aid kit with ligature cutters in reception andthese were checked weekly by staff. Combat Stress/Audley Court did not carry out physical health checks. Itwas therefore not required to check equipmentnecessary to carrying out physical examinations.

• The provider did not have clinic rooms as it did notundertake physical examinations of patients.

• All clinical and office areas were clean, had goodfurnishings and were well-maintained. Estates staff keptthe building and the surrounding gardens exceptionallywell maintained and safe.

• There were adequate handwashing facilities, withhandwashing instructions displayed above the sinksand staff followed infection control practices.

• Equipment kept in the reception area was wellmaintained, cleaned and clean stickers were visible andin date.

Safe staffing

• The substantive clinical staff team at Combat Stress/Audley Court comprised of a lead consultantpsychiatrist, a psychology team of five which included alead, senior, two clinical and one assistant psychologistand a team of four cognitive behavioural therapists. Inaddition, the provider employed three communitymental health nurses, led by a senior nurse and a leadhub nurse who supported a team of seven occupationaltherapists and one occupational therapy assistantpractitioner, a substance misuse nurse and an arttherapist. Most staff were whole time equivalents (WTE).However, two cognitive behavioural therapists and thesenior psychologist were part time. The provider alsoemployed support staff which included a medicalsecretary, administrators, property and maintenance,and quality and governance staff.

• Combat Stress/Audley Court had WTE vacancies for anoccupational therapist, two community psychiatricnurses and a clinical psychologist. The provider did notemploy bank or agency temporary staff.

• The providers staff sickness rate was 2.8% and there hadbeen a 11% staff turnover in the last 12 months.

Community-basedmentalhealthservicesforadultsofworkingage

Community-based mental healthservices for adults of working age

Good –––


• Clinical managers assessed caseloads of individual staffregularly and supported staff to manage theircaseloads. This included making cover arrangements forsickness, leave, vacant post. This ensured patient safety.However, staff told us that the large geographical areacovered by community nurses sometimes madecovering for staff vacancies difficult.

• If Combat Stress/Audley Court patients required rapidaccess to any mental health care, the appropriate crisisand home treatment team were called.

• The provider had a wide-ranging mandatory trainingprogram for staff which included safeguarding, first aidand basic life support training. The provider told us that80.3% of its eligible staff had undertaken this training.

Assessing and managing risk to patients and staff

• The provider completed risk assessments at initialassessment and then at least annually unless therewere changes to the patient’s clinical presentation. Theinspection team reviewed eight risk assessments andfound that all these records were up to date andupdated after any identified incidents or changes to risk.The risk assessments were completed on a specificallydesigned form within an electronic patient recordsystem. All risk assessments were completedcomprehensively and contained detailed information onthe risks themselves and on the measures that would betaken to mitigate against and prevent these risks. Allpatients assessed and receiving treatment at AudleyCourt were considered as presenting a low risk andrecords showed that staff responded promptly todeteriorations in a patient’s mental health andincreased risks.

Safeguarding

• Staff we spoke to knew when and how to make asafeguarding referral and understood and compliedwith the providers safeguarding policies. Staff also knewhow to recognise different forms of abuse.

Staff access to essential information

• Staff used one electronic patient record system for alltheir patients which was undergoing some formatimprovements at the time of inspection. All the clinicalinformation needed to deliver patient care was availableto all staff, of all disciplines, whenever they needed it.

Medicines management

• Combat Stress/Audley Court did not administermedication to patients.

Track record on safety

• There were 13 incidents recorded by the provider in thetwelve months preceding the inspection. Theseincidents included domestic homicide, self-harm, deathfrom long term illness and suicide. Staff were aware ofhow to report incidents and reported them to their linemanger manager for review. All deaths of patients werecategorised according to the provider’s incidentmanagement policy. All staff followed the unexpecteddeath guidance which stated that all requests forinformation from the police or coroners be escalated tosenior management for review and appropriate action.

