All inspections: North East London NHS Foundation Trust

We inspected North East London Foundation Trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall.

We carried out short notice announced inspections of acute wards for adults of working age and psychiatric intensive care units and mental health crisis services and health-based places of safety. We also carried out a short notice announced focused inspection of specialist community mental health services for children and young people in Kent.

We chose these three core services to see if there had been improvements since our last inspection in June 2019.

The trust provides the following mental health services, which we did not inspect this time:

Child and adolescent mental health wards
Forensic inpatient/secure wards (low secure)
Wards for older people with mental health problems
Wards for people with a learning disability or autism
Community-based mental health services for adults of working age
Community-based mental health services for older adults
Community-based mental health services for people with a learning disability or autism

The trust also provides the following community health services, which we did not inspect at this time:

Community end of life care
Community health services for adults
Community health services for children, young people and families
Community inpatient services
Urgent Care

Our overall rating of the trust improved. We rated the trust as good overall because:

Our rating of well led improved; we rated the trust as good. Our rating of effective, caring and responsive stayed the same; we rated the trust as good. Our rating for safe also stayed the same; we rated the trust as requires improvement.

Our ratings for the acute wards for adults of working age and psychiatric intensive care units and mental health crisis services and health-based places of safety core services core services improved, we rated both as good overall. We did not re-rate specialist community mental health services for children and young people following our focused inspection in Kent. In rating the trust, we took into account the current ratings of the mental health and community health services which were not inspected this time.

The core service inspections and well-led review took place at a challenging time for the trust. In terms of the leadership there was an interim chair and chief executive in place. The trust was managing the recovery from the pandemic and learning to live with COVID-19.

Despite these challenges we found the trust had made significant progress since the last inspection:

The culture of the organisation was much improved. Throughout our inspection we heard from staff who spoke positively about the changes which had taken place and the move away from a culture of blame. The previous interim chief executive was described as a ‘breath of fresh air’ who led this cultural shift. The current leadership including the interim chair and chief executive had continued to embed this approach. The trust was working to promote a ‘just and compassionate culture’. There was a recognition that there was still much more to do but the progress was evident.
Staff felt more confident to ‘speak up’. The speaking up arrangements were working well. Themes were being appropriately reported through to the board so improvements could be made. Whilst many of the services delivered by the trust were under extreme pressure, staff from different professions felt able to escalate concerns about patient safety.
The senior executive leadership team was working together in a cohesive manner. There had been some significant changes in the team including a new executive chief nursing officer, new executive director of people and culture and promoted executive director of finance). The executive team were benefitting from ongoing external facilitation to support team building. All the members of the senior leadership team described healthy and productive working arrangements. This had also led to improved working with the non-executive directors and the effective operation of the board.
The representation of allied health professionals in the senior leadership team had improved. The executive chief nursing officer was also the executive director for allied health professionals and psychological professionals. We heard from a range of professionals throughout the inspection who felt this arrangement was working well.
The governance arrangements had been strengthened since the last inspection. The people & culture and finance & investment sub committees of the board had been developed. There had been a review of all the trust committees with the aim of ensuring these were operating effectively. There was a recognition that there was still more to do and that the number of internally facing committees could be further slimmed down to avoid duplication and reduce the amount of time operational staff spent in meetings.
Staff working for the trust put people who used services at the forefront and were committed to providing the best service possible. There was tremendous enthusiasm, commitment and pride in the work of the trust.
The trust had really ‘stepped up’ during the pandemic delivering services to meet the needs of local communities including vaccination services, step-down beds to support acute hospital discharges, the development of the Nightingale Hospital site and long-covid clinics. The trust had also worked effectively to ensure the appropriate guidance, equipment and new ways of working were implemented in order to keep patients and staff as safe as possible. The ongoing digital transformation and use of mobile equipment had supported ongoing flexible working arrangements which were well received by staff.
The trust had delivered high levels of engagement and was learning from what went well in order to deliver ongoing effective communication. Throughout the inspection we heard about the visibility and accessibility of senior leaders and the board.
The trust has continued its commitment to promoting equality, diversity and inclusion. The board was more diverse. The networks had strengthened and actively contributed to decisions about the strategic direction of the trust. The leadership programme for Black, Asian and minority ethnic staff was supporting good career progression.
The trust was fully embracing its work with external partners in systems and place. The trust was located across five integrated care systems. It also worked closely with provider collaboratives. The non-executive directors were aligned to geographical areas. The trust had appointed to new roles to increase capacity for this work including an executive director of partnerships. Operational staff working in the directorates were participating in a range of meetings, taking leadership roles where appropriate. This work was challenging as systems were at different stages in their development and so they were having to identify where their contribution would deliver the most.
We saw increasing use of data in accessible formats to inform day to day care and management decisions. Staff displayed a range of ability in using this data and the trust knew that for some further support was needed to develop their confidence.
We also found significant improvements in the mental health acute and crisis core service inspections. Many more patients in a mental health crisis received the right care at the right time. The trust had designed and implemented an innovative, bespoke integrated crisis assessment hub which was available to a wide range of people, including self-referrals or those signposted by emergency services. Premises were specially designed and staffed by a dedicated staff team. People in crisis could access timely support at the hub to assess their needs. Work had taken place to improve the standards of care and treatment on the acute inpatient mental health wards.

There were some areas where there was more work to do, but the trust was fully sighted on this and had plans in place. These areas included:

Clinical leadership at a directorate level needed to embed further. The trust had established a triumvirate leadership structure with operations, nursing and medical input for each directorate. Other allied health professionals were also being aligned to this leadership team. The medical staff had two sessions (one day) available each week but a number said they were having difficulties covering their clinical work so they could focus on their leadership responsibilities. Other consultants said that whilst they were kept informed of changes, they were not always actively involved in decision making even where this directly impacted their area of work.
Co-production work was developing with an involvement register linking up people with lived experience to paid and voluntary opportunities to support the work of the trust. The introduction of an advisor with lived experience to the board meetings was working well. In addition, people with lived experience or carers were participating in a number of key committees across the trust. There were also people with lived experience regularly participating as members of recruitment panels. The trust recognised that the COVID-19 pandemic had delayed the rollout of people participation committees in each geographical area. These groups were scheduled for implementation later in 2022.
Quality improvement had slowed down during the pandemic with members of the team redeployed to frontline services. Large numbers of staff had been trained and a new QI lead was coming into post in September 2022. During our core service inspections, staff across the trust only occasionally referred to quality improvement and so further work was needed to embed this approach.
Recruitment was an ongoing challenge, but a range of initiatives were in place including oversees recruitment, working with universities to attract professional graduates and extending apprentices. However, there were still pockets where recruitment was a particular challenge. One of these areas was medical staff recruitment for CAMHS in Kent. The trust recognised the need to improve medical staff recruitment but there was more to do.

How we carried out the inspection

During our inspection of the three core services, the inspection teams:

reviewed records held by the CQC relating to each service
visited seven wards at Sunflowers Court. We looked at the quality of the ward environment, management of the clinic rooms, and observed how staff were caring for patients
spoke with seven ward managers and three matrons covering the wards we visited
spoke with two assistant directors in the acute and rehabilitation directorate and one director for Kent community CAMHS
visited four team hubs, in the Dartford, Canterbury, Maidstone and Medway localities; we looked at the quality of the environment for patients and staff, and management of the clinic rooms
spoke with seven community CAMHS team managers
visited three home treatment teams, the integrated crisis assessment hub and health-based place of safety and observed the environment and how staff were caring for patients
spoke with the home treatment teams, the integrated crisis assessment hub and health-based place of safety managers
spoke with 81 patients and carers
reviewed 37 comment cards young people and carers
spoke with 84 staff members, including, doctors, nurses, healthcare assistants, occupational therapists, psychologists, pharmacists, a physical health consultant, a ward administrator and a home treatment team liaison worker
completed a review of medication management on four wards, three community CAMHS teams and the home treatment team clinic room
observed a range of meetings and activities including safety huddles, ward round reviews, multidisciplinary handover meetings, occupational therapy groups, team meetings, handovers, an anxiety and depression session and community meetings
reviewed 130 patient care and treatment records
looked at a range of policies, procedures and other documents relating to the running of each service.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

In the services we inspected, feedback from patients and carers was overwhelmingly positive. On the acute and PICU wards, patients told us that staff were empathetic, went out of their way, and kept on trying. In community CAMHS services we heard that staff were quick to respond in a crisis and that young people responded positively to the interventions delivered. Patients told us that home treatment teams involved them in their care and supported them through periods of crisis.

There were however some areas for improvement identified by people who used the service. On the acute and PICU wards, some patients would like to be able to access one-to-ones with their named nurse more regularly. In community CAMHS, young people and their carers felt they waited too long to access some services. In the home treatment teams, patients would like to see the same staff during their time with the team.

This was a short notice announced focused inspection of community child and adolescent mental health services (CAMHS) in Kent. We carried out this inspection to see if improvements had been made since we last inspected the service in 2019.

During this inspection we looked at all five domains. We did not rate the service at this inspection as we only inspected services in Kent, we did not inspect community CAMHS services the trust provides in four north east London boroughs. We found that:

The service was not always easy to access. Some young people who did not require urgent care waited too long to start treatment. There were long waiting times for assessment on the neurodevelopmental and learning disability needs pathway. Not all young people, parents and carers were updated on when they would be assessed or when treatment would start.
The trust had moved to a new platform to collate and monitor a range of safety and performance data. Further work was needed to ensure that all staff knew how to access and use these systems, and that data was accurate.
Whilst the work of the single point of access had been strengthened, changes needed further embedding to ensure that all referrals were triaged and signposted in a timely fashion.
Staffing remained a challenge, consultant psychiatrist posts were particularly difficult to fill and most were covered by locum staff. Some teams, for example the crisis team, had 50% vacancies, although regular temporary staff were in place.
In some teams not all staff had completed mandatory training.
Staff demonstrated a good understanding of individual patient risk and the plans in place to manage these, however, these were not always consistently recorded in patient care and treatment records.

However:

Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, was not too high to prevent staff from giving each patient the time they needed.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

How we carried out the inspection

we visited four team hubs, in the Dartford, Canterbury, Maidstone and Medway localities; we looked at the quality of the environment for patients and staff, and management of the clinic rooms
spoke with 31 young people, parents and carers who were using the service
reviewed 37 comment cards from young people, parents, carers and patients who were using the service
spoke with a range of staff from Dartford, Canterbury, Maidstone and Thanet child and adolescent mental health services community teams, the single point of access service, the crisis response and enhanced support team, and the neurodevelopmental and learning disability team. This included one director, seven team managers and 13 other staff members comprising of mental health nurses and practitioners, psychotherapists, cognitive behaviour therapists, clinical psychologists and consultant psychiatrists
observed a clinical multidisciplinary team business meeting, a team handover and safety huddle, and an anxiety group session
reviewed 68 care and treatment records of patients
looked at a range of policies, procedures and other documents relating to the running of the service, and the team management for the Dartford, Canterbury, Maidstone and Thanet teams.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with six young people and 25 parents and carers. They were positive about the staff and service they received once treatment started. They spoke highly of the staff saying they were caring and compassionate, focused on individual needs and the interventions offered had a positive impact. They also said that the service and individual staff were quick to respond in times for crisis. Some parents and carers said the wait for assessment and treatment was too long. However, once treatment started, the service that was provided made a difference to the children and young people, and their families.

The majority of the 37 comment cards from young people, parents and carers were positive. These stated that children, young people, parents and carers felt well respected and listened to. They reported staff were supportive and individual and family sessions were very helpful.

This was an unannounced focused inspection of child and adolescent mental health wards at Kent and Medway Adolescent Hospital. During this inspection we inspected across the five domains, Safe, Effective, Caring, Responsive and Well Led.

The service transferred to North East London NHS Foundation Trust from another provider in April 2020. In November 2020 the trust was made aware of concerns by staff working at the service through the trust Freedom to Speak Up Guardian. The CQC also received information of concern about the service at that time. The trust investigated these concerns and took action to improve the service.

As this was a focused inspection, we did not rate each domain and the service overall. However, we found a breach of regulation in relation to staffing. As a result this limited the rating for the effective domain. This meant that the overall rating for effective for this core service went from good to requires improvement. We found that the trust had made significant progress in making improvements to the service. For example, the incident reporting culture and the way in which reported incidents were managed had significantly improved, meaning that staff were now able to learn lessons from incidents to prevent them re-occurring.

Leadership and the culture within the service had started to improve. Staff were better skilled at managing patients with eating disorders around mealtimes. Staff had also implemented a more robust search procedure to prevent banned, harmful items from being brought onto the ward.

We received positive feedback about the way staff supported patients and developed therapeutic relationships with them. Patients also reported that they were happy with the activities on offer and staff made efforts to ensure the educational offer was appropriate for each patient. Staff worked closely with education providers to ensure patients could receive education at the service that was tailored to their individual ability.

