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

Inspection Summary


Overall summary & rating

Good

Updated 2 December 2016

After the inspection in September 2016, we have changed the overall rating for the trust from requires improvement to good because:

  • In March 2016, we rated 7 of the 10 core services as good.

  • In response to the September 2016 inspection findings, we have changed the ratings of one more core service from requires improvement to good. This is the core service for community based mental health services for older people.

  • Also after the September 2016 inspection, we have changed ratings of the following key questions from requires improvement to good:

  • the effective key question for wards for older people with mental health problems,

  • and the effective domain for mental health crisis services.

  • In the services we inspected, the trust had acted to meet the requirement notices we issued after our inspection in March 2016.

  • We also carried out a ‘well led’ review and found that the trust had continued to strengthen its senior leadership team and refine the trust governance processes.

However:

  • Following the March 2016 inspection, we rated two other core services as requires improvement. These are the rehabilitation wards for working age adults and community based mental health services for adults of working age. We also rated the safe domain as requires improvement for forensic services and child and adolescent mental health wards. The trust has provided clear action plans explaining the changes taking place over a longer timescale. The Care Quality Commission will return at a later date to re-inspect these services.

The full report of the inspection carried out in March 2016 can be found here at http://www.cqc.org.uk/provider/RQY

Inspection areas

Safe

Requires improvement

Updated 2 December 2016

We rated safe as requires improvement because:

  • In March 2016, we rated five of the 10 core services as requires improvement for safe. This led us to rate the trust as requires improvement overall for this key question.

  • In September 2016 we inspected one of the core services rated as requires improvement for safe.

  • We have changed the rating of safe for community mental health teams for older people from requires improvement to good. This is because the service had addressed the problems with how they manage and transport medicines that we identified during the March 2016 inspection. In March 2016, we found that in some staff did not always transport medicines to people’s homes safely and the teams did not always keep a record of stock medicines. During this inspection we found the trust had made improvements in this area. A new lockable bag for carrying medicines had been introduced in all the teams. Staff kept accurate records of stock medicines held in the team medicine cupboards.

  • We did not reassess the four remaining core services during the September 2016 inspection and so have not changed their ratings. This means that the rating for the trust for safe remains requires improvement overall.

Effective

Good

Updated 2 December 2016

We rated effective as good because:

  • In March 2016, we rated four of the 10 core services as requires improvement for effective. This led us to rate the trust as requires improvement overall for this key question.

  • In September 2016 we inspected two of the core services rated as requires improvement for effective.

  • When we inspected in March 2016, we found that many staff in the home treatment teams and in Crocus ward, an inpatient ward for older people with mental health problems, were not receiving individual managerial supervision on a regular basis. When we visited in September 2016, we found the trust had made a significant improvement in this area. Most staff were receiving regular one to one supervision. A new policy and system for recording and monitoring supervision had been introduced which was well liked by staff and effective.

  • This is a change of rating since the last inspection.

Caring

Good

Updated 2 December 2016

  • At the last inspection in March 2016 caring was rated as good. Since that inspection we have received no information that would cause us to re-inspect a core service or change the rating.

Responsive

Good

Updated 2 December 2016

We rated responsive as good because:

  • In March 2016, we rated three of the 10 core services as requires improvement for responsive. This led us to rate the trust as requires improvement overall for this key question.

  • In September 2016 we inspected one of the core services rated as requires improvement for effective.

  • At the last inspection in March 2016, we found that the administration support for the Kingston community mental health teams for older people team did not ensure that appointment letters were reaching patients and GPs in a timely manner. The information needed to deliver care, was not always available to staff when they needed it. At the current inspection we found that the administration system that had been introduced shortly before the last inspection had improved and the systems were starting to be embedded across the trust. Letters to patients regarding appointments and to GPs were being sent out in a timely manner. The administration system was being rolled out across the trust.

  • This is a change of rating since the last inspection.

Well-led

Good

Updated 2 December 2016

We rated well-led as good because:

  • At the last inspection well-led was rated as good.

    At this inspection we completed a ‘well led’ review and we found that the trust

    had continued to strengthen its senior leadership team and refine the trust governance processes. The rating remained good.

Checks on specific services

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

Good

Updated 16 June 2016

We rated the acute wards for adults of working age and the psychiatric intensive care unit as good because:

Staff treated patients with dignity and respect. Staff made sure that patients, their carers and families were involved in their care and treatment. Patients had access to independent advocates to support them to raise issues concerning their care and treatment and staff referred patients to advocacy services when required

Staff followed best practice when undertaking the care and treatment of patients. Staff closely monitored the physical health of patients and systems were in place to promptly respond to patients’ health needs.

Despite obvious bed pressures to find enough beds for all patients who needed to be admitted to hospital effective systems were in place to deal with these challenges. Efficient systems were in place to plan and facilitate the discharge of patients.