Reporting incidents and learning from when things gowrong

• Staff told us that serious incidents were investigatedwithin 72 hours and consideration given to any servicedelivery concerns or failures. Staff understood their dutyof candour and were open and transparent in theirdiscussions with patients when something went wrong.Serious incident reports were reviewed quarterly and insome cases a root cause analysis of incidents would beinstigated. Lessons learned from these investigationsand analysis would be shared through team meetingsand periodical bulletins to all staff. Recent lessonslearned from incidents included the recirculation ofpolicy and training to staff on the need to provide atimely and effective response to the police and coronerswhen they requested information on patient deaths. Inaddition, a transfer of treatment information plan wasdeveloped to keep patient’s GPs informed of treatmentepisodes. The consultant psychiatrist was also leadingon the development of a new clinical risk managementpolicy and training for staff. Staff told us they were fullysupported at meetings and in supervision with clinicalmanagers when incidents occurred.

Are community-based mental healthservices for adults of working ageeffective?(for example, treatment is effective)



Good –––


Good –––

Assessment of needs and planning of care

• Patient referrals came from a contracted privatehelpline, from the Combat Stress Contact Us email andfrom professionals within the NHS and independentsocial care and health providers who were directed tothe telephone triage nurse. The telephone triage servicewas not part of Combat Stress but the staff therereceived some supervision from the qualified nurses inCombat Stress.

• Referrals meeting the criteria for treatment at CombatStress/Audley Court were then forwarded to themulti-disciplinary team for further consideration at atriage outcome meeting. Patients accepted fortreatment were then provided with a comprehensivemental health assessment. Combat Stress/Audley Courtwere aware that their patient group were often notregistered with a GP and exposed to the combined riskof psychiatric problems and frequent ill-health. Inresponse the provider told us that they supportedpatients to register and consult with a GP. Staff alsoassessed patient’s physical well-being by taking theirmedical history, gathered information on medication,appetite, substance use and sleep hygiene. Patientswere given a validated and standardised questionnairefor measuring the status of their general health and thishelped inform liaison with GPs and other specialisthealth care providers

• We reviewed eight care plans and in all cases theseplans were detailed and included the needs of patientsidentified at assessment. Care planning had been thesubject of an internal review and a new morepersonalised format had been recently introduced. Allpatients had received a copy of their care plan andwhilst the older care plans were detailed andinformative the inspection team did not find them to beholistic, and recovery orientated. However, where staffhad completed the newly developed care plan on theelectronic patient record, we found that these careplans demonstrated greater detail on patients’ recoverycapital and progress through the various treatmentinterventions.

Best practice in treatment and care

• Clinical staff at Combat Stress/Audley Court provided athree stage treatment program which included a rangeof care and treatment interventions focussed on issuesexperienced by veterans of the armed services. Theseincluded trauma therapy for operational stress, injury,shame and guilt. Staff also provided education andtreatment on anxiety and anger management, livingskills, relapse prevention, guidance on sustainingrecovery, and occupational and art therapy.

• Staff liaised closely with patients GPs and updated themon patients emerging health problems and providedadvice on healthy lifestyle.

• The medical director and the heads of psychologicaltherapies ensured that all therapeutic interventionsprovided to patients met with National Institute forHealth and Care Excellence post-traumatic stresstreatment guideline NG116. Combat Stress/AudleyCourt also participated in the Royal College ofPsychiatrists Accreditation Programme for PsychologicalTherapies Services. Staff participated in clinical audit,benchmarking and quality improvement initiatives aspart of Combat Stress/Audley Court’s annual clinicalaudit schedule. This schedule included record keeping,discharge process, key working, infection control,incidents and safeguarding. Staff also received aquarterly quality and learning bulletin which promotedthe quality improvements that their audits hadsupported.