The CAMHS treatment pathway was under significant pressure as there was an exceptional demand for beds. Despite this, staff were responsive to patients’ needs and kept in touch with colleagues in other teams and organisations to help facilitate smooth and timely discharges.

Leaders were proactively considering how to reduce the level of restriction on patients, for example, by making suggestions about how the environment could be made safer, and by reviewing blanket restrictions such as mobile phone use.

Staff were adapting to an improved 'enhanced care pathway' model which involved MDT ward staff continuing to work with some patients who had recently been discharged.

However, we also identified some areas where the trust needed to consolidate and make further improvements.

Staff supervision and appraisal compliance rates were low. This meant that staff were not guaranteed to receive the support they needed to carry out the duties they were employed to perform. This was because these activities had been suspended due to competing priorities during the Covid-19 pandemic but had recently been re-introduced.

The process by which staff discussed the learning from recent incidents was still being embedded, as were debrief sessions.

Although progress was being made in recruiting to vacant posts there were still many nursing vacancies that needed to be filled.

Patients and relatives were not able to attend weekly multidisciplinary ward round meetings, and instead submitted their contributions for staff to discuss on their behalf.

Some relatives also reported that communication with staff was sometimes challenging, and there was not yet a formal mechanism for gathering feedback about the service from families and relatives.

Staff gave mixed feedback about the culture and how supportive leaders were. They described a very challenging year where they had not always felt well supported. Particular challenges involved the transfer of the service between providers, a consultation process about the future model of the service that had left staff feeling uncertain, and uncertainty and anxiety caused by the onset of the Covid-19 pandemic. Some staff did report that they felt better supported and able to speak up following the recent leadership changes.

Following this focussed inspection of Mental Health Crisis Services and Health Based Places of Safety, we established that the trust now met the requirements outlined in the warning notice issued under Section 29A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which had been served in July 2019.

We had previously inspected this core service during a comprehensive inspection in June 2019. During that inspection we rated safe, responsive and well led as inadequate. Our overall rating for this core service went down and was rated as inadequate. We issued the trust with a warning notice under Section 29A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to concerns identified with the safety and quality of acute crisis assessment team service. We required the trust to meet the requirements of the warning notice by 9 October 2019.

We undertook this focused inspection to check whether the provider had met the requirements. We did not rate the service as a result of this inspection. We found that improvements had been made to the acute crisis assessment team and that the trust now met the requirements outlined in the warning notice.

The trust had acted to promote the safety of patients and staff. Patients were no longer left unsupervised at Sunflowers Court whilst they waited to be assessed, were being assessed, or waited to be admitted to the hospital. The trust had introduced robust arrangements to ensure patients were supervised at all times whilst waiting and appropriate waiting and assessment areas were now available.
Improvements had been made to the way the acute crisis assessment team accessed staff with the necessary range of professional skills and experience, including doctors, when undertaking assessments of patients. This meant staff working in the acute crisis assessment team could now access appropriate multi-disciplinary staff for all assessments.

Leaders had taken appropriate action to respond to the concerns that staff had raised in relation to ‘walk in’ patients who presented at Sunflowers Court requiring an assessment by the acute crisis assessment team. Leaders had also started to monitor how effective the acute crisis assessment team was.

However:

The trust recognised that the acute care pathway remained under pressure and was carrying out a review of this with the aim of making improvements. This work, along with strengthened governance systems related specifically to the acute crisis assessment function, requires continued robust oversight to ensure that the current improvement is maintained, and future challenges are responded to quickly and safely.

Our rating of the trust went down. We rated it as requires improvement because:

We rated safe and well led as requires improvement. We rated effective, caring and responsive as good. In rating the trust we took account of the ratings of the seven services inspected previously.

The inspection of North East London NHS Foundation Trust was one of great contrast. On the one hand we inspected some outstanding services that were going the extra mile to meet the needs of every patient. On the other hand, we saw services where the care was unsafe. The services for adults who needed acute inpatient mental health treatment were under extreme pressure and this was impacting on the safety and quality of patient care. The trust recognised that they needed to open another acute adult inpatient mental health ward but could not recruit enough nursing staff to enable this to happen.

The inspection found some unsafe practice for patients coming at night to Sunflowers Court, the main mental health inpatient base on the Goodmayes Hospital site. They were waiting for variable lengths of time, either for an assessment or admission by the acute crisis assessment team (ACAT) without clinical staff available to provide support and in an unsafe environment. The arrangements for the acute crisis assessment team to work with other professionals and teams in the trust was adversely affecting the responsiveness of the service to meet the needs of patients. Junior doctors and consultants told us of many occasions when they had encountered difficulties working with ACAT; whose role was to be the out of hours ‘gate-keeper’ for acute admissions. They described complex and lengthy escalation processes. They had examples of where delays resulted in potential harm to patients. They also described the impact of this process on their morale, often feeling a lack of respect or professionally under-mined. We took enforcement action to ensure improvements take place in a timely fashion.

Staff engagement was mixed, and some staff described an unhealthy culture. Whilst the trust had achieved positive staff survey results and most staff we spoke to were very enthusiastic about working for the trust, there were still some pockets of unhappy staff who did not feel adequately engaged. The most significant examples were the junior doctors and some consultants working in the mental health services. They described how they had tried to escalate concerns but had not received a timely or adequate response. They explained how their professional views were not adequately respected and how when things went wrong there was a culture of blame rather than learning.
The senior executive leadership team was not working together in a cohesive manner. This was having an impact on the safe delivery of services. For example, whilst an action plan was in place in response to the junior doctor concerns it required collaborative work across the leadership team to make the improvements. Whilst some work had taken place, other significant concerns relating to the admission process to the acute mental health inpatient beds and the broader culture of the inpatient services had not been resolved. Some members of the leadership team recognised the difficulties in working together and expressed a sense of frustration that this was hampering their ability to do their jobs well.
The trust continued to have significant workforce challenges and did not have enough medical or other professional staff in some services to provide consistently safe and high-quality care. Whilst the trust was aware of these short-falls and was working to address them, this had not yet resulted in the necessary improvements. In Kent CAMHS the number of staff available, including bank and agency, was below the agreed establishment levels. Half of the medical posts in Kent were vacant. This was having an adverse impact on the trust’s ability to deliver the service. In acute and PICU services, further work was needed to reduce the use of locum consultant psychiatrists and have more permanent staff in post to improve clinical leadership and the provision of high-quality care and treatment. Early intervention team caseloads were above the numbers recommended by best practice guidance. This could prevent them from giving individual patients the time they needed. In some community mental health teams for adults, there was a high turnover and staff reported feeling ‘burnt out’.
The current governance processes may not provide adequate assurance for the board on workforce and finance. At present, safer staffing data was discussed at each board meeting and a six-monthly workforce report was presented to the Quality Safety Committee and then key points reported to the board. The trust was addressing many complex workforce issues, and this might not provide adequate opportunity for assurance to be gained. Whilst the trust had a positive track record of delivering its financial performance, there were some areas of potential risk identified in financial governance. The trust had a ‘finance matters’ meeting with the non-executive directors which was not a formal sub-committee of the board. There was a potential risk that financial performance might not receive adequate board oversight and that emerging risks and issues may not get escalated appropriately.

However:

The trust had made progress with most of the areas identified at the last inspection. This included extensive consultation and the launch of the trust strategy which was now embedded into the ongoing work of the organisation. It was also good to note the progress with visits to services by non-executive directors including arrangements for sharing feedback; increasing the inclusion of governors to provide them with more opportunities to undertake their role; improving how the trust considers risk and strengthening the board assurance framework; and strengthening the arrangements for patient and carer engagement.

The trust continued to progress its work on equalities, diversity and human rights championed by the current chief executive. This included the ongoing development of staff networks and work to improve the trust’s performance in relation to the Workforce Race Equality Standard.

The trust’s use of technology to support mobile working was impressive, along with the increasing innovative use of digital technology to meet the needs of patients and staff.

It was positive to see the extended reach of the trust’s programme of quality improvement and the impact this was having on staff engagement in improving services.

We were also really interested in the work of the trust in promoting partnership working to achieve greater integration to meet the needs of populations especially across North-East London. On a smaller scale we also heard about how specific services were working innovatively in partnership with other health and third sector providers to meet patient needs.

Our rating of this service went down. We rated it as requires improvement because:

In some teams the number of staff in post, including the use of bank and agency, did not match the providers staffing plan. The vacancy rate in the core service (27%) was significantly higher than the trust average (17%). The vacancy rate for medical staff in Kent was 50%. There was a risk that Kent services may be disrupted by the lack of consistent medical input and leadership. In Kent, some clinicians had high caseloads which could prevent them from giving individual patients the time they needed.
Governance processes needed strengthening to ensure that performance and risk were managed well. Systems to ensure consistency from learning from incidents or to share good practice across the geography were not embedded. Systems were not always in place to ensure equipment was clean and safe to use. Systems were not in place to enable management oversight of supervision within teams or services although this was being implemented. Some performance data was not accurate. In Kent there were operational variations between teams in how young people on waiting lists were monitored with no effective assurance process in place to ensure each was safe and effective.
There were significant waiting lists for both initial assessment and treatment in Kent. The trust had introduced systems to detect and respond to increases in risk whilst young people waited. However, we saw examples in Kent where these systems had not been effective in identifying changes in risk or ensuring an appropriate response. Across Kent, there were 4143 young people at the end of May who had been waiting over 16 weeks for treatment following referral. Of these, 3372 were waiting for treatment through the neurodevelopmental and learning disability pathway and 771 were waiting for treatment through the other pathways available. We were told by family members that they were not consistently given information about the length of time they would be waiting for services to start.
Equipment used to monitor physical health or to treat young people in an emergency was not always calibrated or checked. Less than 75% of staff had completed mandatory immediate life support training.
Improvements were needed in how staff assessed and managed risk in Waltham Forest. Thirty percent of the care and treatment records we looked at in this team did not include an assessment of risk or management plan. In other teams across the geography there were inconsistencies in where risk information was included in patients records.
The operation of the Kent single point of access was on the directorate risk register. Not all referrals in Kent were screened in a timely fashion and prioritised for follow up by the correct team.
Whilst incidents were appropriately investigated, learning from these was not consistently shared across the whole geography. Where learning from incidents was to be shared in a specific learning forum, these were not always convened in a timely fashion.
Some patients and carers in Kent were not clear what treatment and support they should be receiving from the team.

However:

Clinical premises where patients were seen were safe and clean. Staff followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood the principles underpinning mental capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
Staff assessed and treated patients in crisis promptly.
The criteria for referral to the service did not exclude children and young people who would have benefitted from care.

Our rating of this service stayed the same. We rated it as good because:

Feedback from patients and those who are close to them was continually positive. Staff went the extra mile and their care and support exceeded expectations. Patients and those close to them were active partners in their care and staff were fully committed to this partnership approach. Patients’ individual preferences and needs were always reflected in how care was delivered. Between April 2018 to March 2019, the ward received 58 compliments, which accounted for 1% of all compliments received by the trust as a whole.
There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promotes people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring, respectful and supportive. These relationships were highly valued by staff and promoted by leaders.
Staff encouraged patients to have a voice and be actively involved in decisions about their care. The consultant psychiatrist encouraged patients to take a central role in their ward round, listened to their views and took these into account when reviewing changes in care and treatment. Patients could submit a written document completed with the help of staff or a relative prior to the ward round outlining what they wanted to discuss.
Patients were able to give feedback about the ward at community meetings. For example, patients discussed issues such as the ward being too hot, limited mealtime options and activities to do in the summer. Staff were proactive in providing possible solutions such as speaking to maintenance department about the heating, the catering company about the food and suggesting activities for the summer to include gardening and a summer sports day. Minutes were available to patients in easy read format.
There were high levels of satisfaction across all staff. There was strong collaboration and team-working and a common focus on improving the quality and sustainability of care and people’s experiences. Some staff had lived experience that added real value. Quality improvement methodology was embedded on the ward. Staff were empowered to lead and deliver change. Quality improvement projects involved patients and carers.
Governance arrangements were robust, and incidents and risks were reported, analysed and shared. Leaders had high quality management information, which showed trends and risks in the service. They were able to use this information to manage risks and improve the service. We were given examples of learning from incidents that had led to changes to improve the service.
The service provided safe care. The ward environment was safe and clean. The ward had enough nurses and doctors. Managers ensured that staffing levels were adjusted to reflect the fluctuating needs of patients and the risk levels present at that time. Any potential impact of staffing vacancies was mitigated by the use of bank and agency staff familiar with the ward and its patients. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment; they also engaged carers in the planning and reviewing process. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and autism and engaged in clinical audits to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Managers ensured that these staff received training, supervision and appraisal. The ward manager had actively recruited learning disability nurses. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. The ward proactively referred all patients to speech and language therapists from community teams.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

However:

Two patients and two carers felt that there did not have much choice at mealtimes and food was unappetising when it was served.