Wards were clean and well maintained with good furnishings and sufficient facilities to ensure that patients’ needs were met. There was good infection control.

There were sufficient staff on the wards for wards to be safe and to ensure that patients had leave and attend activities to support their recovery. Staff were properly qualified and experienced to undertake their duties and to support patients’ needs. Staff on the wards received good support from management, were supervised and encouraged to develop their skills and knowledge.

Wards were well run by managers who delivered effective leadership to support and motivate their staff. Managers put effective systems in place to help monitor and improve standards. Systems were in place to ensure that staff promptly reported any incidents on the ward and that they then took any actions required to respond to them.

However, not all wards met targets for mandatory staff training. Some care plans for patients’ lacked detail in stating their wishes and preferences. Staff did not always ensure where detained patients had not initially understood their legal rights that they then repeated this information sufficiently promptly. Several patients felt that staff were too busy to spend time with them. Staff did not always store or administer medications in accordance with best practice or trust policy. The toilet facilities on one ward compromised patients’ dignity. There was scope for more activities to be provided at the weekend.

Child and adolescent mental health wards

Good

Updated 16 June 2016

We rated child and adolescent inpatient mental health services as good because:

Staff were kind and treated children and young people with dignity and respect. Young people were able to participate actively in decisions about their care and in decisions about the running of the ward. Staff undertook a comprehensive assessment of the physical and mental health of each young person on admission and these were monitored throughout their stay.

The ward provided a comprehensive range of treatments using medication and therapies in accordance with best practice from bodies such as the national institute for health and care excellence. Care and treatment was provided by a team of qualified doctors, nurses, social workers and therapists, all of whom showed a good knowledge and understanding of the young people. Staff received specialist training for their role, including a psycho-social interventions course, dialectical behavioural therapy training and training on the Children’s Act 1989.

Young people had access to quiet areas of the ward. Outside there was a courtyard where young people could play games. The trust had adapted a bedroom and bathroom for young people with disabilities. Young people could continue with their education at an on-site school.

The manager supported staff to raise concerns. The views of young people and their families were collected and reviewed to measure the quality of the service.

However, staff were not recognising that when young people were using the low stimulus room that this was seclusion and so the correct safeguards including medical and nursing reviews were not in place. . Staff supervision records were not being stored appropriately.

Community mental health services for people with learning disabilities or autism

Good

Updated 16 June 2016

Community mental health services for people with learning disabilities were good because:-

People who used services and carers told us that staff were kind, caring and helpful. Staff had a very good awareness of the individual needs of people who used services and this was reflected in comprehensive, detailed and individualised care plans and thorough risk assessments which involved people who use services and reflected the communication needs of people who used the services.

Staff had a good understanding of how to report incidents and were able to give examples of incidents in the service and reflect learning from incidents and complaints. Staff undertook a wide range of clinical and non-clinical audits within the teams and worked to improve outcomes through these.

There were no waiting lists for the service. People referred to the service were seen in a timely manner and had access to out of hours emergency support if necessary.

Staff were very positive about the local leadership both from their line managers and from the consultants within the team and this was the basis of positive team work in a multidisciplinary setting.

However, the team manager post for Wandsworth community mental health learning disability team was vacant and had been vacant for 15 months at the time of our inspection. This post was being covered by the manager of the Merton and Sutton team. Efforts had continuously been made to recruit into this post but it did leave both teams without a full time manager on site.

Community-based mental health services for adults of working age

Requires improvement

Updated 16 June 2016

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

Work was needed to ensure patients were safe and had their needs met. In some adult community teams there was more work to be done to ensure individual patient risk assessments were up to date and reflected their current risks. The trust needed to monitor waiting times for patients to access psychological therapies when they were ready for this treatment, to ensure this was provided in a timely manner. A small number of patients needed to be allocated to a care co-ordinator.

In a couple of teams more work was needed to encourage patients to attend their appointments or follow them up if they did not attend. The trust must also ensure patients in Kingston receive their appointment details and records of reviews in a timely manner, although work was taking place in order for this to improve. The Wandsworth rehabilitation and recovery team had to ensure that the patients they supported were achieving positive outcomes. A few outpatient interview rooms needed to improve their sound-proofing. Some patients needed a copy of their care plan.

In terms of management, some teams felt they would like to see senior staff more frequently. The performance information used by managers needs to be amended where teams have reconfigured so managers have access to the correct data to inform improvements that need to be made.

However, staff were responsive and respectful to patients and had a good understanding of their individual needs. Staff had established positive relationships with patients and communicated well with relatives and carers. Patients themselves spoke positively about the support they received from staff and felt they were treated with dignity and respect. Patients could give real time feedback to staff.

