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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 June 2016

We have given an overall rating of requires improvement to South West London and St George’s Mental Health NHS Trust.

We have rated three of the ten services that we inspected as requires improvement and seven as good. The services that require improvement are the community based mental health services for adults of working age and for older people and the rehabilitation mental health wards for working age adults.

The main areas for improvement were as follows:

  • The trust had not ensured that the wards providing rehabilitation were supporting patients to achieve greater independence. The exception to this was Burntwood Villa where there was a well developed model of rehabilitation.
  • In the forensic service and the child and adolescent mental health ward the trust was not recognising when they were secluding patients. This meant that the appropriate safeguards in terms of regular observations and medical review were not in place to keep people safe.
  • Across a number of wards and teams staff were not being supported with regular one to one supervision. This often reflected the workload of the team and because some managers in the community were responsible for supervising too many staff.
  • The trust had restructured the administrative support to teams in Kingston into a central hub. The implementation of this change was having ongoing negative consequences with patients not receiving appointment letters, delays in information reaching GPs and staff in the trust not being able to access patient information they needed for outpatient appointments. Whilst improvements were underway there were still more needed to ensure a safe service.
  • The maintaining of up to date risk assessments across a number of teams needed to be improved. They also had to be stored consistently so they can be located when needed. This meant there was a risk of staff not safely supporting patients with their individual risks.
  • There were significant challenges in the community services for working age adults, especially the recovery teams where staff morale was lower and staff were worried about meeting the complex needs of the patients on their caseloads.

Despite these areas for improvement there was much for the trust to be proud of as follows:

  • The senior executive team were committed to improving services and providing a high standard of care for patients.
  • Most staff said how much they enjoyed working for the trust and valued the leadership provided by the senior team. Many specifically mentioned the role played by the chief executive.
  • Most staff we met were caring, professional and in manay cases innovative in their work.
  • The culture of the trust was largely healthy with patients and staff feeling able to raise issues they felt needed to improve without fear of retribution.
  • The trust board provided effective challenge and helped to ensure the trust met its strategic objectives.
  • There were robust ward to board governance processes in place that supported managers throughout the trust to identify when improvements needed to take place.
  • The trust was working with local communities to overcome the stigma of mental illness and make services more accessible.
  • There had been significant improvements in the acute care pathway. Whilst demand was still very high and this presented a daily challenge, patients had an improved level of support to access the services they clinically needed.
  • Staff had access to a wide range of opportunities for learning and development, which was helping many people to make progress with their career whilst also improving the care they delivered.

There were many areas of ongoing work within the trust. This included an active staff recruitment campaign. There were also other developments to improve patient and staff engagement. These will need time to progress but the inspection team agreed that the trust had the necessary leadership in place to take this forward.

We will be working with the trust to agree an action plan to address the issues we found during our inspection.

Inspection areas

Safe

Requires improvement

Updated 16 June 2016

We rated safe as requires improvement for the following reasons:

Forensic inpatient wards

  • The time management practices being used on Halswell and Turner wards amounted to seclusion. However staff did not recognise this as being the case. They therefore had not put into place the safeguards for seclusion that are 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.

Child and adolescent mental health wards

  • A low stimulus room was used for seclusion. The policy needed to be clearer, to state that the use of this room did amount to seclusion and the safeguards within the Code of Practice must be applied.

Rehabilitation mental health ward

  • Staff completed risk assessments for all patients. However, not all identified risks were addressed in care or management plans.

  • Staff at Thrale Road were not carrying out one to one sessions with patients every two weeks as outlined in patient care plans and the reason for this was not recorded.

Community based mental health services for older people

  • Sutton, Merton and Richmond teams did not have adequate medicines management. Medication was not transported securely between the team’s base and patients home, and medication stock levels were not being documented.

  • Patient’s risk assessments were not recorded consistently.

Community based mental health services for adults of working age

  • In some teams staff did not update risk assessments to reflect current risks.

  • Staff were not transporting medication safely.

  • There were a high number of vacancies in most of the teams we visited. Vacant posts had been filled by agency staff or absorbed into team workloads but staff were concerned about meeting the needs of individual patients.