Our rating of this service stayed the same. We rated it as requires improvement because:

In the previous calendar year rapid tranquilisation was used on 322 occasions. Staff did not always complete post-dose physical health monitoring after patients had received medication by rapid tranquilisation. This meant there was a risk of not identifying a deterioration in a patient’s physical health. The same concern was identified at the previous inspection and whilst the trust had implemented systems to try and address this matter, they were not yet embedded.
Cultural challenges were described by the junior doctors where they felt bullied at times by the nursing staff. They also described the difficulties in speaking out when they were concerned about unsafe practice. Whilst the trust had an action plan in place this was not yet adequately addressing their concerns.
Further work was needed to reduce the use of locum consultant psychiatrists and have more permanent staff in post to improve clinical leadership and the provision of high-quality care and treatment.
Governance processes to monitor the use of restrictive interventions were not adequate. Staff did not have timely access to data on the use of restrictive interventions such as the use of restraint, prone restraint and rapid tranquilisation. This reduced their ability to monitor their progress in reducing the use of restrictive interventions

However:

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Although the quality of clinical audits varied between the wards staff were engaged in these audits and evaluating the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
Although the service was operating under significant bed pressures at the time of the inspection, staff were doing all they could to manage beds well so that a bed was available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this. Out of area placements were sought for patients as a last resort.
Since our last inspection in August 2017, the service had improved to minimise the likelihood that patients would need to be moved without clinical justification or return from leave with no bed to return to.
The service was well-led and the governance processes had improved since the last inspection in August 2017 to help ensure ward procedures ran smoothly.

Our rating of this service stayed the same. We rated it as good because:

Patients’ individual needs and preferences were central to the delivery of tailored services. Patients led their own ward review meetings. The services were flexible, provided informed choice and ensured continuity of care.
Feedback from patients and those who are close to them was continually positive. Staff went the extra mile and their care and support exceeded expectations. Patients and those close to them were active partners in their care and staff were fully committed to this partnership approach. The service had listened to patient feedback regarding food. Innovative plans to develop a kitchen in the ward, so that food could be prepared on-site were planned and a capital bid made.
There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring, respectful and supportive. These relationships were highly valued by staff and promoted by leaders. The ward had an elected patient representative who attended staff team meetings. Improvements had been made to the service as a result of feedback. Patients and carers were confident in raising concerns and no complaints had been received. Two percent of all the compliments received by the trust related to Morris Ward.
The ward continued to maintain excellent links with the community and engaged patients in a range of activities seven days a week. Since the last inspection the ward had developed one of its gardens to provide an innovative programme where patients looked after a range of small livestock, including chickens and rabbits. This therapeutic activity supported patient’s recovery.
The service provided safe care. The ward had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward team included the full range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

Whilst a need for call alarms in patient bedrooms had been identified, no dates for these works had been set. Staff did not describe how they were managing this risk until the alarms were installed.
The ward manager had identified that staff would benefit from further training to ensure that incidents where patients were administered rapid tranquilisation were accurately identified and reported. Further work was needed to ensure that physical health checks post rapid tranquilisation was consistently recorded, including when a patient declined these.

Our rating of this service stayed the same. We rated it as good because:

The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
Staff understood the principles underpinning capacity, competence and consent and managed and recorded decisions relating to these well.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions. Feedback from people who use the service, their families and carers was continually positive about the way staff treated them.
The service was easy to access and staff and managers managed waiting lists and caseloads well.
The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly.
The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly. The requirement notice made at a previous inspection in relation to monitoring waiting times from referral to treatment had been met.

However:

A small number of patients (12) had waited more than 18 weeks to start their treatment at the time of our inspection.
Across the three teams, there were vacancies for speech and language and occupational therapists. Challenges in recruiting to the posts permanently and in the interim, meant there was a risk that individual teams may not always include, or have access to speech and language therapists or occupational therapists.

Governance systems required strengthening to ensure they were consistent and that a high quality and safe service was delivered from all locations. We identified isolated pockets of poor practice relating to caseload numbers, lone working practice, medicines transportation, recording of allergy information, identification of patients prescribed high dose anti-psychotics, provision and monitoring of clinical supervision; efficacy of audits and recording of risk information across the geography.
Some teams did not have effective systems and processes to safely prescribe, administer and record medicines. Staff in the Redbridge community recovery team did not have a process to identify and regularly review the effects of high dose anti-psychotic medications on each patient’s physical health. At Waltham Forest community recovery team, the room used to store medicines experienced high temperatures which could impact the efficacy of medicines stored there. In the same team, staff had not been equipped with lockable bags to transport medicines. Allergy information was not always recorded on patient’s medicines charts.
Staff in Waltham Forest community recovery team did not follow trust protocols for lone working which could put them at risk.
The numbers of patients on the caseload of teams and of individual members of staff was in some cases high. In early intervention teams these were above the numbers recommended by best practice guidance. Staff in some teams with a high turnover of staff reported feeling ‘burnt out’.
Learning from incidents was not always consistently implemented across all teams. When incidents of unexpected death were investigated and underlying physical health issues were found to be the cause, learning from these incidents was not routinely shared with staff, which could mean that opportunities to learn and develop practise were missed.
Whilst the majority of teams received regular supervision, staff in the Barking and Dagenham community recovery team did not. Managers across all directorates reported that the introduction of a new system to record and monitor supervision had been problematic as it was difficult to use and extract management data from.
Locality teams were working in partnership to improve their relations with the acute crisis assessment team. Locality teams were frustrated that their multidisciplinary referrals were being rejected without appropriate feedback.
Not all staff felt respected, supported and valued. A small number of staff felt there was a culture of blame in the team when incidents occurred. They also commented that there was a lack of meaningful consultation when changes were made to the teams and that they did not feel heard, or feared retribution when they raised concerns.
There were some long waits to access individual psychology in Barking and Dagenham access, assessment and brief intervention team. New referrals were triaged and prioritised and patients were offered groups whilst they waited. The team were actively recruiting psychologists to increase their psychology offer.

However:

Clinical premises where patients were seen were safe and clean. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients.
The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training. Staff worked well together as a multidisciplinary team.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care.

The arrangements in place for the acute crisis assessment team (ACAT) to assess and admit patients to an inpatient bed was unsafe. Patients attending out of hours at Sunflowers Court for assessment by the ACAT or waiting to be admitted to wards after their ACAT assessment, were not appropriately supervised. There was a risk that the patient could cause harm to themselves or others whilst unsupervised, particularly in secluded areas of the building.
The arrangements for the acute crisis assessment team to work with other professionals and teams in the trust was adversely affecting the responsiveness of the service to meet the needs of patients. Seeking a doctor to support the assessment process could cause delays and put pressure on medical staff working in other parts of the trusts crisis services. We also heard multiple examples from junior doctors and consultants about the difficulties of working with ACAT as part of the decision-making process for admitting patients to an inpatient bed. They described complex and lengthy escalation processes. They had examples of where delays resulted in potential harm to patients. They also described the impact of this process on their morale, often feeling a lack of respect or professionally under-mined.
Leaders of all levels within the service were aware of the operational challenges for the ACAT potentially impacting on the safety of patients. There had not however been a timely response in addressing these, despite the concerns being known for some months. At the time of our inspection appropriate measures to ensure that ACAT provided high quality care to their patients waiting to be seen or admitted to Sunflowers Court were still not in place.
The trust did not record data recommended by best practice to monitor the work of the health-based place of safety. For example, there was no data relating to occasions when the heath-based place of safety was full to capacity and the police or ambulance service needed to convey the patient elsewhere, such as the nearest emergency department. The trust did not routinely gather data to show the number of patients who had stayed in the HBPoS for more than 24 hours and the reasons why these incidents had occurred.
Staff did not have access to the feedback from patients, family members and carers. The trust did not share patient survey results and findings with the HTTs. Therefore, the HTTs were unable to assess, monitor and improve the quality and safety of their services from a patient and family perspective.

However:

Clinical premises where home treatment team (HTT) patients were seen were safe and clean and the physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff followed good practice with respect to safeguarding.
Staff working for the HTTs developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
Managers ensured that staff had completed most mandatory training, although only 75% of staff had completed training on the management of violence and aggression. Staff were supervised and appraised. Staff worked well with relevant services outside the organisation.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
HTT staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
The mental health crisis services were easy to access. Those who required urgent care were taken onto the caseload of the HTTs immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

After this most recent inspection we have changed the overall rating for the trust to good because:

Following the last inspection in April 2016, the trust had implemented a comprehensive improvement plan and had taken action to meet the requirement notices and enforcement action taken after the inspection in April 2016. In addition the majority of recommendations had also been put into practice.
Following this most recent inspection, only one of the fifteen core services remains rated as requires improvement (wards for adults of working age and psychiatric intensive care unit). The rest are rated as good and one core service (child and adolescent mental health wards) is now rated outstanding.
The most significant improvement was for child and adolescent mental health inpatient wards where, in an 18 month period, the ratings for the service had improved from inadequate to outstanding. The trust had shown vision and strong leadership in reviewing the model of the service being provided.
In addition the trust had stable leadership through the board and the executive leadership team who had an appropriate range of skills, knowledge and experience.

The trust was making good use of IT and promoting mobile working. The systems also promoted access at different levels of the organisation to timely information on performance.
The trust had a strong track record in terms of its equality and diversity achievements and had made good progress with their workforce race equality standard results from 2016 whilst recognising there was more to do particularly in relation to some of the other protected characteristics.
The trust was working to ensure a good balance between providing assurance and promoting quality improvement. The first year of adopting a formal quality improvement methodology had gone well and was producing positive results.

However:

The safe key question remains rated as requires improvement and there are further improvements that the trust must make in six of the core services. This includes addressing areas such as ensuring staff had completed mandatory training, hand-washing, fire safety, medicines management, use of prone restraint, updating risk assessments and maintaining clinical equipment. The trust must address these as a matter of urgency.

There is also scope for the trust to improve leadership and management further. This included reviewing the capacity of the executive leadership team, having a clear strategy for the trust, strengthening board visits and the feedback from these, supporting governors to perform their duties, strengthening the freedom to speak up guardian role and completing the review of some of the key documents used by the board as part of their assurance process.

Overall rating for this core service is good because:

Following our last inspection in April 2016, we issued one requirement notice requiring the service to take action to remedy breaches to Regulation 17, in relation to good governance and issued 15 actions the provider should take to improve. During this inspection, we found that the service had dealt with or shown improvement for most of the previously reported concerns.
Although the trust had addressed the previous inspection’s requirement notice through the implementation of electronic diaries, the leadership team recognised some staff were still using paper diaries whilst awaiting agile working equipment. The trust mitigated risks by completing data management audits of these diaries alongside supervision with line managers. However, the trust still had to ensure all staff had access to electronic diaries through the appropriate equipment.

The trust had been addressing concerns around heavy caseloads through different methods. These included increasing staff skill mix, using a new caseload allocation tool and performance allocation tool, implementing managerial supervision to discuss caseloads, checking staff wellbeing and negotiated extra funding for staff from commissioners. However, the decommissioning of services, changes to service contracts, changing populations needs and recruitment challenges meant caseloads remained high for some services.

The trust had implemented a transition policy in August 2017 but commissioning issues still affected the transition arrangements. Service leads acknowledged there were some gaps and recognised that receiving services had different criteria. Transition was recognised as a national commissioning issue. However, where transition arrangements were in place, the process was effective.

The trust had recently developed a 10 year vision and strategy for the service. Senior leads told us the trust medical director engaged with staff and members of the public and patients to develop the strategy. However, the document was in its infancy and the trust acknowledged that not all staff would be aware of the document, and more time was required to embed it fully.

The trust had demonstrated improvements in reducing staff vacancy rates in some services but recruitment of specialist therapy roles remained a challenge for the trust. However, the trust managed vacant staff posts effectively by using bank and agency staff as required.

Although the trust had made improvements to waiting times for some services, further work was still required to be compliant with national guidance and maximum waiting times of 18 weeks. Staff recruitment and capacity issues affected wait times, but the trust had conducted data cleansing exercises to ensure only those clients who needed assessment and interventions remained on the waiting list.

The trust had cleared the initial backlog of transferring scanned consent forms for immunisations by using additional administration staff. However, on this inspection, there was still a backlog due to lack of appropriate equipment such as scanners. The trust was addressing this at the time of the inspection and had developed an action plan to monitor progress.

The community health services for children, young people and families (CYP) service had systems for identifying, reporting, and managing safeguarding risks. The safeguarding team provided good support to staff across CYP services through supervision, training, monitoring of incidents and advice via the duty desk.