Patients had access to individual crisis plans and staff were confident about how they would address any safeguarding concerns to keep people safe. There was effective multi-disciplinary team working to support patients with complex needs.

The reconfigured teams were making services more accessible and promoting good work with other teams in the trust and external professionals and organisations. Staff had access to opportunities for learning and development.

Community-based mental health services for older people

Good

Updated 2 December 2016

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

  • Following our inspection in March 2016, we rated the services as good for effective, caring and well led.

  • During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe and responsive as requires improvement following the March 2016 inspection.

  • The community based mental health services older people were now meeting Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Forensic inpatient/secure wards

Good

Updated 16 June 2016

We rated South West London and St George’s Mental Health NHS Trust forensic inpatient wards as good because:

The wards were clean and safe. Procedures and practices were in place for the management of infection control. Staff of all disciplines had a good understanding of relational security and staff were committed to minimising the use of restraint and seclusion in the service.

Staff assessed risks to patients were on admission, regularly reviewed these and linked them to their plan of care. Staff knew how to protect patients from harm and were knowledgeable about how to recognise signs of potential abuse and the reporting procedures that were in place. There were enough suitably qualified and trained staff to provide care and treatment to a good standard. The multi-disciplinary teams were pro-actively involved in patient care, support and treatment.

Patients had access to a variety of psychological therapies either on a one to one basis or in a group setting. Psychologists, occupational therapists and exercise therapists were part of the multi-disciplinary team and were actively involved as part of their treatment. Both individual clinicians and the senior management team within the service had a good understanding of the effectiveness of the care and treatment, which they delivered.

We saw kind and caring interactions between staff and patients on all the wards. Staff demonstrated a good understanding of patient’s individual needs and preferences. Staff made every effort to maximise people’s dignity. Patients had access to an independent advocacy service. The majority of patients told us they felt safe.

There were different forums for patients to be consulted on their views and to feed back their experiences about how the service was run. Patients spoke positively about the wide range of therapeutic, educational and physical therapies that were offered. There was a robust complaints procedure in place. Patients knew how to complain. Complaints were responded to according to the trust policy.

Staff were provided with regular supervision, annual appraisals and had access to mandatory and specialist training and training provided within the trust.

Staff were aware of and had a good understanding of the trust’s vision and values and how these were implemented in everyday practice. The culture within the service was open and transparent, staff morale was good and Senior managers within the service were visible and accessible to staff and patients.

However:

  • Time management practices being used on Halswell and Turner wards were not recognised as seclusion practices and patients subject to these practices did not meet the safeguards set out in the MHA Code of Practice.
  • Patients on Halswell, Ruby and Turner wards reported that fresh air breaks did not take place regularly, and that on occasions leave was cancelled due to insufficient staff on duty. There was no evidence that this was being monitored or recorded by the staff.

Long stay/rehabilitation mental health wards for working age adults

Requires improvement

Updated 16 June 2016

We rated long stay/rehabilitation mental health wards for working age adults as requires improvement.

These services were very mixed. Burntwood Villas demonstrated many very positive examples of supporting patients with their rehabilitation. The other services had progress to make and needed managers with the leadership skills to ensure the services had a recovery orientated approach. Many patients had a longer length of stay than was anticipated in the operational policies for the service. There were significant differences in the support being given to patients to promote their independence. For example at Burntwood Villas patients were accessing educational and work opportunities in the community and in the other services the activities were mainly on the ward and would benefit from having a greater focus on rehabilitation, for example developing more skills such as cooking or progressing towards self-medicating.

In terms of safety on the wards, not all identified risks from risk assessments had management plans in place. At Thrale Road there had been occasions when medication was out of stock and also the temperature of the medication had been too high and this had not been addressed. Nine staff on Phoenix ward were waiting for training on moving and handling including how to use the hoist and the team was supporting two patients with mobility issues. Whilst staffing levels were safe, on Thrale ward regular 1:1 sessions were not always taking place with patients and staff.

Not all staff were having access to regular individual supervision. Access to occupational therapy input varied and this was having an impact on the support available to patients.

However, most patients said there were supported by staff who were caring and respectful. On Phoenix ward a few patients said that the attitude of a few staff needed to improve. The morale of the staff was positive. Governance processes were in place to support the management of the services.

Most patients said they felt involved in their care. We found particularly strong evidence of this at Burntwood Villas. Regular ward community meetings took place and patients were able to suggest improvements to the wards, although at Westmoor House these were not always recorded or followed up. Staff and patients were aware of the advocacy services available and information leaflets about the service, different diagnoses, medication and how to complain were placed at the entrance of the wards and in communal areas.

Staff were aware of how to identify and report an incident and a safeguarding issue. Staff had an understanding of their responsibilities under the duty of candour, being open and transparent and explaining to patients if and when things went wrong. Staff carried out physical health examinations on admission and carried out regular, ongoing physical health monitoring for patients.

