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Provider: South West London and St George's Mental Health NHS Trust

Inspection Summary


Overall summary & rating

Updated 12 June 2014

South West London and St George’s Mental Health NHS Trust provides integrated mental health and social care services to the communities of Kingston, Merton, Richmond, Sutton and Wandsworth.The trust also offers a number of specialist regional and national services. These include the National Deaf Services, which support Deaf people with mental health needs, an Eating Disorders Service, and the Behavioural Cognitive Psychotherapy Unit, which provides treatment and support for people with obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) services.

The trust operates from over 90 sites (most of which offer services covered under the Trust Headquarters registration) with three main inpatient sites. The trust currently employs about 2,300 staff, serving a population of just over 1 million people, having 460,000 patient contacts a year. The trust has an annual budget of £156 million and is nearing its final stages towards achieving Foundation Trust status.

The trust has three acute inpatient services at Springfield Hospital in Tooting, Tolworth Hospital in Surbiton and Queen Mary’s Hospital in Roehampton. The trust also has other inpatient services at Hayden House in Battersea, Westmoor House in Roehampton and Thrale Road in Wandsworth.

CQC has inspected all of the trust’s locations in the last two years. Inspections of the acute services at Tolworth Hospital resulted in compliance actions. The trust had prepared action plans in both these areas and we checked their progress as part of this inspection.

During our visit we held focus groups with a range of staff (qualified and in training nurses and doctors, allied health professionals, Associate Hospital Managers and the trade unions). We talked with carers and/or family members, observed how people were being cared for,and reviewed patients’ care and treatment records. We visited the three hospital locations and community bases.

We carried out unannounced visits on 21 March to Ward 3 atSpringfield Hospital and 1 May 2014 to Seacole Ward at Springfield Hospital.

During this inspection we visited the following services:

Springfield University Hospital

Core service provided: Five acute admission wards; two specialist deaf services; one Health Based Place of Safety; two eating disorder wards; one ward forolder people; five long stay/forensic/secure service; and one child and adolescent mental health service.

The wards are a mix of same sex and mixed accommodation.

Capacity: 250 beds

Queen Mary's Hospital

Core service provided: Three acute admission wards.

The wards are a mix of same sex and mixed accommodation.

Capacity: 67 beds

Tolworth Hospital

Core service provided: Two wards for older people; one acute admission ward.

The wards are all mixed sex accommodation.

Capacity: 48 beds

As part of the inspection we met with key members of staff and executives. In these meetings it was clear that the trust board were aware of the progress required to become a Foundation Trust. Members of the board gave us a clear account of the challenges they faced and the journey they had been on to put quality at the front of the agenda which, in their view, it had not been in place when they took up office. During the inspection it was clear that there was still some required work, for example some of the front line staff we met with did not understand some of the initiatives which have been put in place to improve quality. Board members, in general, recognised this to be the case.

CQC were assured that the members of the board had a good recognition of the current position of the quality within the trust.

We found that the non-executive directors were a strong and effective group who had a good knowledge of their role and who exercised their duties effectively.

People using the service told us, and we observed, that the trust’s staff were caring and had a good approach to patient care, and interacted positively and compassionately with people. Much of the care deliveredfollowed best practice and we also saw examples, where no guidance existed,of the trust's staff working with the National Institute for Health and Care Excellence to produce this.

We found that the trust's staff had completed mandatory training; however we also noted that in several clinical areas training for the specific needs of the people using the services was not available. Many of the staff working in older people’s services had not undertaken training in dementia care and this was having an impact on the quality of care received by people using this service.

The working relationship between inpatient and community services was well established across trust's service areas. We also saw good examples of people using services being engaged and involved in the planning and review of their care.

We found that application of the Mental Health Act across the services was good. People were lawfully detained and had their rights read to them at the appropriate times. We noted that some of the actions identified in the monitoring of the Mental Health Act had not been completed by the trust.

There had been concerns about compliance with the rapid tranquilisation policy. However, the trust had identified this in an audit and was making improvements. We confirmed this when we looked at records on four separate wards.