Staff were encouraged to raise concerns and to report incidents and near misses. The CYP service effectively shared learning from incidents and good practice with staff through regular meetings, newsletters and across localities. Staff told us they valued working for the trust and that service leaders were supportive, accessible and approachable.

The CYP service demonstrated effective internal and external multidisciplinary (MDT) working. Clinical practitioners worked with other staff as a team around the child. The co-location of services in health centres and partnership working with other service providers facilitated MDT working.

The trust health centres and children centres we inspected were clean, tidy, and clutter free. Waiting rooms and clinic rooms were child friendly with toys, books and other resources appropriate for different ages.

Staff supported the patients and families they worked with, and provided patient-centred support in clinics and in homes. The trust actively sought feedback from people using the service and engaged them to improve services.

People using the trust’s community CYP services were treated with dignity and respect. People felt listened to by health professionals, well informed and involved in their treatment and plans of care.

The service was responsive to the needs of people using it and had adapted to meet the diverse needs of the community it served. Staff, patients and families we spoke with told us they had good access to translation services.

There was a robust governance framework and reporting structure. Staff had confidence in their immediate line managers and leadership at board level.

However:

We saw inconsistent compliance with controls and standards for hand hygiene and infection prevention at some of the locations we visited and among staff.

Compliance targets across localities were not consistent, with some localities performing significantly worse than others in the delivery of certain aspects of the health visiting service.

The trust managed complaints appropriately, completing relevant investigations and responding within the time scales set in the trust policy. However, we found completion of the online recording system incomplete as risk assessments and lessons learnt sections were blank in some cases.

We rated end of life care (EOLC) good because:

There had been a restructure in EOLC in the trust. This meant most specialist palliative care was outsourced and provided by hospice staff. District nurses worked in integrated community teams and were responsible for providing treatment and support to palliative and EOLC patients in the community.
Staff understood their responsibilities to raise concerns and to record safety incidents.
There was an open culture in reporting incidents and there were systems in place to learn from incidents and reduce the chances of them happening again.
There was identification of patients at risk of deterioration and we saw evidence of the use of emergency health care plans in ensuring that all patients had a plan in place should their condition deteriorate.
There was appropriate equipment available in patients’ homes and use of anticipatory prescribing of medicines at the end of life.
Mandatory training levels were good, with all specialist palliative care team staff.
An integrated electronic records system was in use across specialist palliative care staff community. Although, in Essex, patients electronic records could be viewed by acute hospital staff and GP practices; and in London, trust staff had access to patients’ electronic records, but did not have access to other community providers’ records.
The trust had implemented the ‘individual care plan’ which was being used as a guide for the delivery of end of life care. We saw that treatment escalation, emergency healthcare plans and advance care plans were in place to support patients and those close to them in making decisions at the end of life.
There was a commitment to working collaboratively to deliver joined-up care through multidisciplinary working. This was demonstrated through the trust’s community services collaborating with hospice staff and staff from local NHS acute trust. There were established links with GPs and local nursing homes.
The trust were rolling out ‘essential to role’ EOLC training to all relevant staff.
Consent practices were embedded across teams providing EOLC.
Staff demonstrated compassionate care to patients and their families. We observed a commitment to providing care that was focused on meeting the emotional, spiritual and psychological needs of patients as well as their physical needs.
There was a visible person-centered culture. Staff were highly motivated to offer care that was kind and promoted people’s dignity. Relationships between people who used the service, those close to them and staff were caring and supportive. These relationships were valued by people and their families.
The trust were developing pathways of care to provide care that met people’s individual needs.
There was an open approach to handling complaints.
There was a vision and strategy that focused on the early identification of patients at the end of life, patients being cared for in their preferred place of care and the use of partnership working to develop services.
There was end of life care representation and leadership at trust board level.
There was comprehensive leadership within the palliative care service with clearly defined leadership roles. The director of nursing was passionate about the service and encouraged staff to deliver high quality EOLC. Local managers were proactive and demonstrated an understanding of the issues facing EOLC services.

However, we also found:

Incident reporting rates for palliative and EOLC were low in integrated community teams teams when compared to specialist palliative care teams.
Staff were not aware of whether the trust had audited anticipatory medicines.
Staffing levels had improved in the previous 12 months, but retaining staff was an issue across integrated community teams.
Waltham Forest had the worst results in England in the national care for the dying audit 2016, for patients achieving their preferred place of care at the end of their life.
Some staff we spoke with told us they were not aware of any audit proposals in 2017, even though there had been an audit of ‘do not attempt cardiopulmonary resuscitation’(DNACPR) decisions in 2017.
Staff at Mayfield inpatient unit had piloted the provision of EOLC in a rehabilitation focused inpatient unit. However, staff felt they had not been fully prepared for the palliative care remit.
Staff told us they didn’t feel connected to other teams across boroughs and there were very few opportunities for staff to meet with colleagues from other directorates across Essex and London to share learning.
The trust had introduced a new EOLC strategy which aimed to meet patients’ needs through direct care, advice, information and education, enabling patients to die in their place of choice. However, across community services staff told us the EOLC strategy was relatively new and teams needed time to embed it.
Some local managers we spoke with were unaware that there was a specific risk register for EOLC.

Information about the service

North East London NHS Foundation Trust (NELFT) provides integrated community and mental healthcare services to a diverse population of over 2.5 million people in the London boroughs of Barking and Dagenham, Havering, Redbridge and Waltham Forest. NELFT also provides services in the Essex boroughs of Basildon, Brentwood and Thurrock. The trust employs approximately 6,000 staff. End of life care (EOLC) services are provided by individual directorates based upon London and Essex boroughs. However, there was a NELFT organisational structure to support the individual directorates.

In Essex boroughs NELFT are commissioned to provide community EOLC services through St Luke’s Hospice. The community EOLC service provides specialist palliative care to adults in their own homes. Day care services are provided by St Luke’s and St Francis Hospices. Patients are also supported by community nursing and district nursing services working in integrated community teams (ICT)) to work with patients in nursing and residential care home settings, as well as working with patients who live in their own homes.

Mayfield inpatient unit provides two specialist palliative care inpatient beds.

St Luke’s and Saint Francis Hospices provide a 24 hour advice line, specialist nursing services and out of hours palliative care nursing services. The multidisciplinary team includes physiotherapy, occupational therapy, chaplaincy, clinical pharmacist, complementary therapists and access to medical social workers.

The Redbridge specialist palliative care team is a multi-disciplinary team, which provides expertise in holistic assessment, management of difficult symptoms and patients with co-morbidities.

We visited the specialist palliative care team in Redbridge. We visited district nursing services based in ICT in: Waltham Forest, Barking and Dagenham, Thurrock, Basildon, Redbridge, and Havering. We visited Mayfield inpatient unit in Thurrock. We visited Waltham Forest children’s community services. We also visited EOLC facilitators in Basildon and Havering.

Overall rating for this core service: Good

North East London NHS Foundation Trust provides adult community health services across parts of London and Essex. This includes 45 distinct specialties or services including district nursing and integrated care teams. To come to our ratings we spoke with 20 patients, eight relatives and carers and 56 members of staff in a variety of roles. We observed 13 home visits and reviewed over 300 individual items of evidence.

We last inspected this service in April 2016 and rated it requires improvement. This reflected concerns about the documentation of medicines and risk assessments, a lack of consistency in staff appraisals and ineffective governance systems.

Overall we rated adult community health services as good because:

There were a number of strategies and programmes in place to improve patient safety, which were led or supported by a dedicated harm free care team. This work had resulted in reduced falls and pressure ulcers and an improved early warning scores system.
Staff recruitment remained a significant challenge for the trust. For additional shifts, 41% were filled by agency staff and 59% by bank staff. However, some teams had restructured to enable staff to better manage workloads, and strategies were in place to improve retention and make the recruitment process more efficient.
There was significant evidence that care and treatment was based on best practice national and international guidance. Clinical teams used research, pilot projects and audits to benchmark their standards of care.
There was consistent use of multidisciplinary working and coordinated care and treatment pathways for patients in all areas of the trust.
Staff had access to specialist training and clinical competency development on a regular basis.
During all of our observations and home visits we saw staff treated patients with care, compassion and kindness.
There was a consistent focus on adapting services to meet the needs of local people. This included through service redesign and adaptation as well as ensuring care was delivered in line with equality and diversity priorities.
The dementia crisis support team had developed and implemented an innovative model of care for patients that improved access to specialist services and reduced mortality and hospital admissions.
Individual teams implemented projects to improve access, including restructuring and improving assessment methods.
There was evidence of learning from complaints including the implementation of new policies and practices.
Local clinical governance processes had been improved and a quality improvement and monitoring system had been established. As a result there were clearer links between locality teams and the trust board.
The strategic patient experience partnership had a demonstrable role in quality improvement and took the lead in strategies and projects to improve patient experience.

However:

Only one locality team met the trust’s target of 85% for completion of appraisals.
Completion of mandatory training was variable between teams and localities.
There was a lack of evidence that action plans from audits were consistently followed up or implemented.
Although clinical governance processes had improved, some staff did not feel part of the trust. Results from the 2016 staff survey indicated a number of areas for improvement.

We rated children and adolescent mental health wards as outstanding overall because:

There was strong and inspirational leadership at a trust and service level that had transformed this service and over an 18 month period the ratings moved from inadequate to outstanding.

During this most recent inspection, both staff teams were fully committed to ensuring that they provided quality services and continued to improve through innovation. Staff from both teams were involved in a number of quality improvement projects and accreditation. Young people receiving care were encouraged to become actively involved in these quality improvement projects and their input was valued.

Staff treated young people and their families as partners in their care. They understood the importance of being kind and respectful. There was genuine empathy and understanding of individual needs and wishes, which was reflected in the work undertaken with young people and their families. There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Staff morale was high and commented that this had steadily improved since the ward had re-opened in September 2016.

The leadership, governance and culture of the service drove improvement and underpinned the delivery of high quality person-centred care. Staff were accountable for delivering change. Leaders had an inspiring shared purpose and motivated staff to succeed. There were high levels of staff satisfaction and staff were proud of the organisation as a place to work and spoke highly of the culture. Staff at all levels were actively encouraged to raise concerns. Managers made themselves available and were actively involved in ward based activities.

There were robust and effective governance procedures. Managers and senior members of the multi-disciplinary team met regularly to discuss issues relating to the running of both services. There was a good flow of information from these meetings to the trust leadership team and back to the frontline staff. The trust’s development and implementation of the YPHTT demonstrated a clear proactive approach to seeking out and embedding new and more sustainable models of care. The service was seeking accreditation and beginning the process of identifying a research model to formally evaluate outcomes for patients accessing the YPHTT.

Young people said that they received excellent care, staff were amazing and that they felt safe on the ward.

Although the ward had staffing vacancies, the managers had planned for this and ensured that there were sufficient staff on duty. Existing staff members or a small group of regular bank and agency staff filled vacant shifts. The trust monitored safe staffing levels against admission numbers. The Young Peoples’ Home Treatment team was adequately staffed and staff turnover was low.

The building was modern and there were various outside spaces, which all young people could access. Families could stay in a family suite on site if needed. The building was visibly clean and well furnished. Young people could personalise their bedrooms. The environment was well maintained and potential ligature anchor points were appropriately managed.

Staff had a good understanding of risk. Both teams had regular risk meetings, which were attended by a broad range of disciplines. All staff had the opportunity to contribute to the risk identification and formulation of risk management plans. Risk assessments were frequently updated. Both teams had clear time frames to assess new referrals and formulate the young person’s care plan, which meant that there was no delay to care and treatment commencing. Both teams liaised with the trust’s safeguarding team and other external organisations appropriately and in a timely manner when risks were identified. There were clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was evident in these services. Teams considered the review of incidents to be an opportunity for learning.

Planning and delivery of care was holistic, personalised and recovery focussed. Planning and delivery of care placed children and young people at its centre and staff ensured that patients, their families and carers had appropriate information so they could make informed decisions. Staff from both teams ensured that they monitored all aspects of the young person’s well-being including their physical health. There were mechanisms to identify when a young person’s physical health was deteriorating. Where young people had additional physical health needs, staff escorted them to their hospital appointments. Since the previous inspection in October 2016, there had been improvements in how patients’ physical health checks were recorded.

However:

We identified a number of minor procedural lapses in governance systems. A fire evacuation drill was overdue. Staff arranged for this to take place shortly after the inspection. Fire alarm checks and staff radio checks were not completed as frequently as required by the trust.

Whilst the majority of equipment used to monitor patients’ physical health was maintained, a blood glucose monitoring machine had not been calibrated. This was escalated and addressed by ward staff during the inspection.

The majority of frontline staff were not aware of the name of the trust’s Freedom to Speak up Guardian and their role. However, all of these staff stated that they could get these details from the trust’s intranet.