Mental health crisis services and health-based places of safety

Good

Updated 2 December 2016

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

  • Following our inspection in March 2016, we rated the service as good for safe, caring, responsive and well led.

  • During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective as requires improvement following the March 2016 inspection.

  • The mental health crisis services and health based places of safety were now meeting Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Specialist community mental health services for children and young people

Good

Updated 16 June 2016

We gave an overall rating for the specialist community mental health services for children and young people of good because:

Young people and their families were treated as partners in their care. Staff treated young people and their families with kindness, dignity and respect.

Managers supported staff to deliver effective care and treatment. Staff adopted a multi-disciplinary and collaborative approach to care and treatment. There was strong leadership at both local team and service levels, which promoted a positive culture. There was a commitment to continual improvement across the services.

There were clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was apparent across the services.

Most young people, children and families could access services promptly. There were robust systems in place to manage referrals and waiting lists. However, in one area, there was a waiting list for treatment and this team was not meeting local targets. Staff worked to ensure young people attended their appointments. Numbers of patients who did not attend were closely monitored

However, the processes for assessing and managing the risk for young people identified as low risk were inconsistent across the teams. The local arrangements for lone working and for managing incidents of violence were being reviewed but this work needed to be fully implemented.

The interview rooms at the Kingston service were not sufficiently sound proofed to avoid confidential conversations being overheard. Support was needed for the administrative staff while they were going through changes in how their work was delivered.

Specialist eating disorders services

Updated 5 April 2016

The service had a clear action plan in place that focused on improving the care and treatment provided to patients on the ward. There had been improvements in the ward environment and there was an ongoing programme of refurbishment.

The ward admitted patients from across the country and was able to care for patients with complex health needs, through the provision of high dependency beds.

There were systems in place to ensure that learning from incidents took place throughout the service.

Feedback from patients using the service was generally positive. Patients' voices were evident in their care plans. They participated in meetings and received information about their care. Staff took patients’ views into account  when appropriate when planning individualised meals.

There was evidence of collaboration between patients and staff. They had worked together to produce a therapeutic eating charter and other information highlighting best practice in care for patients with eating disorders.

The service used a range of outcome measures to determine the efficacy of the care and treatment provided. Staff had working lunches to discuss how best to support and care for patients.

There was a strong focus on original research to improve the care and treatment of patients using the service. The patients and multi-disciplinary team contributed to the work of the St George’s University of London Eating Disorders Research Committee.

Avalon ward had nursing vacancies and there was regular use of agency staff. Recruitment was a priority for the trust and there was an ongoing recruitment campaign.

However, not all staff had completed required statutory and mandatory training or updates of training. Overall, 46% of permanent staff had completed their required training. There were significant shortfalls in fire safety awareness training, basic life support techniques and medicines management training.

Patients’ risk assessments were not always updated after incidents, which meant that staff might not be able to respond appropriately.

Results of checks on the physical health of patients were not always up dated promptly in patients’ electronic records. There was a risk that staff would not escalate concerns to medical staff quickly.

The cleaning records for the ward clinic rooms were not up to date and the rooms and equipment were dusty. A clinical specimen had been stored in the same fridge as medicines and there was a risk of contamination.

Staff had not always checked emergency equipment every day to make sure it was fit for purpose.

Wards for older people with mental health problems

Good

Updated 2 December 2016

We rated wards older people with mental health problems as good overall because:

  • Following our inspection in March 2016, we rated the service as good for safe, caring, responsive and well led.

  • During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective as requires improvement following the March 2016 inspection.

  • The inpatient wards for older people with mental health problems were now meeting Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Other specialist services

Updated 5 July 2016

  • The majority of patients on Bluebell ward came from London and the south of England. The ward had a mix of hearing and deaf staff. All staff were proficient in british sign language (BSL).The staff were skilled and there was high completion rate of mandatory training

  • There were systems in place to ensure that learning from incidents took place throughout the service. The ward had robust systems for dealing with complaints. Patients had complained about the admission of hearing patients onto Bluebell ward due to bed pressures in other parts of the trust. The trust had revised their protocol for admitting hearing patients onto the ward. They had put in additional safeguards.

  • The ward had robust processes to manage medicines.

  • Bluebell ward had nursing vacancies and there was regular use of bank and agency staff. The ward tried to use bank and agency staff who could sign. This meant that bank and agency staff could communicate with the deaf patients and staff.

  • The comments from the patients using the service were generally positive. The patients were partners in their care and their voices were evident in their care plans. They participated in meetings and received information about their care.

  • The staff were responsive to the needs of patients and supported patients to access spiritual support. The ward was able to provide patients with cultural and religion specific foods.