We looked at records for people prescribed medicines ‘as required’. We saw patients who were administered as required lorazepam and promethazine with no record in their progress notes as to why it was being given. This meant it could not be checked if these medicines were being used appropriately.

The planning and delivery of care in some clinical areas did not meet the service users individual needs or ensure their welfare and safety as we found comprehensive management plans were not consistently being put in place for people using the service where a risk to themselves or others had been identified.

Inspection areas

Safe

Updated 12 June 2014

There were examples of learning from incidents at individual sites and across the trust.

However, we identified a range of errors and weaknesses in the reporting ofrisks and quality and theaction taken following an incident at Springfield University Hospital, which could affect the trust’s overall assurance. The trust needs to disseminatethe learning from these incidents betterto protect people using the service and to use the information to drive improvement across all areas.

The trust's Quality Assurance framework was used to monitor thetrust's risks.

The staff we spoke to duringour inspection across all thetrust's sites clearly understood theirroles and responsibilities around safeguarding the people they were caring for.

Staff also had a good awareness of the trust’s whistleblowing procedure and were able to describe several methods for raising concerns.

Generally, services at South West London and St Georges Mental Health Trust were safe. Incidents were reported and reviewed.

Effective

Updated 12 June 2014

In the majority of services we inspected, most teams were using National Institute for Health and Care Excellence (NICE) guidance as part of their treatment plans. In the deaf child and adolescent mental health services (CAMHS)area, where there were no current guidelines, the team were working with NICE to develop these.

Care and treatment in most services was effective. Information about people’s needs was effectively handed over between the community teams and inpatient areas. In the CAMHS this was particularly effective.

In the 2012 NHS Staff Survey, 95% of staff indicated they had received an appraisal in the past 12 months. Partial information for 2013/14,presented to the board in December 2013, showed that Personal Appraisal Development Reviews (PADR) were currently at 84%.

The trust monitored their use of the Mental Health Act. This monitoring had identified there were areas for improvement, butthe use of the Act was mostly in line with the Code of Practice.

Many staff told us that there was no money or time given for training beyond mandatory training.

Caring

Updated 12 June 2014

The majority of patients and carers we spoke to described staff as caring and compassionate. While we were on the wards we saw staff treating people with dignity and respect.

The electronic patient notes (EPN) did not show that people were involved in decisions about their care or had contributed to their care plan.In areas where the EPN was not being used, we saw examples of people being involved in decisions about their care, contributing to their care plans and having their own copies of these plans.

Interventions, including restraint and seclusion, needed to be reviewed to ensure they were being properly recorded and monitored and were happening safely across all parts of the trust by properly trained staff.

Responsive

Updated 12 June 2014

Some people could access services, including inpatient and community teams, at the right time and without delay. However, bed occupancy was a concern. On several of the wards we visited we found patients sleeping out on other wards due to bed shortages.

In the children and adolescent mental health service, children and young people were waiting a long time to receive the right service after initial referral. The individual needs of people in the older people’s services were not always met due to a lack of specific training for staff. There was no psychiatric intensive care service at the trust for female patients and we heard that patients had to be transferred to services out of the area.

Many clinical areas had mixed sex wards. This meant, in the acute admission wards, CAMHS wards and older people’s service, people did not always receive the care they required and their privacy and dignity was not always maintained.

The trust had recently changed the process for replying to and investigating complaints. This had shortened the length of time complaints were taking to be reviewed, and meant no complaints werebacklogged.

Well-led

Updated 12 June 2014

All members of the trust's board, with the exception of the director of finance, were relatively new in post, and since their appointment the trust has made some significant changes to the leadership of the organisation. The board members were able to describe to us the vision and direction of the trust. The non-executive members explained how they were able to challenge where appropriate. We found that these directors were a strong group who understood their roles and duties effectively.Before ourinspection we engaged with stakeholders, who described the trust as 'being on a journey'. Without exception, the people we spoke with, were confident that the new chief executive and the trust's board were able to provide the leadership and governance required.