At a previous inspection in October 2016, we found that some meal choices were not available in sufficient quantities. During this inspection this had improved, however, patients said that the quality of food was poor. Managers and staff were actively working to address this and had organised meeting with the catering provider.

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

At this inspection we found the trust had made considerable progress from the previous inspection in April 2016 but in some cases it had not yet fully completed or embedded these improvements. There were some areas where we have asked the trust to do some further work and some new areas for improvement have been identified.
Staff did not consistently monitor patients’ vital signs after the administration of rapid tranquilisation, which put patients at risk. Some medicines used for rapid tranquilisation had not been administered in line with trust policy and procedure.
Some patients did not have a bed on the ward when they returned from leave unexpectedly. Some patients were subject to non-clinical moves between wards because of bed pressures.

Governance and assurance processes had improved since our previous inspection. However, further improvement was needed to ensure consistency in the quality and safety of services across all wards.
On Titian ward, personal alarms were not available in sufficient numbers for all staff and visitors. The trust was working to address this. Staff accompanied visitors without alarms and the trust was servicing existing alarms and purchasing additional alarms to ensure sufficient numbers were available.
Whilst overall fire risks were assessed and managed appropriately, on Hepworth ward an action from the fire risk assessment was outstanding and staff were unclear how this was being addressed. Patients covertly smoking on some wards presented a safety risk.
We saw that there had been improvements in systems to ensure that equipment used to monitor patients physical health had been calibrated but on some wards we saw that some equipment had not been calibrated.
The trust aimed to reduce the use of prone restraint by 50%. Whilst progress had been made on acute wards and the use of prone restraint had reduced by 40%, on the PICU ward the use of prone restraint over the six months prior to the inspection had doubled.
There had been improvements in how the trust assessed and managed risk but, this required further embedding. On some wards, staff had not updated risk assessments following an incident, or the recorded assessments did not fully reflect the patient’s potential risks. On Kahlo ward, patients who were admitted with unlabelled medicines had these returned to them when they were discharged. This contravened trust policy. We saw that when staff completed incident reports they did not accurately reflect whether the patient or staff member had experienced harm as a result of the incident.
Take up of mandatory training by staff had improved since the last inspection and overall 85% of staff had completed mandatory training, in line with trust targets. However, staff take up of some individual elements of mandatory training, for example safeguarding adults, Mental Capacity Act (MCA) and information governance, was below this target and further work was needed to improve this. During this inspection staff on acute wards said they would benefit from specialist training in caring for patients with personality disorder. Although staff supervision rates had improved since the April 2016, further work was required to embed this and to ensure that all staff received regular supervision. Ward managers did not have access to information regarding rates of staff appraisal, which meant they could not be sure that all staff received an appraisal when it was due.
Some areas of the wards did not promote patient privacy and dignity. Whilst the wards and clinic rooms were visibly clean, records to show the cleaning of clinic rooms on Hepworth and Titian wards, which the trust required, were not completed.
Staff were not aware of the freedom to speak up guardian, their role or how to contact them.

However:

Ward managers, modern matrons, and other leaders provided strong leadership at ward and service level.

Since the last inspection in April 2016, staffing levels had been increased on wards.

A programme of works to address ligature risks on wards was underway. Comprehensive ligature risk assessments were in place on all wards. Staff knew the ligature risks on each ward and the measures in place to manage and mitigate these. Patients were assessed for their risk or fixing ligatures and appropriate management plans were in place, including the use of one to one observations.

There had been improvements in care planning. The care plans we saw were recovery orientated and the majority reflected the views and preferences of patients.

Overall, improvements had been made to the management and administration of medicines. We saw good practice in managing and administering medicines on all of the wards.

Improvements had also been made to ensure that maintenance issues were reported and addressed promptly.

Patients were assessed in a timely manner on admission and had their physical health needs met.

We found the following areas of good practice:

At the April 2016 inspection, systems to monitor changes in risk for children and young people waiting for assessment and treatment were not robust and not all patients had a care plan. At this inspection, we found that this had improved. Patients who had been assessed or had commenced treatment had risk assessment and management plans in place. All patients had a care plan. However, further improvement was needed as half of the care plans we looked at did not include goals for recovery.

Safe staffing levels were maintained, vacant posts were being recruited to and agency staff covered the majority of unfilled posts. Whilst caseloads were increasing, they were manageable and were kept under regular review. Teams were made up of a wide range of professionals. Staff were skilled and experienced. Eighty percent of staff had completed mandatory training.

Staff made comprehensive assessments of the children and young people referred to the service. They identified the patients’ physical health needs and addressed them. They delivered treatment and therapies in accordance with NICE guidance.

Staff were compassionate, demonstrated an in-depth knowledge of the young person’s circumstances and were respectful towards them. Young people felt listened to and said that their views were valued. The majority of carers were positive about the service they had received. They said that staff appeared to understand their child and their needs. Young people were involved in the development of the service and in recruitment of staff.

Managers had put robust governance systems in place to monitor the effectiveness and safety of the service. Systems to identify themes from incidents across the directorate were in place.
Team managers were experienced and led staff teams effectively. Service wide changes were being made as a result of learning from a recent cluster of serious incidents. Robust systems were in place to safeguard patients.

However, we found that following areas the trust needs to improve:

The trust were not meeting their target times for referral to assessment of 12 weeks. Increasing referral rates meant that it was unlikely this would improve. Teams knew how they were performing against targets and were working hard to ensure patients were seen as quickly as possible. The trust were also not meeting their referral to treatment target time of 18 weeks, however compliance against this target was better and 92% of children and young people were being seen within 18 weeks.

Alarm systems to ensure the safety of staff and patients were not in use.

Whilst the majority of physical health tests were carried out by GPs, some checks were carried out by staff. Not all equipment used in in these checks was regularly calibrated. At some sites children and young people’s privacy and dignity were compromised as height and weight measurements were taken in a corridor.
Staff did not clean toys at the Chelmsford site regularly. This could present an infection control risk.

Whilst staff were receiving regular supervision, at Harlow there was no system to monitor the content and frequency of supervision.

Staff demonstrated a sound understanding of the Mental Capacity Act and Gillick competency. However, where decision specific capacity assessments were made these were not recorded in patients’ records and there was no system to monitor the appropriate use of the Mental Capacity Act.

Our overall rating of wards for older people improved. We rated it as good because:

The trust had made improvements since the previous inspection in April 2016. At our previous inspection of wards for older people in April 2016, we found that the trust was in breach of Health and Social Care regulations. These breaches were in relation to safety, dignity and respect and staffing. At this inspection, we found that the trust had taken appropriate action to improve the service.
There was now a robust system in place to reduce the risk of falls. Patients were now able to access their bedrooms at any time as they wished. The trust had improved ward premises. The wards had been redecorated, there was new furniture and the risk to patients from ligature points had been reduced. Patients on all wards now had easily accessible call bells to alert staff if they needed support. Staff understood the legal requirements of the Mental Health Act. Patient privacy and dignity was promoted.
Staff thoroughly assessed patients in relation to their physical and mental health when they were admitted to the ward. Staff screened patients for risks in relation to falls, skin care, continence and nutrition. Staff worked in partnership with the patient and their carer to develop care plans which reflected the patient’s choices. Staff liaised with a geriatrician and other clinical specialists to ensure care and treatment was effective.
Staff checked the physical health of patients each day and took action to address any deterioration in the patient’s health. Multidisciplinary team work was effective and care plans addressed patients social and rehabilitation needs. Staff were experienced and well-trained.
Patients were encouraged to be as independent as possible. There was a range of activities available on the ward. Discharge planning was effective for almost all patients. The trust worked with other agencies to manage delayed transfers of care.

Staff were kind and caring. They were able to communicate well with older frail people. Staff welcomed carers onto the wards. Staff gave carers appropriate support and advice.

However:

Patients on some wards were accommodated in shared bedroom areas which compromised their privacy and dignity.

Some ward layouts did not allow staff to readily observe all areas and whilst the risks associated with this were mitigated through observations, the trust had not considered the use of aids such as convex mirrors to improve visibility.
Whilst the take up of mandatory training averaged over 80% in most areas, there were two exceptions. Ward managers were taking action to ensure staff attended any courses they had not yet completed. We did not see that lower compliance levels with these mandatory training courses had impacted upon the quality and safety of care and treatment being provided.

Whilst learning from incidents was taking place in team meetings, the template to record team meetings did not allow for the recording of these discussions. This meant that staff who could not attend the team meeting could not readily access this information in one place.

We rated children and adolescent mental health wards as good overall because:

The trust had made significant improvements to the service since the last inspection in April 2016 and we concluded that they were focussed on continuing to improve. The trust had fully addressed, or significantly improved, the problems that caused us to find it in breach of regulations at our inspection in April 2106.

Young people received care and support according to their individual needs. Young people said that they received good care, staff were kind and that they felt safe on the ward. During the last inspection, we observed that staff were not always responsive to the needs of young people at the unit. We noted that there had been significant improvement during this inspection.

At our last inspection in April 2016, the unit did not always have sufficient staff on duty to ensure that they could meet the needs of the young people and that safe care and treatment was offered at all times. Since the last inspection the service had recruited additional staff. The service was adequately staffed and staff turnover was low. Existing staff members or a small group of regular bank and agency staff filled vacant shifts. There were a low number of unfilled shifts. Two hundred and nine shifts were filled and 29 shifts were unfilled between the 29/09/16 – 26/10/16..These unfilled shifts did not impact upon patient care or safety because there were fewer young people admitted to the ward during this period. The service had capped the number of young people admitted to the ward during the two month phased re-opening period to ensure that there was enough staff to offer safe care and treatment. The trust said that they would continue to monitor safe staffing levels against admission numbers.
Since the last inspection, the unit had been extensively reconfigured and refurbished. The building was modern and there were various outside spaces, which all young people could access. Families could stay in a family suite on the unit if needed. The building was visibly clean and well furnished. Young people could personalise their bedrooms. The rooms were comfortably furnished, with curtains and blinds so that young people could have their privacy. There was a range of food to meet the cultural and religious needs of the young people. This was an improvement since the last inspection. When the service was inspected in April 2016, the ward environment was stark and not child friendly. The environment was not clean and the furnishings were in a state of disrepair. Young people’s bedrooms did not have curtains and blinds. The food provided on the ward did not meet the cultural or religious needs of the young people.
Staff now managed ligature risks appropriately. During the last inspection, we found ligature points in the disabled toilet on Willows ward, which had not been identified in the ligature audit.
Staff generally had a good understanding of risk and risk assessments were frequently updated. The unit had clear time frames to assess new referrals and formulate the young person’s care plan, which meant that there was no delay to care and treatment commencing.
At the time of the previous inspection, the ward staff had insufficient access to doctors out of hours. During this inspection we noted that this issue had been reviewed and was being monitored. If young people had additional physical health needs, staff escorted them to their hospital appointments.
At our last inspection, staff members were not routinely receiving clinical supervision sessions. During this inspection, we found that most staff had regular supervision (81%) and appraisals (88%). .

During the last inspection, we noted that all doors were locked within the unit and young people had to rely on staff members to move throughout the unit. We observed young people unable to summon staff members to assist them moving between different areas of the unit and being left behind locked doors. Since that inspection in April 2016, the unit had reviewed their restrictive practices.The unit now had limited blanket restrictions in place and restrictive practices. For example, young people were now more able to move freely in the unit. All young people had been given their own access fob which gave them unrestricted access to the patient areas in the unit. The staff only areas and external doors remained locked. However, the external doors opened automatically in the event of a fire or fire drill. There were no episodes of seclusion and the trust had updated their search policy.

At the last inspection, we found that the level of incidents reported on the electronic reporting system did not correspond with incidents recorded in young people care notes. Incidents were consistently under reported. During this inspection, we noted that staff understood how to report incidents and this was embedded practice. The unit had robust procedures to manage incidents. Incident thresholds were consistent across the service and all staff knew how to report them electronically. Staff were aware of safeguarding processes and had received training.

During a previous inspection in April 2016, we found that there were substantial failures in the governance at the unit. During this inspection, we found that the unit had robust and effective governance procedures and met regularly to discuss issues relating to the running of the ward.

However:

For one young person, the trust had not ensured that they undertook and recorded a test of the young person’s competency to agree to an informal admission at the earliest opportunity. This young person’s competency had been assessed and recorded several days after their admission.

Whilst the unit’s compliance rate for mandatory training had improved to 82%, it remained below the trust target of 85% because staff were unable to access timely refresher courses. The trust stated that bank and agency staff had been trained in safeguarding.

The records of environmental checks we were shown were incomplete and poorly organised. Although the service was visibly clean, we were not shown any records confirming how frequently the service had been cleaned.