  • At Central Wandsworth and West Battersea community team had a small number of patients being held by the team waiting to be allocated to a care co-ordinator.

However, staff knew how to support patients to mitigate the risks associated with ligature points across the trust. Staff knew how to report incidents and these were managed well to ensure they were appropriately investigated and learning took place as needed. The safeguarding procedures were robust and the trust was working with external partners. Restraint was used appropriately and where prone restraint took place the reasons for this were reviewed. On wards for older people the risks of falls and pressure ulcers were being well managed.

Effective

Requires improvement

Updated 16 June 2016

We rated effective as requires improvement for the following reasons:

Rehabilitation mental health ward

  • Thrale Road, Westmoor House and Phoenix Ward did not clearly demonstrate how the recovery orientated approach to care was being implemented by the staff team. There was very limited evidence that patients were being fully supported to develop a range of independent living skills.

  • Not all staff were receiving regular monthly supervision on Phoenix Ward and feedback from staff at Westmoor House meant it was unclear whether this was taking place on a monthly basis.

  • Input from occupational therapists varied across the services and this meant some patients would benefit from more input to promote their rehabilitation.

Community based mental health services for adults of working age

  • Some staff, especially from the Kingston and Richmond recovery support teams were not being supported with regular individual supervision.

  • Electronic patient care records were not always regularly reviewed and updated and easy to locate.

  • At Central Wandsworth and West Battersea community team and East Battersea community teams, some recently appointed staff were not having sufficient opportunities for individual support such as shadowing to help them manage complex caseloads.

  • Whilst psychological therapies were available within each of the teams we visited, some patients who were ready for this therapy were having to wait for this.

  • Staff were not confident in conducting Mental Capacity Act assessments and referred concerns regarding capacity to the medics in the team.

Wards for older people with mental health problems

  • The line manager on Crocus ward did not provide consistent 1:1 supervision to staff that they managed.

  • Patients on Crocus ward did not have access to sufficient occupational therapy input.

Mental health crisis services and health based places of safety

  • There was no formal individual supervision structure embedded across the services and some staff were not receiving regular individual supervision.

  • Physical health checks of patients prior to commencing antipsychotic medications were being completed according to guidance, ensuring safe prescribing. However, supporting patients to have physical health checks was not done routinely for all patients on caseloads.

  • The recording of care plans and risk assessments were not consistent and this could make it hard to find the current information.

However, the trust was carrying out a range of audits to monitor and improve standards of care. Staff felt well supported and able to access a range of training to develop their skills. There were many good examples of multi-disciplinary team working and of teams working with external agencies to meet the needs of patients. The Mental Health Act was well managed within the trust.

Caring

Good

Updated 16 June 2016

We rated caring as good for the following reasons:

  • Staff were enthusiastic, passionate and demonstrated a clear commitment to their work. Care was delivered by hard-working, caring and compassionate staff.

  • People and where appropriate their carers, were usually involved in decisions about their care.

  • Opportunities were available for people to be involved in decisions about their services and improvements were taking place when concerns were raised.

  • Work was taking place to improve patient involvement.

  • Advocacy services were available and patients were supported to access these services.

However, there are a few wards where staff need to aware of their manner and approach to ensure their communication with patients is appropriate at all times. On Crocus older persons ward an effort must be made to ensure patients clothing does not get mixed up.

Responsive

Requires improvement

Updated 16 June 2016

We rated response as requires improvement for the following reasons:

Rehabilitation mental health ward

  • Patients, with the exception of Burntwood Villas, did not have access to the support to enable them to access the therapeutic activities to enhance their rehabilitation.

  • At Thrale Road and Westmoor House staff were not fully supporting the needs of patients whose first language was not English and who required an interpreter.

Community based mental health services for adults of working age

  • The Kingston recovery teams were struggling to reliably send out letters about appointments and reviews following changes in the administrative support to the team.

  • At the Central Wandsworth and West Battersea community team more than 15% of patients were not attending their appointments. The team could not demonstrate that active steps were being taken to engage with patients who did not attend.

  • For most teams, space was limited and staff had difficulties accessing interview rooms.

  • Interview rooms were not soundproofed and discussions could be heard outside doors.