Skilled staff to deliver care

• All interventions provided at Combat Stress/AudleyCourt were carried out by skilled and qualified staff.These staff included a doctor, psychologists, nurses,occupational therapists and cognitive behaviourtherapy trained staff. Further specialist training for staffwas available for staff when required.

• The provider did not meet its clinical supervisioncompletion target of 91% for the period November 2018to April 2019. However, figures showed an improvementof 77% to 90% over the same period and staff we spokewith at the time of inspection said they had access toregular clinical supervision. The provider had anaverage appraisal completion rate of 95%. Managersalso ensured that staff had regular meetings to reflecton their clinical practice and continued professionaldevelopment.



Good –––


• Managers told us that if poor staff performance occurredit was addressed promptly and effectively, and concernsescalated to human resources or occupational health.

Multi-disciplinary and inter-agency team work

• The provider held regular multidisciplinary teammeetings and staff used these to discuss clinical care.There was good communication between staffmembers of all disciplines and an emphasis on highquality liaison with external health and social careproviders including social care, primary care, substancemisuse services, community mental health and localauthority safeguarding teams.

Adherence to the MHA and the MHA Code of Practice

• Combat Stress/Audley Court did not routinely use theMental Health Act (MHA) and it was not applicable to theservices they provided except when liaising with mentalhealth services when there was a deterioration inpatients mental health.

Good practice in applying the MCA

• The provider required all staff to complete MentalCapacity Act awareness training as part of mandatorytraining requirements. The staff completion rate for thistraining was 68.6%. Staff we spoke with demonstratedan understanding of the Mental Capacity Act and its fiveprinciples and demonstrated that they could apply thisknowledge specifically to the armed forces veteranpatient group. Staff also knew who to consult regardingthe Mental Capacity Act and recorded their observationsof a service user’s capacity on the providers electronicpatient record.

Are community-based mental healthservices for adults of working age caring?

Good –––

Kindness, privacy, dignity, respect, compassion andsupport

• Staff discussed interactions with their patients withwarmth and compassion. They demonstrated respectfor the individuals they provided therapeuticinterventions to, and spoke passionately about theirwork and the teams they worked in.

• Staff supported patients to understand, manage andbecome involved in their care through regularconsultation and discussion.

• Staff described how they worked with patients toidentify and access other services to support care andtreatment provided in the community. Staff alsoprovided examples of referrals they regularly made topeer support and carers organisations for veterans.However, some patients said they needed more help intaking part in community activities.

• Staff understood the individual needs of patients anddemonstrated this by providing information in wayspatients could understand and working with patients toidentify and access social support. This was donethrough art projects and a wide range of informationleaflets.

• Staff discussed confidentiality and information sharingwith patients and staff said they could raise concernsabout disrespectful, discriminatory or abusivebehaviour or attitudes towards patients without fear ofthe consequences.

Involvement in care

Involvement of patients

• We saw evidence in care records of the involvement ofpatients in their care. The provider had also recentlydeveloped a new online survey for patients to measuremental health outcomes, engagement in wider societyand physical health outcomes.

• Patients had fed back that they felt that they couldmanage their mental health better; had a betterunderstanding of their problems and were more able torecognise their risks and triggers to relapse. Somepatients also said they needed more support inmanaging their physical health.

• The provider conducted a survey from May 2018 to April2019. One hundred and fifty responses were receivedand 99% of patients thought that sessions were at theright level; 96% thought the sessions were useful or veryuseful. 94% intend to use the knowledge gained in thefuture and 91% found Combat Stress handouts useful.



Good –––


• The provider told us that they were aware ofindependent advocacy services and would referpatients to them in complex cases. However, there wereno leaflets advertising independent advocacy.

Involvement of families and carers

• Where patients gave permission, staff informed andinvolved families and carers appropriately. For example;staff worked closely with family members or carers tohelp them understand veteran specific mental healthissues.

• The provider referred to a local voluntary carerorganisation who specialised in providing support tofamilies or carers of combat veterans and allied services.