At the time of the previous inspection, the care plans reviewed were not recovery orientated and focused on behaviours nor were they holistic. They did not include young peoples’ views and goals. Risk assessments were sparse. During this most recent inspection, we found that there had been improvements in care planning. However, the care plans we reviewed were not recovery orientated. There was limited assessment of the young person’s strengths. Care plans had limited information regarding the young person’s views.

The unit had developed its own “Brookside information booklet” and had some leaflets that were designed specifically for young people in the reception area. However, the unit did not have information on display that reflected the diverse needs of the young people.

Overall we rated this service as good.
This was because we found a good culture for the timely reporting of incidents and the trust were able to identify themes and trends among community inpatient services. Safeguarding processes had a level of profile that enabled the identification of possible abuse and encouraged reporting. Processes for the safe administration of medication were in place and the overall standard of documentation was good. Wards were clean and staff were trained in infection prevention and control. Premises and equipment were largely well maintained and managed. However, we also found that equipment had not been serviced and space available for meaningful therapeutic activity compromised the service provided to patients.
Community inpatient services were operating with a substantial nurse vacancy rate and on the whole we found this had been largely well managed. However, we found a number of examples where rehabilitation therapy staffing and facilities had led to a basic provision of rehabilitation service. Patients received timely pain relief and received adequate assistance to eat and drink. Staff were also able to access key skills training appropriate to their role. We found good examples of integrated and multidisciplinary working. Patient discharge was appropriately planned and managed.
Staff understood their roles with consent and capacity. We also observed staff to be caring in their interactions. All patients we spoke with told us that staff were kind and treated them with respect. We did not come across any examples where this was not the case. Patients and relatives felt involved and included in care and treatment. Services were meeting the needs of vulnerable people. Assessments for wound management were completed and reviewed in accordance with the stated frequency. Community therapy assessments had taken place and case notes showed updates on preparation for discharge. Patients reported to us that their care and treatment needs were being met.
Staff reported to us that they had confidence in their leadership, who they found responsive. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of the service.

We rated long stay/rehabilitation mental health wards for working age adults as good because:

There was evidence of good medicine management and patients medicine records were clear and accurate. The pharmacy team reviewed medicine charts including antipsychotic medication. Staff recorded patients allergy status on the prescription charts. Staff recorded where patients self administered medicines.
Comprehensive and holistic care plans demonstrated patient involvement. Patients and carers were involved in care planning and care plans were written in a person centred way.
Patients’ physical health was assessed and regularly monitored by staff. Patients’ physical health was discussed and reviewed during ward rounds.
We saw kind and caring interactions between staff and patients. Patients told us that staff were polite and respectful. Staff were knowledgeable about patient needs. There was evidence of family and carer involvement in care planning.
There was evidence of discharge planning in patient records. Staff discussed discharge planning with patients, familes, carers and community services.
Staff received regular supervision and appraisals. Staff received monthly supervision which could be increased if appropriate or requested. We saw evidence that all staff had completed their annual appraisal within the preceding 12 months.

However:

We saw high use of bank staff, although regular bank staff was used where possible.
There was no dedicated psychology input on the ward. However, staff could refer patients for psychological interventions. Staff told us there was a long waiting list and referrals were not based on wards although patients were fast tracked where possible.
Patients were unable to make a drink or snack as required.
Staff and patients expressed anxiety regarding the planned ward closure.

Overall we rated this service as good.
This was because we found a good culture for the timely reporting of incidents and the trust were able to identify themes and trends among community inpatient services. Safeguarding processes had a level of profile that enabled the identification possible abuse and encouraged reporting. Processes for the safe administration of medication were in place and the overall standard of documentation was good. Wards were clean and staff were trained in infection prevention and control. Premises and equipment were largely well maintained and managed. However, we also found that equipment had not been serviced and space available for meaningful therapeutic activity compromised the service provided to patients.
Community inpatient services were operating with a substantial nurse vacancy rate and on the whole we found this had been largely well managed. However, we found a number of examples where rehabilitation therapy staffing and facilities had led to a basic provision of rehabilitation service. Patients received timely pain relief and received adequate assistance to eat and drink. Staff were also able to access key skills training appropriate to their role. We found good examples of integrated and multidisciplinary working. Patient discharge was appropriately planned and managed.
Staff understood their roles with consent and capacity. We also observed staff to be caring in their interactions. All patients we spoke with told us that staff were kind and treated them with respect. We did not come across any examples where this was not the case. Patients and relatives felt involved and included in care and treatment. Services were meeting the needs of vulnerable people. Assessments for wound management were completed and reviewed in accordance with the stated frequency. Community therapy assessments had taken place and case notes showed updates on preparation for discharge. Patients reported to us that their care and treatment needs were being met.
Staff reported to us that they had confidence in their leadership, who they found responsive. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of the service.

Overall, we rated community health services for adults at North East London NHS Foundation Trust (NELFT) as requires improvement because:

There were major staffing shortages and recruitment challenges across all staff groups and localities. High percentages of bank and agency staff were used to run services and this was affecting continuity of care for patients. There was extensive recognition amongst all staff of heavy and unsustainable caseloads across services, particularly in district nursing.
There was inconsistency in the completion of healthcare records, including in risk assessments, diagnostic tools, progress notes and medication charts. A system to effectively monitor and audit the quality of patient records was not in place.
There was inconsistent measurement and analysis of patient outcomes across services and localities. Some local areas had clear patient outcome measures in place but others had limited systems for monitoring outcomes. There were examples of large backlogs of incomplete patient outcomes recorded from visits, which staff stated was due to a lack of staff capacity.
The service had only recently made Mental Capacity Act (MCA) training mandatory, meaning that many staff had not been trained and did not have an understanding of the MCA and Deprivation of Liberty Safeguards.
Inspectors observed a lot of variation in referral to treatment (RTT) times for accessing services across different localities, and the trust did not have a system in place for effectively monitoring RTT, particularly in district nursing.
As community health services for adults worked with many Clinical Commissioning Groups (CCGs), services were delivered in many different ways between boroughs, meaning some areas could not provide services which were available in other parts of the trust.
Although the trust was moving towards delivering a more standardised model of care across the different boroughs, there was still a lot of variation in how services delivered care in response to the needs of local health economies.
There was no clear, documented vision for the service as a whole, and it was not clear how community health services for adults were represented at board level. Staff stated they felt more connected to their local area than to the wider Trust, and did not have much communication with similar teams in other areas.
Community health services did not have an effective structure in place for clinical governance or risk management, and services did not have a robust system of audit in place or effective means for measuring quality.

However:

The service had robust systems in place for identifying and reporting safeguarding risks, and staff recorded and investigated incidents appropriately.
Permanent staff were meeting trust targets for mandatory training. Staff told us that they were given appropriate training to develop the skills required to undertake their roles.
There was evidence of good treatment across community health services for adults which was delivered in line with national guidance and best practice. There was good provision of evidence-based advice and guidance to staff, and the trust had established several groups across services, such as the clinical excellence networks, to identify and disseminate best practice amongst the teams.

Inspectors found good examples of a caring culture despite staff pressures. Staff were welcoming and professional, and we saw staff communicating with patients with empathy and in a polite and caring way. Feedback from patients regarding nursing staff was universally positive, and results from satisfaction surveys were encouraging.
Staff worked in partnership with patients and their family members when delivering care, and helped patients to access the information they needed to support treatment and wellbeing.
The service had a robust system in place for collecting and responding to complaints, and managers fed back findings from complaints in team meetings to support learning for staff.

There was good understanding of the different cultural needs and backgrounds of patients and staff, and the Trust had set up an award-winning Ethnic Minority Network to promote diversity and inclusion within the culture of services. Services offered good access to translation services, with patient literature available in many community languages and in accessible formats.
The service had established single points of referral across localities to offer easier access to patients, and the rapid response teams/community treatment teams provided an alternative to hospital admission for patients needing emergency treatment.

Inspectors saw some good examples of local leadership across community health services for adults, despite challenging circumstances. The staff we met told us that they felt cared for, respected and listened to by their colleagues and local line managers.

The executive team and local trust leads were also visible across services and were available to meet with staff through a number of initiatives.

Overall rating for this core service: Requires Improvement

We found that services for children and young people at North East London NHS Foundation Trust (NELFT) required improvements to safety, effectiveness and well-led. We rated the service as ‘good’ for caring and responsiveness.

The Community health services for children, young people and families (CYP service) had good overall safety performance across services and localities with low levels of serious incidents and good management of incidents generally. However, there were major staffing shortages and recruitment challenges across all staff groups and localities. There was extensive recognition of heavy and unsustainable caseloads for practitioners across all universal and specialist services. There were some data protection risks, including examples of staff using paper diaries to record sensitive personal information. We also found inconsistent compliance with paper record keeping processes in some services.
Universal and specialist services were based on evidence and good practice and delivered in line with national guidance. There was effective internal and external multidisciplinary working and there were pockets of excellent service provision. However, there was inconsistent measurement and analysis of patient outcomes across services and localities because of staffing capacity and heavy caseloads.
Staff across the CYP service were courteous and professional and service users were treated with dignity and in an age appropriate way. We saw staff communicating with service users with empathy and in a polite and caring way. Parents of children using services gave us universally positive feedback about the service.
There was good access to multiple CYP services, facilitated by the co-location of services in health centres and coordinated appointment bookings. However, there were challenges with long wait times and waiting list breaches for referrals to therapy and diagnostic services such as speech and language therapy, occupational therapy and social communication pathways.
The staff we met reflected the trust values and were dedicated to providing a good service. There were some highly effective, dynamic and progressive local leaders in some services who worked hard to improve quality and develop services. However this was not consistent across localities. There was no clear or documented vision for the CYP service as a whole and practitioners were not clear about the strategic direction of the CYP service.

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

There were some environmental concerns that would compromise the safety of patients.Wards had blind spots which would prevent observation of patients. There were multiple ligature points in ward areas and patient bedrooms. Ligature assessments and action plans were brief and lacked detail. This made it difficult for staff to identify ligature points and to mitigate the risks to patients. There were a number of outstanding maintenance issues on some of the wards visited. For example Ogura ward had 40 issues outstanding.

There were out of date medications in some of the clinic rooms. There was equipment that was past its review date.

Risk assessments, risk formulations and care plans were not always being updated and reviewed. Patients’ personal preferences were not always reflected in care plans. Not all patients had been given a copy of their care plan.

Not all staff were receiving supervision on a regular basis. Not all staff had received an appraisal.

Patients had mixed opinions about staff members. On two wards we were told that staff members entered patient bedrooms without knocking. We were also told staff members were not always responsive to patient needs. Staff sometimes cancelled patient leave and activities.

However:

All wards visited complied with Department of Health guidance on same sex accommodation.
Across all wards, 87% of staff were up to date with mandatory training..
Staff were aware of safeguarding processes and had received training. The acute wards had a named safeguarding lead nurse who communicated with the local authority about issues on the wards
Staff were knowledgeable about incidents and knew what was required to be reported.
There was good medical cover to the wards during the day and night.Patients admitted to the wards were assessed by a doctor at the time of admission and by a consultant psychiatrist within 24 hours.
There was regular physical health monitoring of patients on all wards. Staff followed NICE guidelines. For instance, there were psychological therapies available to patients.

Multi-disciplinary teams on all the wards had a multi skilled staff team of mental health professionals. The teams met regularly.

There was a good choice of food available, including foods for cultural and religious beliefs. A range of information was on display for patients including how to make a complaint, information about medications and advocacy services.

We rated the forensic inpatient/secure ward as good because:

The environment was clean and well maintained. The clinic room was well stocked and maintained, with emergency medical equipment checked daily.

All the patients on the ward told us they felt safe and that their possessions were secure. Risk assessments were thorough, up to date and agreed with individual patients.

There were appropriately qualified and trained staff on the ward at all times. There was good multi-disciplinary working across the team with a variety of mental health professions included. Staff regularly received supervision and appraisals. Levels of staffing were adjusted to the acuity of need on the ward.

Psychological assessment and treatments were readily available on the ward. The service offered a three month psychological follow up after discharge to prevent readmissions to the service which was not funded or commissioned for.

All staff had a good understanding of the Mental Health Act and Mental Capacity Act and maintained good documentation relating to the Acts.

Staff were caring, supportive and respectful of patients and their recovery. Care plans were contemporaneous, personalised and demonstrated clear evidence of patient involvement. Staff facilitated family involvement groups to promote family and carers participation with patient recovery. The team’s dedication to involving patients in activities and therapeutic activities in the community was good. The service had good links with a local professional football club, a local horticultural activity centre and the local college.

However:

An incident occurred a week before the inspection and an incident form had not yet been completed at the time of the inspection. A serious incident update form has since been completed and lessons were learned from the incident.

Mental Health Act original documentation was archived. Only the renewal papers were available on the ward which meant that staff could not follow the chronology of various documents related to the detention of patients immediately on the ward.