At the time of our inspection, a transformation programme was underway within the directorates. Feedback from staff we met during the inspection indicated that there was a mixed level of engagement with this process. Many staff spoke highly of their line managers, butfelt disconnected with more seniormanagers.

While there was some concern about the future of the community CAMHS service, the staff in these teams were resilient to this and were delivering a very good level of care to the people using the service.

Systems were in place to enable people using services, staff and others to give feedback. These included Listening into Action (LiA), a programme to place staff at the centre of decision making in the trust,which empowered staff to make changes to the way they work to improve the quality of the care provided. The chief executive had also hosted five ‘staff conversation’ sessions. Over 300 staff attended these. The themes emerging from these events have also been addressed by the LiA team.

While staff engagement was improving, this was an area for more work as this was integral to making the changes a success.

There was also a Service User Reference Group that met monthly. Members of this group told us that it felt like it has lost its way and become tokenistic.

Checks on specific services

Wards for older people with mental health problems

Updated 24 August 2015

  • Working age adults were being admitted to the wards for older people. This compromised the safety of patients. There had been serious incidents on Crocus ward involving younger adult patients.
  • The wards for older people did not comply with guidelines for gender separation. Some patients had to walk through communal areas to reach the bathroom, which compromised their privacy and dignity.
  • Staff carried out a visual check on patients' skin integrity when they were admitted to the wards. They did not carry out a formal assessment of risk of developing a pressure ulcer for every patient. This was contrary to trust policy.

  • Staff had left patient related information unattended in a ward dining room;
  • Patient observation records were not always completed or were completed retrospectively;

However, staff carried out assessments of patients' risk of falls and put plans in place to address the risks identified. Staff managed medicines safely. The ward environments had been adapted to make them more suitable for patients with dementia. There were sufficient staff to care for patients safely. Staff had been encouraged to report all incidents. Consequently, there had been an increase in the number of patient falls reported by staff.

Staff assessed patients' needs and put care plans in place to address the needs identified. Patients had good access to physical health care. Several staff had completed specialised training in dementia care. Staff received regular supervision and most had completed an annual appraisal. Multi-disciplinary teams worked well together on the wards.

Acute wards for adults of working age and psychiatric intensive care units

Updated 24 August 2015

  • Ligature risk assessment and management was inconsistent and staff did not always recognise risks or know how to manage risks safely.

  • On Lilacs ward, patient risk assessments and management plans were not always updated following risk incidents. Staff had not always followed risk management plans.
  • On Lavender ward some patients were administered ‘as required’ medicines every night. The reasons why patients required these medicines was not always recorded or reviewed.

  • Some equipment on Lilacs and Lavender wards was not maintained on a regular basis to ensure it was fit for purpose.

  • On Lilacs ward not all patients were aware of their care plans. Care plans did not address all of the patients needs, and did not reflect their preferences. Many patients were not involved with the development of care plans.

  • Staff on Lilacs ward in particular lacked understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. There was a risk that they did not recognise when a patient was unable to give consent and did not understand their legal responsibilities.

  • Staff on several wards did not receive regular supervision.

  • Patients on Lilacs ward and ward one did not have access to a regular programme of meaningful activities as these were often cancelled or not being provided.

  • Detained patients on Lavender ward did not always have a consent or authorisation certificate in place.

However, on ward three a harm free care pilot had been conducted. This was now on-going. This looked at medicine errors, violence, self harm and falls. This information was presented in an easy to understand way. All wards, except the PICU, provided mixed sex accommodation. These wards adhered to national guidance by having separate male and female areas. Emergency resuscitation equipment was in place and checked regularly. Where rapid tranquilisation was used physical monitoring of patients took place at regular intervals. Learning from serious incidents led to improvements in care.

On Lilacs ward, a morning multi-disciplinary handover took place every weekday. This enabled continuous medical review of patients without waiting for the next ward round. Some of the wards had recruited peer support workers. The peer support workers were part of the team. They offered insight into what it was like to be a patient. They helped patients orientate themselves to the ward. They also helped staff and patients to work positively together.