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

We are carrying out checks on locations registered by this provider using our new way of inspecting services. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 27 - 28 September 2016

During an inspection to make sure that the improvements required had been made

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


CQC inspections of services

Service reports published 14 November 2017
Inspection carried out on 4 - 5 September 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 249.06 KB (opens in a new tab)
Service reports published 11 October 2017
Inspection carried out on 28 February and 1 March 2017 During an inspection of Specialist eating disorders services Download report PDF | 375.45 KB (opens in a new tab)
Service reports published 2 December 2016
Inspection carried out on 27 & 28 September 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 215.42 KB (opens in a new tab)
Inspection carried out on 27 & 28 September 2016 During an inspection of Community-based mental health services for older people Download report PDF | 223.7 KB (opens in a new tab)
Inspection carried out on 27 & 28 September 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 217.62 KB (opens in a new tab)
See more service reports published 2 December 2016
Service reports published 5 July 2016
Inspection carried out on 3 March 2016 During an inspection of Other specialist services Download report PDF | 241.43 KB (opens in a new tab)
Service reports published 16 June 2016
Inspection carried out on 15 March 2016 During an inspection of Child and adolescent mental health wards Download report PDF | 301.15 KB (opens in a new tab)
Inspection carried out on 22 and 23 March 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 305.04 KB (opens in a new tab)
Inspection carried out on 14-18 March 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 399.51 KB (opens in a new tab)
Inspection carried out on 14th – 18th March 2016 During an inspection of Community mental health services for people with learning disabilities or autism Download report PDF | 281.11 KB (opens in a new tab)
Inspection carried out on 15-17 March 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF | 341.01 KB (opens in a new tab)
Inspection carried out on 14 – 18 March 2016 During an inspection of Forensic inpatient/secure wards Download report PDF | 311.76 KB (opens in a new tab)
Inspection carried out on 14 – 18 March 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 347.14 KB (opens in a new tab)
Inspection carried out on 15 March – 18 March 2016 During an inspection of Community-based mental health services for older people Download report PDF | 301.38 KB (opens in a new tab)
Inspection carried out on 14 – 18 March 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF | 318.29 KB (opens in a new tab)
Inspection carried out on 14 – 18 March 2016 During an inspection of Long stay/rehabilitation mental health wards for working age adults Download report PDF | 356.56 KB (opens in a new tab)
See more service reports published 16 June 2016
Service reports published 5 April 2016
Inspection carried out on 15-16 October 2015 During an inspection of Specialist eating disorders services Download report PDF | 288.82 KB (opens in a new tab)
Service reports published 24 August 2015
Inspection carried out on 13-15 May 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 276.94 KB (opens in a new tab)
Inspection carried out on 13 - 14 May 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 258.43 KB (opens in a new tab)
Inspection carried out on 14 -18 March 2016

During a routine inspection

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 carried out on 13 - 15 May 2015

During an inspection to make sure that the improvements required had been made

In the acute wards for adults of working age and psychiatric intensive care units we found that:

  • 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 some acute 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.

In the wards for older people with mental health problems we found:

  • 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.

However, on ward three a harm free care pilot had been conducted. This looked at medicine errors, violence, self harm and falls. This information was presented in an easy to understand way. All acute adult 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 acute inpatient wards had recruited peer support workers. They were part of the team and offered insight into what it was like to be a patient. They helped patients orientate themselves to the ward and helped staff and patients to work positively together.

On the older people’s wards 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 and there had been an increase in the number of patient falls reported by staff as a result. 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

Inspection carried out on 17 - 21 March 2014

During a routine inspection

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.

Intelligent Monitoring

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.


Joint inspection reports with Ofsted

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.


Mental Health Act Commissioner reports

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.