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Provider: North East London NHS Foundation Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 September 2019

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

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

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

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

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

However:

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

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

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

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

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

Inspection areas

Safe

Requires improvement

Updated 6 September 2019

  • At this inspection we rated safe as requires improvement in four of the eight core services. We rated safe as inadequate in one core service and good in the other three core services. When these ratings were combined with the other existing ratings from previous inspections, seven of the trust services were rated requires improvement, one as inadequate and seven were rated good.
  • The trust was not always adequately managing risks to patients and staff. The arrangements in place for the acute crisis assessment team (ACAT) to assess and admit patients to an inpatient bed was unsafe. Patients attending out of hours at Sunflowers Court for assessment by the ACAT or waiting to be admitted to wards after their ACAT assessment, were not appropriately supervised. There was a risk that the patient could cause harm to themselves or others whilst unsupervised, particularly in secluded areas of the building.
  • The trust had not yet ensured that patients were kept safe following the use of rapid tranquilisation. In the previous calendar year rapid tranquilisation was used on 322 occasions. Staff did not always complete post-dose physical health monitoring after patients had received medication by rapid tranquilisation. This meant there was a risk of not identifying a deterioration in a patient’s physical health. The same concern was identified at the previous inspection and whilst the trust had implemented systems to try and address this matter, they were not yet embedded.
  • The trust had not ensured the wards provided a safe environment to care for patients. On the forensic wards, whilst a need for call alarms in patient bedrooms had been identified, no dates for these works had been set. Staff did not describe how they were managing this risk until the alarms were installed. This meant that patients might not be able to call for help in an emergency.
  • The trust did not have enough medical or other professional staff in some services to provide consistently safe and high-quality care. Whilst the trust was aware of these short-falls and were working to address them this had not yet resulted in the necessary improvements. In Kent CAMHS the number of staff available including bank and agency, was below the agreed establishment levels. Half of the medical posts in Kent were vacant. This had an adverse impact on the trust’s ability to deliver the service. In acute and psychiatric intensive care unit (PICU) services, further work was needed to reduce the use of locum consultant psychiatrists and have more permanent staff in post to improve clinical leadership and the provision of high-quality care and treatment. Early intervention team caseloads were above the numbers recommended by best practice guidance which could prevent them from giving individual patients the time they needed. In some community mental health teams for adults there was a high turnover and staff reported feeling ‘burnt out’.
  • The trust was working to reduce restrictive interventions on mental health inpatient wards but ward teams did not have access to data on their use of interventions, so they could monitor their progress.
  • The recording of potential risks for patients was not always completed and stored in a robust manner. In acute and PICU services, although changes in patient risk were discussed and understood amongst staff, patient risk assessments were not always updated to reflect these changes on Ogura ward. In community mental health services for children and young people, improvements were needed in how staff assessed and managed risk in Waltham Forest. Thirty percent of the care and treatment records we looked at in this team did not include an assessment of risk or management plan. In community mental health adult teams, there were inconsistencies in where risks assessments were recorded in patients records. This meant that staff may not find this information in a timely manner.
  • The trust had not ensured that the equipment used for emergency first aid was in good order. In Maidstone some of the emergency first aid equipment had not been checked including adrenaline and some dressings.
  • Some improvements were needed to ensure medicines were safely prescribed, administered, recorded and stored. The room used to store medicines at Waltham Forest community recovery team experienced high temperatures which could impact the efficacy of medicines stored there. In the same team, allergy information was not always recorded on patients’ medicines charts. In inpatient settings, some clinic room temperatures also exceeded the acceptable range on some occasions. The trust was in the process of considering how to address this problem when we inspected. At Barking Community Hospital, patient group directives for medicines were not regularly reviewed to ensure they were up to date. Staff did not always review the effects of medications on each patient’s physical health. Staff in the Redbridge community recovery team did not have a process to identify and regularly review the effects of high dose anti-psychotic medications on each patient’s physical health.
  • Staff did not always manage risks to themselves. For example, staff in the Waltham Forest community recovery team did not follow trust protocols for lone working which could put them at risk.

However:

  • Inpatient wards and community bases were clean, well equipped, well furnished, well maintained and fit for purpose.
  • The trust had systems in place to safeguard patients from abuse and the services worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff had easy access to clinical information and it was easy for them to maintain high quality clinical records – whether paper-based or electronic.
  • The trust managed patient safety incidents well. Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support. Incidents were investigated in a timely manner and the reports were completed to a high standard. Pressure ulcers were the most frequently reported incident and the trust had a range of measures in place to try to reduce their incidence. However, there was still scope to improve the learning from incidents, particularly across geographically spread teams providing similar services.