• The provider gave opportunities for families and carersof patients to give feedback on the service they receivedthrough their website portal.

Are community-based mental healthservices for adults of working ageresponsive to people’s needs?(for example, to feedback?)

Good –––

Access and discharge

• For the period 1st May 2018 to 30th April 2019 patientswaited 32 days from referral to initial assessment and 47days from initial assessment to onset of treatment.However, the provider told us that after introducing anew triage system, figures from 1 May to 9 July 2019,showed patients waited 29 days from referral to initialassessment and 31 days from initial assessment toonset of treatment. The provider did not have set atarget for time from referral to triage/assessment andfrom assessment to treatment.

• The service had clear criteria for which patients wouldbe offered its specialist services. The service did notexclude patients who needed this treatment unless theywere assessed as high risk. In which case they would bereferred to an appropriate service provider for treatmentuntil stable enough to access the services of CombatStress/Audley Court.

The facilities promote recovery, comfort, dignity andconfidentiality

• The Audley Court premises had a range of rooms tosupport therapeutic treatment and care. This included aspacious and pleasant waiting area, therapy andinterview rooms. All interview rooms had adequatesoundproofing. We saw that information leaflets wereavailable in all waiting areas. These includedinformation about veterans’ support groups,therapeutic art projects, activity groups and, help-linenumbers.

Patients’ engagement with the wider community

• Staff supported patients to maintain contact withveteran peer support groups and with their families andcarers. This included sharing information, with a serviceuser’s agreement, and directing family members andcarers to a dedicated support organisation. Patientswere encouraged to develop and maintain relationshipswith people that mattered to them, both within theservices and the wider community. Staff deliveredinterventions at the Audley Court building, in theirhomes and at other satellite venues.

Meeting the needs of all people who use the service

• The provider made adjustments for disabled peopleand all clinical services on the ground floor of AudleyCourt were easily accessible. The provider did not haveleaflets in different languages as members of UK ArmedForces have to have basic English written literacy. Inaddition, they did not routinely use translation orinterpreter services as members of UK Armed Forces arealso required to have English verbal literacy. However,Audley Court/Combat Stress did occasionally useinterpreters to support patients who did not haveEnglish as their first language to help them understandmore complicated therapeutic concepts.

• The provider displayed leaflets from ShropshireHealthwatch and liaised with them at the local MilitaryCovenant meetings. Covenant meetings encouragedlocal communities to support the armed forces,remember the sacrifices veterans made and toencourage and support veteran’s integration intocommunity life and activities.

Listening to and learning from concerns andcomplaints



Good –––


• During the period May 2018 to April 2019 the providerreported a total of forty-four complaints. Twenty-eight ofthese complaints, 63.6%, were connected to a protestoutside of the Audley Court premises and from otherex-patients who were challenging the termination ofresidential services at Audley court and in some casesthe way they had been discharged. These complaintsrelated to patient concerns outside of this CQCinspection and some complaints referred to events thatoccurred up to, and over seven years ago. As acomparison in the period April 2017- March 2018, fifteenformal complaints were received. Of the recentcomplaints, 6 were upheld by the organisation.

• We saw the provider displayed information to advisepatients on how to complain or raise a concern.Additionally, the provider made this informationavailable on its website.

• Staff knew how to handle complaints from patientsappropriately and, where possible, tried to resolve themlocally. The provider had a clear procedure to manageformal complaints. This included standards foracknowledging and investigating a concern andprocedure to guide staff’s practice in investigation. Thisguidance included a complaints template. Staff receivedfeedback on the outcome of the investigation ofcomplaints through their quality and learning bulletinand local governance team meetings.

• The provider told us they had learned lessons fromveteran’s complaints regarding the discharge of patientsand had reviewed its discharge policy and processconsidering these.

.

Are community-based mental healthservices for adults of working agewell-led?