Community based mental health services for older people:

  • The changes to the administration support for the Kingston team had led to patient’s appointments being cancelled and staff unable to locate patient records.

However, there had been significant improvements in the management of access to acute beds across the trust and the acute care co-ordination centre was working well. Discharge co-ordinators on wards were helping to facilitate all the practical arrangements associated with each persons discharge. Most community teams were meeting their targets for assessing and treating people in a timely manner. This was particularly commended in the CAMHS teams where the service had gone through a period of change. Teams offered patients flexible appointments when needed to support their engagement with the service. The trust recognised the needs of people in terms of working towards providing services that met their needs in relation to their protected characteristics. There was some excellent work taking place with local communities to break down the stigma associated with mental illness. The trust was managing complaints in a timely manner and supporting people to raise concerns where needed.

Well-led

Good

Updated 16 June 2016

We rated well led as good for the following reasons:

  • Teams across the trust recognised the visions and values and how these were applied in their day to day work.

  • The trust had robust governance processes in place from ward to board and the quality of information enabled staff across the trust to know where improvements were needed.

  • The trust board provided a high standard of challenge and held the executive team to account.

  • The chief executive and senior executive team, despite going through a period of change, displayed a high level of commitment to ensuring high quality services for people using services provided by the trust.

  • The trust in the main has a healthy culture and works hard to engage with people who use services and staff.

However, the rehabilitation services need strong leadership to ensure they deliver their goals and support patients to achieve greater independence. Senior staff need to ensure that they regularly engage with staff working in community teams. Some staff in the adult community needs need support to have the correct management information. A couple of final fit and proper person checks need to be in place. The whistle-blowing process needs to be made more accessible for staff. Whilst plans were progressing across services on the acute care pathway and specialist services for accreditation with the quality improvement peer review schemes operated by the Royal College of Psychiatrists, this had not yet been fully implemented.

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

Requires improvement

Updated 16 June 2016

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

Sutton, Merton and Richmond teams did not have adequate medicines management arrangements. Medication was not transported securely between the teams base and patient’s homes, medication stock levels were not recorded at the team base. Patients’ risk assessments were not recorded consistently and were not always updated in a timely manner. In Merton, Kingston and Wandsworth, patients were not always receiving regular physical health checks.

Staff in Merton team did not receive regular individual supervision.The administration support for the Kingston team was not operating well which led to patients’ appointments being cancelled and staff being unable to locate patient records.

Senior managers in the trust had not visited the teams. Staff felt isolated from the trust and individual teams were working in silos. There was low staff morale in Kingston and Richmond teams. Staff told us this was because of the transformation process, poor engagement with the trust and the uncertainty about the future of Barnes Hospital. Staff gave feedback on services to the senior management team and felt they were not always taken seriously or treated with respect when they do.

However, staff were professional, caring and showed kindness and respect to patients and their carers. We observed at the Kingston Memory Clinic that patients understood their care, treatment and condition. There was evidence of appropriate involvement of, and provision of support to families and carers. For example teams had good working links with the Alzheimer’s Society.

Arrangements for lone working were in place to ensure staff safety across the service. Arrangements for safeguarding were clear with good systems in place to monitor and follow up concerns.

Practice was evidence based and there was good access to a wide range of interventions. These included anti-psychotic medication for people with dementia and cognitive behavioural therapy for depression. The memory services provided effective post diagnostic interventions and support for both patient’s and carers.

There was effective multi-disciplinary team working within teams. The teams worked well with GPs, the local authorities and other local services and groups. This enabled patients and their carers to experience a more joined up service. The staff teams displayed effective team working and mutual support.

Staff had manageable caseloads and managers ensured that workloads were evenly distributed across the teams. Referrals were prioritised and dealt with in a timely manner. There were good pathways to the service and patients were promptly allocated to an appropriate staff member. Wandsworth and Sutton took a proactive approach to re-engage with patients who missed appointments. Staff would make telephone calls and clinicians would follow up with home visits.

Patients at Merton attended clinic appointments at the Nelson Health Centre. We observed this was a dementia friendly environment and patients and carers fed back that it was accessible, bright and a pleasant atmosphere. Adjustments were made for patients requiring disabled access, brail on signs and hearing loops. There was easy access to interpreters.