The advocacy services did not hold a dedicated, regular drop in clinic for patients.

We rated child and adolescent mental health wards as inadequate because:

The ward environments were not safe, clean or suited to the care of children and young people. The environment on the Willows ward was stark and unappealing. There were a number of historic maintenance issues on the ward which had not been remedied, for example we found broken dining room chairs which posed the risk of harm to young people. The overall cleanliness of both wards on the unit was poor and we found potential infection control risks. Cleaning records were not all up to date.The layout on both wards did not allow for good observation of young people. There were blind spots throughout the wards with no aids to assist with observations, for example convex mirrors. The wards completed a yearly ligature audit. The audit identified ligature risks around the unit and documented action to mitigate the risks. Actions included replacing ligature points with anti-ligature alternatives. Most ligature risks had been address through a recent programme of maintenance works at the unit. However, we found ligature points in the disabled toilet on Willows ward which had not been identified in the audit. There were no curtains or blinds on the bedroom windows on the Willows ward. This impacted on the privacy and dignity of young people. The family visiting room did not provide privacy when young people had visitors at the unit.
The wards were not adequately staffed. The unit had a vacancy rate of 58% and had a high reliance on bank and agency staff. Not all shifts were covered by sufficient numbers of staff to meet the needs of young people. During our inspection we observed two shifts without the minimum staffing levels. Access to doctors out of hours was not sufficient. It could take several hours for a doctor to attend the unit. Doctors who attended the ward out of hours did not always have a background in child and adolescent mental health. Staff members were not routinely receiving clinical supervision sessions.
There was a high usage of restraint and rapid tranquilisation at the unit. Staff restrained young people in the prone position and some restraints culminated in the administration of rapid tranquilisation.
The unit had blanket restrictions in place and restrictive practices. All doors were locked within the unit and young people had to rely on staff members to move throughout the unit. We observed young people unable to summon staff members to assist them moving between different areas of the unit and being left behind locked doors.

The level of incidents reported on Datix did not correspond with incidents recorded in young people care notes. Incidents were under reported.
Staff searched young people routinely following leave but the search policy was not in date. One young person had been asked to remove clothing during a search.
The wards were not effectively developing care plans or risk assessments. Care plans we reviewed were not recovery orientated and focused on behaviours. Care plans were not holistic and did not have young peoples’ views and goals. Risk assessments were sparse. The assessments contained little background and historical information about young people.

We could not find evidence in the case notes that staff had assessed whether the children and young people had the capacity to consent to admission and treatment.
The unit did not formally seclude young people. The unit did not have a seclusion room. However, during our review of care records the care plans showed evidence that young people may be secluded without proper safeguards in place.

Staff were not always responsive to the needs of young people at the unit. During our inspection we observed young people asking for staff assistance to get a drink or go to the toilet. Staff responded by saying they were too busy.

Young people reported the food was poor quality.

However:

The physical health needs of young people were assessed and monitored appropriately.
Staff were aware of safeguarding processes and had received training. The CAMHS service had a named safeguarding nurse lead who communicated with the local authority about issues on the wards.

We were told by staff that following incidents there was a de-brief for both the staff and young people. Incidents were discussed at daily risk meetings. The unit had also introduced daily safety huddles that were held in the morning and afternoon.
Feedback about incidents was done through daily risk meetings, weekly multi-disciplinary team meetings and in the weekly Brookside Quality and Performance meeting.
There was an advocacy service available to formal and informal young people at the unit.

Due to the severity of the concerns found during the inspection we issued the trust a warning notice under section 29A of the Health and Social Care Act 2008. The warning notice was issued as the CQC’s view of the quality of the health care provided required significant improvements. These improvements were as a result of risks to the health, safety and welfare of young people using the service were not always completed or mitigated. Care and treatment was not always provided in a safe way for young people. The warning notice also required improvements in relation to the unit not having effective systems or processes in place to ensure that the care and treatment provided to young people was in a safe environment.

We rated wards for older people with mental health problems as Requires Improvement because:

The ward environments did not always guarantee the safety of patients. All of the wards contained ligature risks of varying degrees. Work was underway to remove these risks but there was no completion dates set for this work. The layout of the wards we visited did not allow for staff to see directly into the patient bedroom corridors unless a member of staff was placed in this area or just outside. Patient bedrooms and en-suite bathrooms on one ward did not have an alarm system for patients to use to summon help from staff. The ward used a blanket restriction of locking the patient bedrooms during the day.
Two days prior to our visit, a patient sustained a fracture during an un-witnessed fall, whilst getting out of bed. The bedroom had no assistive technology such as an alarm or motion sensor pad to alert staff that the patient was getting out of bed, despite the patient being at risk of falls. The wards had implemented a daily ward check to prevent plastic bags and other contraband items being brought on to the ward following a serious incident. However this learning was applied inconsistently across the wards with plastic bags permitted in patient bedrooms in two out of three wards. During our visit the staff did not increase the level of care and intervention in response to one patient’s changing presentation during the day. However, the patient records did show that the patient had received regular physical health checks and a recent physiotherapy assessment.
The wards did not always support the dignity and privacy of patients and the wards were only partially dementia friendly in appearance. Apart from one, all of the bedrooms we saw were very bare and depersonalised in appearance. Patients were not able to open or close the viewing panel of their bedroom doors from inside, which could impact on their privacy. Each bedroom we looked at contained a safe with keypad access which would require the patient to memorise the keypad pin number. Patients with cognitive impairment or a mental health problem that affected their memory may have found this difficult and staff told us that patients never used the safes.
Not all staff had been adequately trained to carry out their responsibilities. Apart from training incorporated into the care certificate, not all of the staff across the three wards were specifically trained in dementia as recommended by National Institute for Health and Care Excellence. Not all healthcare assistants had access to Mental Capacity Act 2005 training. Mental Health Act 1983 training was not compulsory in the trust so there was minimal uptake of this training.
There was a lack of psychological review and formulation of patients with dementia following admission and prior to commencement of, or discontinuation of antipsychotic medicine for behavioural symptoms. The wards had limited input from a psychologist because the trust employed only one full time psychologist across the service. Input to the wards ranged from once a week to three times a week. Therapy was offered on an out-patient basis only.
The care plans were variable across the wards. The majority of care plans were holistic and personalised, but many lacked patient views and were not recovery focussed.
Some of the wards had delayed discharges. The wards told us the delayed discharges were often due to difficulties in finding appropriate supported accommodation and funding issues.
The wards used several information technology systems along with hard copies of documents. This meant that key information was stored in different places and could make it difficult for staff to access documents readily.

However:

All of the care records we looked at during our visit had robust, thorough risk assessments in place. These were reviewed and updated weekly or fortnightly, and more frequently if necessary. All of the care records we looked at showed good evidence that a physical examination had taken place on admission and that physical health reviews were done monthly, or more frequently if required. There was good assessment and monitoring of patient’s nutrition and hygiene needs.

Medicine was prescribed within the British National Formulary range.
There were no seclusion rooms on the wards and staff told us that they did not seclude patients. Instead they used de-escalation techniques to manage challenging behaviour. The wards began implementing ‘Safewards’ in November 2015. Safewards identifies areas where conflict may happen and provides ten interventions which aim to specific tools/behaviours to reduce these. All the wards had a ‘safety cross’ quality dashboard visible on the wards which displayed performance in key areas of safety and quality in an open and transparent way.
There was good adherence to both the Mental Health Act 1983, the Code of Practice 2015 and the Mental Capacity 2005. Many improvements had been made on the wards that had previously received a visit from a Mental Health Act reviewer.
Staff were trained in safeguarding and demonstrated that they had a good, detailed understanding of the safeguarding processes.
Staff described a friendly and inclusive ward culture and that they enjoyed being part of the team.
All of the wards adhered to the Butterfly scheme, which was designed to improve patient safety and wellbeing in hospital. Its focus enabled staff to respond appropriately to people with memory impairment or dementia. The wards also offered ‘Namaste Care’ which is a sensory based programme designed for use with people who have advanced dementia and is a dementia friendly approach to care. On some wards there was an excellent use of both pictorial images and words to help patients with cognitive impairment negotiate the ward. Food menu options were both in written and pictorial versions. We saw that a good variety and choice of food options were offered, including a healthy choice, vegetarian, Halal, Caribbean, pureed and gluten-free. There was a good range of activities provided on each of the wards, seven days a week.
Patients on all of the wards told us that they were treated with dignity and respect, and that staff assisted them with things like personal care. We observed staff interactions that were patient, person-centred and caring. Carers of patients on the wards told us they were involved in their relative’s care and supported when their relative was in hospital.

We rated wards for people with learning disabilities or autism as good because:

The ward environment was clean and safe. Risks associated with the environment and individual patients had been appropriately assessed. The service had a strong track record on safety, with no serious incidents recorded in the last six months. Staff reported incidents appropriately and there was evidence of sharing and learning from previous incidents.

The ward was well staffed and had adequate medical cover. Staffing levels were adjusted to reflect the fluctuating needs of the patient cohort and the risk levels present at that time. Any potential impact of staffing vacancies was mitigated by the use of bank staff familiar with the ward and its patients. The ward benefitted from an experienced MDT, including an appropriate level of psychology input. Although there was a reliance on locum professionals, the ward manager had ensured that they were of a high calibre, to safeguard the smooth running of the service.

Staff received the training and support necessary to perform their roles. Staff received training in positive behavioural support, accredited by the British Institute of Learning Disabilities; safeguarding adults at risk, the Mental Health Act 1983 and the Mental Capacity Act 2005. Selected members of staff from the ward were due to take part in a ‘train the trainer’ scheme to assist with the training of staff from adult mental health wards in positive behavioural support (PBS). Approximately 90% of staff had received an appraisal within the last 12 months, and staff received support regular supervision and staff meetings.
All patients had a good quality care plan that was personalised to their individual needs and focused on recovery. The physical health needs of patients were assessed and monitored appropriately. The multidisciplinary team (MDT) used the health of the nation outcome scale for people with learning disabilities (HoNOS-LD) and the Life Star holistic tool, in order to measure the progress of patients on the ward. Clinical staff participated in a wide range of clinical audits to monitor the effectiveness of services provided.

Patients and carers told us they were highly satisfied with the way staff treated them. We observed consistently high quality interactions between staff and patients on the ward. Staff displayed a great deal of passion for their work and had an excellent understanding of the specific needs and characteristics of each patient.

Patients and carers were involved in the care planning and risk assessment process.The ward actively sought the involvement of carers. Carers regularly attended weekly ward round meetings to discuss progress and plan for discharge. Staff encouraged patients to attend community meetings and daily planning meetings. Patients and their carers told us they felt able to give feedback on the service. At the time of discharge, all patients and carers were asked to give their feedback on the service provided by the ward, in the form of an exit questionnaire. Patients were involved in the recruitment process for new ward staff. The ward manager told us that a patient was normally part of each interview panel. During the past six months, there had been no complaints about the Ward.

The ward had a relatively low bed occupancy rate (73% for the period May to October 2015 (inclusive)). Patients’ beds remained open for them to return to following leave from the ward. Patients were not moved between wards during an admission episode unless they needed to be transferred on clinical grounds.

The ward had a range of rooms and equipment to support treatment and care, including a well-appointed sensory room. Patients had access to a choice of activities and outings each day and had the ability to request specific activities during a daily planning meeting.

The ward had notice boards displaying information on a wide variety of topics and an extensive range of information leaflets in easy-read format. Information on medicines was also available as an audio CD. The ward had recently introduced menus in a pictorial and easy-read format to assist patients in making informed meal choices. Patients had access to a culturally diverse range of meal choices that reflected their own cultural and ethnic backgrounds. The ward environment had appropriate adjustments for people with restricted mobility.

Staff were aware of the trust’s vision and values and these were clearly displayed on the wards. The appraisal system used by the ward was based upon the trust’s visions and values. The ward manager was able to submit items to the trust’s risk register during a monthly health and safety meeting. There was a high level of morale within the multidisciplinary team and the ward staff. Staff told us that the teams operated with a high degree of mutual support. Staff told us they felt able to approach the ward manager to raise any concerns, and were aware of the whistle blowing process. They did not raise any concerns relating to bullying or a fear of victimisation.

The ward had participated in (and had gained accreditation in) the Quality Network for Inpatient Learning Disability Services (QNLD) accreditation scheme; and, a joint study with the Florence Nightingale Trust into the benefits of equine facilitated psychotherapy for people with learning disabilities. Ten patients from Moore Ward took part in a six-week course of psychotherapy sessions involving contact with horses, after which it was found that there was a significant improvement on all the domains of the Life Star and a trend towards a reduction in psychological stress.

However:

Although staff had received most mandatory training, as of March 2016, only 50% of staff were trained in the “manual handling of people”.

One patient and a carer told us they felt that the meal portion sizes were too small and that meal times were inflexible. Both patients we spoke with told us they were not always able to have a hot drink in the late evening.