Good –––

Leadership

• Leaders at Combat Stress/Audley Court had the skills,knowledge and experience to perform their roles andhad a detailed understanding of the issues combat

veterans faced in civilian life. Until the day of inspection,the provider had an interim director of operations.However, the provider now has a permanent director inpost.

• Senior clinical managers we spoke to had a consistentand fluent understanding of the services they managedand were able to describe clearly how their staff workedto provide high quality care. This included listening to,and acting on feedback from patients and staff, and onlearning from organisation’s extensive audit andgovernance program.

• Staff knew who the providers senior leaders were andknew them by name. There had been extensiveorganisational change in recent years and some staff wespoke to commented that this change had not alwaysbeen communicated effectively. However, leaders,including directors had delivered training workshops,provided video updates to all staff after directors’meetings, increased Chief Executive Officer emailupdates and attendance of directors at remote sites.The recently launched intranet was improvingcommunications with staff.

Vision and strategy

• The provider had a clearly expressed vision for formerservicemen and women, with mental health problems,to live full and meaningful lives. The organisationalvalues of respect for individual talents and diversity,being united in purpose and focusing on the bestoutcomes for patients were formulated in meetings withstaff, and through discussion with the employeerepresentative group. Senior leadership had successfullycommunicated the organisations values to the frontlinestaff in the service and promoted them on their web site.Senior leaders we spoke with understood theimportance of actively applying these values in the workof their therapeutic and educational clinical teams.

• Staff said they had the opportunity to contribute tovison and values discussions and we were told about aseries of workshops to inform and embed theorganisation’s values and behaviours into their work.The workshops were led by directors and delivered to70% of staff during twelve workshops. Further



Good –––


workshops were planned to ensure full staff attendanceand some staff had attended follow up sessions todiscuss progress in their personal goals, related to theorganisational values.

Culture

• Staff we spoke with felt respected, supported andvalued. In October 2018 a charity-wide staff survey wascarried out which found that over 70% of staff wouldrecommend Combat Stress as an employer and over80% of staff either agreed or partially agreed they wereproud to work at Combat Stress. The same surveyconfirmed that staff were aware of how to report unsafepractices and staff told us they felt confident to whistleblow their concerns without fear of retribution. Theorganisation had identified improved communications,better pay and clarity on the strategic direction of thecharity as being the top three staff concerns.

• Managers dealt with poor staff performance whenneeded and the registered manager reported nobullying or harassment cases. Staff told us this had beenproblem in the past. However senior managers andleaders had acted to make sure this stopped.

• The provider monitored sickness and absence rates andwe found low sickness and high staff retention rates.

Governance

• Combat Stress’s operations in England and Wales wereregistered with the Charity Commission, the body thatregulates charities. The provider met its responsibilitiesas a registered charity and comprised a Board ofTrustees who met Fit and Proper Persons requirementchecks. The corporate structure also includedcommittees for Finance, Audit and Risk Management,Clinical Governance, Income Generation andRemuneration & Nomination.

• The provider had robust governance systems in placeand a quality assurance framework which includedactions to establish a single point of contact for patientsand the commissioning of further research into theefficacy of its treatment programme. In addition, therewere plans to implement a real time performancedashboard to manage performance and improve theexperience of patients using services.

• Combat Stress’s quality and clinical governancemanager had ensured, along with the Audley Court

clinical governance committee, that there were systemsand procedures in place to ensure that the premiseswere safe and clean; that there were enough staff whowere trained and supervised and that patients wereassessed and treated well. This process was overseen bythe national clinical governance committee, chaired bythe medical director. Incidents were reported andinvestigated, and the organisation’s clear governanceframework ensured lesson were learned from these. Anemployee forum also ensured staff views on quality andsafety were heard.

• The safeguarding lead for Combat Stress/Audley Courtwas the medical director who worked with staff locallyto ensure that patients and their families/communitieswere safeguarded. Safeguarding referrals were treatedas incidents and reported through the clinicalgovernance structure.