The services had been innovative. At Kingston the psychiatrist had developed a tool for assessing patients with memory difficulties and this was implemented within the team. The admiral nurse developed a family assessment tool which is currently used by the team. The behaviour and communication service at the Wandsworth team had won three awards in service improvement, dementia care and mental health. The Wandsworth team produced their own staff bulletin which shared good practice and commended individual staff. There was leadership within this team.

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 16 June 2016

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

The trust was providing crisis services which met the guidelines of the mental health crisis care concordat. The principles of this concordat were embedded in the service.

We saw excellent examples of interactions between staff and patients. All the staff we observed were caring, compassionate and kind. The service supported and treated the people using the crisis and home treatment teams and health-based place of safety with respect, warmth and professionalism.

Assessment and management of risk was of a high standard in the home treatment teams. Staff were well equipped to manage risk and skilled in identifying and mitigating risks for patients and staff. In addition, there were adequate numbers of staff to provide care and support to a good standard. The trust was addressing vacancies in permanent employed qualified nurses.

The environments were clean and well presented in all of the home treatment teams, and patients were seen at the home treatment locations if required.

Overall, care planning involved patients and carers and was recovery orientated. Discharge planning was evident across all of the services and collaborative crisis planning was taking place. The teams worked flexibly to engage and work with people in the community, adapting to meet the needs of people and ensuring that visits and appointments were kept. Home visits were rarely cancelled and if changes to visit times were made the teams communicated effectively with patients to share information and promote engagement.

The teams consisted of experienced and knowledgeable staff. Staff said they could access the training they needed to fulfil their roles and were encouraged by local management to access additional training for their development. Staff received feedback from their managers following incidents. This was discussed in supervisions, handovers and team meetings.

Staff 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, not all staff across the home treatment teams were accessing regular one to one supervision.

Patients we spoke with told us that there were sometimes inconsistencies in staff who visited their homes and this was a challenge for patients and impacted on the experience of care.

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.

Wards for older people with mental health problems

Good

Updated 16 June 2016

We rated wards for older people with mental health problems provided by South West London and St George’s NHS Trust as good because:

Patients and their relatives and carers described staff as caring and kind and told us they were treated with dignity and respect. We observed many examples of care that met the individual needs and wishes of patients. Patients were able to give feedback on their services through the ward community meetings. Patients and their relatives participated in meetings where their care was discussed. Staff on the wards were very mindful of ensuring patients had their needs and preferences met in terms of their disability, language, religion and culture and supporting their ongoing relationships with those they were close to.

The wards were safe and staff were taking steps to ensure that significant areas of risk such as falls and pressure care were being assessed and managed. The wards were working hard to ensure there were sufficient staff on duty, although on Crocus ward there were more staff working who did not know the patients well. Staff understood safeguarding processes and these were used appropriately. Medicines were well managed and there was good working with the pharmacy team.

Staff completed timely assessments of patients’ needs. They were very aware that most patients had physical health needs and monitored these closely and addressed specific needs as they arose. There was good multi-disciplinary working on both wards and close working relationships with staff from the local community teams. Discharge planning started as soon as the person was admitted.

Staff mostly felt well supported and had access to mandatory training, specialist training, appraisals and team meetings. On Jasmines ward there was regular staff supervision but on Crocus ward this was not taking place regularly.

Managers had access to good information to support them to manage the ward. There was regular contact with senior staff in the trust. Staff felt able to raise concerns although they were not aware of how to use the whistle-blowing process.

There was however a difference between the two wards. The staff team on Jasmines ward was more stable and knew the patients well. There was an excellent programme of therapeutic activities. The ward was very homely and dementia friendly. Staff morale was very positive. Crocus ward was a larger ward with five more beds. There were more staff who did not know the ward as well and this impacted on the consistency of care and meant that regular staff were working extremely hard. There were also less therapeutic activities which meant patients had fewer opportunities to leave the ward and more time when activities were not taking place. Crocus ward was still providing safe care and treatment but needed to make some changes to ensure the care was always of a high quality.

Wards 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.

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.

Reference: Specialist eating disorder services not found

Updated 24 August 2015

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.