Bedrooms lacked any appreciable level of personalisation.

Access to the ward garden was problematic for people with restricted mobility, due to a protracted route around the perimeter of the Sunflowers Court site.

We rated community-based mental health services for adults of working age as good because:

The teams were safely staffed, with recruitment progressing to fill vacancies.
Staff in all the teams demonstrated a good understanding of safeguarding policies and procedures to keep people safe from abuse.
The caseloads of the teams were monitored regularly in meetings and individually in supervision. There were effective internal meetings and communication with the rest of the mental health pathway was good.
The community recovery teams had developed a physical health clinic and were expanding the amount of physical health screening available to people who used the service.
Nearly all of the people who use the service and carers we spoke with were positive about the care and treatment that they were receiving. They said that staff were respectful, kind and caring.
The teams had good access to psychiatry support and could arrange appointments at short notice, or get support from a doctor when they needed it.
Currently the community recovery teams did not operate a waiting list for allocation which meant that new referrals could be seen in a timely way.

However:

In some electronic records at the community recovery teams, risk assessments were not being recorded fully, and updated in a thorough manner, which meant that information that care professionals may need to use was inaccurate.
The AABITs had a fragmented approach to physical healthcare. People who moved between teams had varying input from GP's regarding their physical health. The relationship between the teams and primary care impacted people’s understanding of their care plans which were delivered by the GP.
There was a lack of involvement of people who used the service in the creation of some of the care plans in the community recovery teams, and some care plans we looked at were limited and did not reflect a broad, recovery focused, set of goals for every person.
A log of complaints received by each team, and progress to resolve complaints, was not available for us to view in the community recovery teams at the time of our visit.

We rated mental health crisis services and health-based places of safety as good because

The service provided safe and clean environments for people who used it.
Staff were experienced in managing crisis situations and services were designed to ensure that people were offered appropriate support in a timely manner.
The service provided a good range of psychological therapies. The home treatment teams had staff trained in open dialogue, a talking therapy which encourages families to discuss sensitive issues arising from psychosis.
Staff were caring and went the extra mile to ensure people were supported even if it meant adjusting their working hours.
The service was appropriately accessible to people 24 hours a day. This is in line with the Mental Health Crisis Care Concordat’s recommendations.
The service had systems in place to keep themselves updated with local support agencies. This ensured they were able to provide an effective signposting service to support people with a range of social issues. The service was also committed to being inclusive toward people from black and minority ethnic backgrounds.

However:

People who had been bought to the health-based place of safety did not always receive adequate assessment of their social needs before being discharged home. This meant that they could be returning to social situations detrimental to maintaining a healthy mental state.

We rated specialist children and young people’s community mental health services as good because:

There were strong and effective safeguarding processes in place throughout all of the teams and staff had the knowledge and skills to apply these processes effectively. All children and young people receiving care and treatment had access to specialist staff to offer treatment and care in a crisis and out of office hours. All children and young people in treatment had a risk assessment. All staff knew how to report incidents and received feedback in order to make changes to practice to prevent any re-occurrence.
Teams delivered a wide variety of psychological therapy and interventions including those recommended by The National Institute for Health and Care Excellence (NICE). Staff received training and put their learning into practice in their daily work. The multi disciplinary teams had exceptionally strong links to external agencies such as schools, the local authority, primary care and voluntary sector organisations.
Highly effective interventions were offered by passionate and committed staff. Staff were motivated and continually strived to provide the highest quality care and treatment for children and young people. We received feedback from children, young people and their families which was highly complimentary about the staff. Young people were actively engaged in a range of highly innovative participation projects.
All referrals were made directly into the single point of access teams. All referrals were triaged and urgent assessments were prioritised. Staff offered to see children and young people in satellite clinics which were non institutional and community based. This made it easier for children and young people to access support. Staff developed innovative feedback systems with children and young people. This feedback helped teams to improve the services.
Information about the newly re-commissioned services in Essex and the associated change process was comprehensive and inclusive. The trust senior managers and team managers were honest and transparent with staff and patients when discussing the services and challenges facing the teams. Managers used governance structures to make well informed decisions about service delivery.

However

There was no pro-active system in place to assess the risks to young people whilst they were waiting for assessment or treatment. This meant that opportunities to manage risk could be missed.
In the Walthamstow team nine children and young people did not have a care plan documented in their electronic care records.
Morale was very mixed in the teams. However this was in the context of the trust winning a new tender and 229 staff being moved into the trust from four other organisations. The process was however being managed effectively.

We rated community-based mental health services for older people as good because:

Arrangements for safeguarding were clear with good systems in place to monitor and follow up concerns. Patient areas at Barking and Dagenham and Waltham Forest were clean and well-maintained. Staff had manageable caseloads and managers ensured that workloads were evenly distributed across the teams.

Staff provided an effective service and the majority of care plans were personalised, up to date and reflected patient’s views. Staff followed best practice by using National Institute and Care Excellence (NICE) guidance and participated in clinical audit. Patients had access to psychological therapies such as cognitive stimulation therapy and took part in post diagnosis groups. Staff were considerate of patients physical needs and used a variety of assessment tools when assessing for cognitive impairment. Teams had experienced staff who had access to good specialist training and managers appraised and supervised them on a regular basis. Teams worked well with other internal services and external agencies, such as GPs, the voluntary sector and local authorities.

Staff were caring and interacted well with patients and carers. Patients and families were involved with their treatment and staff had addressed patient’s individual needs. Staff encouraged patients to give feedback on services.

The services were accessible and responded promptly to referrals. Staff engaged creatively with people who experienced more difficulty accessing services and had worked with the local community to make them aware of services. Teams had a wide range of information available for patients and environments at Barking and Dagenham and Waltham Forest were welcoming.

Teams were well led and had the right meetings, policies and procedures in place. Staff felt senior managers were visible and that managers supported them. Memory services were accredited with the Royal College of Psychiatrists.

However:

The environment at Havering was not fit for purpose and unwelcoming. Interview rooms at Havering and Barking and Waltham Forest did not have alarms which could compromise staff and patients safety. The environment at Barking and Dagenham did not have a dementia friendly environment.

Risk assessments at Barking and Dagenham contained little detail in regards to risk management andfour out of the six the care plans we reviewed were either missing or out of date.

Managers had difficulties in accessing information to monitor the quality of their services which were sourced from a large number of different systems. Records of supervision at Barking and Dagenham and Havering were unavailable for this reason.

We rated North East London NHS Foundation Trust as requires improvement for the following reasons:

The child and adolescent mental health wards were a particular of concern, where we identified concerns in relation to a number of areas including staffing, restrictive practices, lack of incident reporting and lack of recovery orientated care planning. On this ward, and that of the acute wards for adults of working age and older people mental health wards risks were not always mitigated in relation to the needs of the patients. The environment of the acute wards for adults of working age and older people mental health wards were not safe as the trust had failed to ensure that the risks to patients from ligature anchor points were identified, assessed and appropriate works to address them scheduled. We served a Warning Notice on the trust in relation to these areas.
In the community health services there were major staffing shortages and recruitment challenges across all staff groups and localities. There were high caseloads for staff, high use of agency and bank staff, all which had an impact on the delivery of the services.
The trust had not demonstrated appropriate learning from incidents and not taken appropriate steps across all of the mental health services to ensure that risks to patients from ligature anchor points had been taken to minimise the risks these might pose to patients.

Training in the Mental Health Act was not part of the mandatory training for staff in the mental health services which could lead to staff not working effectively with patients at risk of harm to themselves or others.
There was a lack of consistent recording of patient risk across the services to ensure these were captured and plans made to minimise risks.
Improvements were needed in the rate of supervision and appraisals of staff across the trust.
Improvements were needed in the capturing of information about people who use the services as diversity information was not routinely recorded across services.
The trust did not have a Patient Advice and Liaison Service (PALS) and so this advice was not available to people. This meant that patients and users of the service had to contact the service directly and go through complaints procedures without the additional support of an advice and liaison service. This might deter people from raising concerns or complaints.
The board did not have assurance that all clinical risks, including those linked to regulatory compliance had been addressed. The trust governance structures had not been fully embedded and did not ensure consistency across services.
The trust quality assurance processes had not identified if learning from incidents were implemented or that services were deteriorating.
The trust did not meet the fit and proper persons’ requirement for directors and was not compliant with the law. Also, there was a lack of robust induction or training for the trust governors, which meant they might not be as effective as they could be in their role.

However:

The trust had good overall systems and processes for managing safeguarding children and adults at risk.
There was good access to physical healthcare across the services and this was kept under regular review.
Directors and managers demonstrated commitment and enthusiasm to the trust and spoke passionately of the work being undertaken to develop services.
The trust had taken positive action in response to the recent NHS staff survey to involve and engage staff more in the development of the trust.
There was a well-established patient experience partnership group with direct links to the board to enable strategic developments for people using services.
Staff well-being, particularly through the black and minority ethnic network has worked to address inequalities, which has been recognised at a national level. The workforce race equality standards have been met.

We rated community mental health services for people with learning disabilities as good because:

People referred to the services were safe because there were systems to assess their needs and ensure people who had the most urgent need were seen first and that people’s health was monitored while they waited.
Robust safeguarding procedures and practice ensured that people who used the services were kept safe.
People who used the services and their families were involved in the support they received.
Teams comprised of a wide range of professionals to meet the diverse needs of a wide range of people who used the services.
Staff morale was good and teams were dedicated to provide support led by a strong leadership team.

However:

The teams did not used outcome measures in the work they did with people who used the service.
Mental Health Act training was not mandatory for the teams we visited.
Training completion rates were low in some areas such as Mental Capacity Act (MCA), health and safety, and safeguarding.

The previous inspection of services for older people with mental health problems at Sunflowers Court was carried out in December 2014 under our previous inspection regime. Consequently, the service was not rated.

This inspection, carried out on 20 October 2015, focused on whether North East London NHS Foundation Trust had made improvements in relation to those areas where the service was previously non-compliant with health and social care regulations. We did not make any judgements about ratings.

Services for older people with mental health problems will be rated at the next comprehensive inspection of North East London NHS Foundation Trust.

This inspection found:

Staff knew how to access emergency equipment, such as ligature cutters, in an emergency.
Staff had developed individual plans to manage the risks to the health and safety of each patient.
Relatives reported that staff cared for patients safely.
Staff treated patients with kindness and respect.

Staff supported patients to participate in activities.
Patients and relatives on both wards were able to access information about how to complain and advocates visited the ward.
Overall, staff involved patients and their relatives in planning and reviewing their care and treatment.

However:

Where patients lacked mental capacity, staff had not fully involved relatives in making decisions about their family member’s care and treatment.
Minutes of community meetings did not always explain how staff would address the complaints and concerns raised by patients.
Patients were not supported to make advance directives about their care and treatment.

We carried out our previous inspection of acute wards for adults of working age and psychiatric intensive care units at Sunflowers Court in December 2014. This was completed under our previous inspection regime. Consequently, we did not rate the service.

This focused inspection, carried out on 20 October 2015, checked whether North East London NHS Foundation Trust had made improvements in relation to those areas where the service was previously non-compliant with health and social care regulations.

We will rate acute wards for adults of working age and psychiatric intensive care units at our next comprehensive inspection of North East London NHS Foundation Trust.

This inspection found:

Staff prescribed and managed anti-psychotic and sedative medicines safely. Staff followed trust procedures to ensure they protected patients from the risk of over-sedation.
Staff carried out appropriate checks on the physical health of patients.

Staff knew how to access emergency equipment, such as ligature equipment, in an emergency.
Staff had developed individual plans to manage risks to the health and safety of each patient.
Staff treated patients with kindness and respect. Staff involved patients and their relatives appropriately in planning and reviewing their care and treatment.
Activities were available to patients on Titian and Ogura wards.

Patients on both wards were able to access information about how to complain and advocates visited the wards.

However:

Staff did not always explain in the notes of community meetings how they would address the complaints and concerns patients had raised.
Whilst staff appropriately observed patients assessed as being at risk, we identified a number of ligature points on Titian ward. The trust had not completed a risk assessment to identify all the ligature points on the ward and the trust did not have an action plan or schedule of works that explained how the trust would address these risks. Staff had not appropriately assessed or managed potential ligature risks associated with the use of plastic bin bags in communal areas of the ward.
Patients could not always keep their possessions secure because on Titian ward there was a blanket ban on patients having the key to the locker in their bedroom. Senior managers informed us during the inspection that they would immediately rectify this and patients would receive a key to their locker unless this posed a risk to health and safety.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

All Inspections

The trust provides the following mental health services, which we did not inspect this time:

The trust also provides the following community health services, which we did not inspect at this time:

Our overall rating of the trust improved. We rated the trust as good overall because:

How we carried out the inspection

What people who use the service say