• The provider had an established cycle of quality auditsthat required staff participation. The provider made theoutcomes of audits available to staff through useful andwell-presented quarterly bulletins.

• Staff understood arrangements for working with otherpartner agencies to meet the needs of the patients.Senior staff worked to improve access pathways withexternal organisations. This included providers ofphysical health, mental health and substance misuseservices.

Management of risk, issues and performance

• Staff maintained and had access to the risk register at adirectorate level and could escalate concerns whenrequired from a team level. Staff told us the highestorganisational risks were staffing and vacancies, theprovision of care within available resources andfinancial sustainability. The inspection team found thatthat staff concerns matched those on the risk register.Where cost improvements were taking place, we did notfind these compromised patient care. The risk registerhad also included the day to day management of therisks posed by veteran’s protests.

Information management

• The provider had systems to collect data that were notover-burdensome for frontline staff. The provider



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collected data which included information on incidentand safeguarding reports and on how many patientshad used their services. The provider also employedadministration staff to collect and input data.

• Staff had access to the equipment and informationtechnology needed to do their work and spokepositively about the ongoing improvements to the riskassessment and care planning templates on theproviders electronic patient record system.

• Managers had access to information to support themwith their management role. This included access topolicies and procedures, and key performanceindicators. The provider presented this information in anaccessible format and it was timely, accurate andidentified areas for improvement.

Engagement

• Staff, patients and carers had access to up-to-dateinformation about the work of the provider and theservices they used. The provider used social media anda web site to promote its services and inform patients ofdevelopments in its services.

• Users and carers had opportunities to give feedback onthe service they received in a manner that reflected theirindividual needs. Well displayed posters advisedpatients on how to give feedback and a website alsoprovided a portal to submit various types of comments.In addition, all patients were given a 'Listening,Responding, Improving' leaflet. These were also locatedthroughout Audley Court.

• Managers and staff had access to the feedback frompatients, carers and staff and used it to makeimprovements to the community services it offered.These improvements included a review of its dischargepolicy and the enhancement of its liaison with externalstatutory and independent providers agencies. Thelatter helped in the preparation of patients to receiveCombat Stress/Audley Court therapeutic services.

• The provider used veteran surveys to support theirinvolvement in decision-making about changes to theservice. Patients and staff could meet with members ofthe provider’s senior leadership team to give feedback.Senior staff also engaged with external stakeholderssuch as The Royal British Legion to provide enhancedservices at Christmas.

Learning, continuous improvement and innovation

• Following feedback from staff that they did not alwaysfeel their voice was heard, leaders supported staff toconsider opportunities for improvements through theemployee forum. This provided opportunity for all staffto voice their opinions. Leaders also assisted theemployee forum in publicising their successes, and thisresulted in renewed interest, both in requests to theforum, and employees wanting to be members.

• Combat Stress conducted research and was committedto publishing in external peer-reviewed academicjournals as part of its commitment to the advancementof patients’ mental health. Staff had opportunities toparticipate in this research and there was a strongemphasis and focus on the needs of the families andfriends of patients.

• Innovations were taking place in the service. Thisincluded tele-therapy to help meet the demand andchallenges of a higher prevalence of mental healthdifficulties in military patients compared to the generalpopulation. The development was in response to recentresearch that suggested that only 30- 50% of veteransaccessed services for support. Staff and leaders wereinvestigating more accessible, flexible and cost-effectivemethods of delivering psychological therapies topatients using remote technology.



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Areas for improvement

Action the provider SHOULD take to improve

• The provider should ensure that they continue todevelop ways of supporting patients to manage theirphysical health.

• The provider should ensure that they continue todevelop ways of supporting patients to taking part incommunity activities.

• The provider should continue to focus on effectivelycommunicating the implications of organisationalchange to staff.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Combat Stress/Audley Court · • Combat Stress/Audley Court provided a safe and clean environment...

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