Effective

Good

Updated 6 September 2019

  • At this inspection we rated effective as good in all eight core services. When these ratings were combined with the other existing ratings from previous inspections, all of the trust services were rated good.
  • Staff assessed the physical and mental health of patients on admission to a service. They developed individual care plans, which they reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs, were mostly personalised, holistic and recovery-oriented.
  • The trust provided a range of care and treatment interventions suitable for the patient groups and mostly consistent with national guidance on best practice. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives.
  • The trust recognised the importance of having a strong programme of quality assurance. There were 77 clinical audits taking place in the current financial year. This included 31 national and other ‘must do’ audits. There were an additional 46 audits reflecting trust priorities. During the inspection we saw improvements being made in response to audit findings.
  • The trust had systems in place to induct and deliver ongoing training to ensure staff had the range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. However, further work was needed to ensure consultants received an appropriate induction. Also, a business information system was being implemented to ensure that staff received regular supervision.
  • The trust ensured that staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Managers made sure that staff explained patients’ rights to them.
  • Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

However:

  • Some mental health staff and teams within the trust were not working together effectively to meet the needs of the patients. An example of this was between medical staff in community mental health teams and liaison psychiatry and the acute crisis assessment team (ACAT) which operated as the out of hours gate-keeper for acute inpatient mental health beds. We heard about the frustrations of trying to work together, not feeling that professional skills were respected and of lengthy escalation processes.
  • In some teams there was not access to the range of specialists needed to meet the needs of the patients. In the three community mental health teams for adults with learning disabilities and autism, there were vacancies for speech and language and occupational therapists. Challenges in recruiting to the posts permanently and in the interim, meant there was a risk that individual teams may not always include, or have access to speech and language therapists or occupational therapists.
  • In some adult community mental health teams there were long waits for specific types of individual psychological therapies. Patients were offered alternative services such as attending groups facilitated by psychologist’s whilst waiting for the treatment.

Caring

Good

Updated 6 September 2019

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

  • At this inspection we rated caring as good in five core services. We rated caring as outstanding in three core services. When these ratings were combined with the other existing ratings from previous inspections, 11 of the trust services were rated good, and four were rated outstanding.
  • In some services we received extremely positive feedback about the caring approach of the staff. On the forensic ward, learning disability ward and learning disability community services we heard how staff went the extra mile and the care and support exceeded expectations. Patients and those close to them were active partners in their care and staff were fully committed to this partnership approach.
  • In these three services, patients’ individual preferences and needs were always reflected in how care was delivered. There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring, respectful and supportive. These relationships were highly valued by staff and promoted by leaders.
  • Across all services, staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Across most services, staff involved patients in planning their care and the development of their risk assessments and actively sought their feedback on the quality of care provided. They ensured that patients had easy access to independent advocates. However, in some areas patients and carers did not feel so well involved. For example, feedback from patients using acute and PICU mental health services about their involvement in their care was mixed. Some patients did not feel they were adequately involved in developing their care plans. Some acute and PICU patients also reported they did not know how to provide feedback about the service.
  • The trust promoted the involvement of patients. They had a strategic patient experience partnership which held regular meetings. There were also meetings in each locality chaired by patients and carers. There was a centralised patient experience department promoting involvement across the trust. Examples of the involvement activities were helping with interviews, staff training, PLACE assessments, attending participation meetings and other events. Patients and carers were involved in many of the quality improvement projects.
  • Staff informed and involved families and carers appropriately. They supported carers to complete a carers assessment. They provided opportunities for carers to become better informed or participate in the service such as through carers groups. There were some good examples of co-production work with carers.

Responsive

Good

Updated 6 September 2019

  • At this inspection we rated responsive as good in five of the eight core services. We rated is as requires improvement in one core service, inadequate in one core service and outstanding in one core service. When these ratings were combined with the other existing ratings from previous inspections, 11 of the trust services were rated as good and one as outstanding. One of the trust services was rated inadequate and two of the trust services were rated requires improvement.
  • The design, layout, and furnishings of the wards and team bases supported patients’ treatment, privacy and dignity. On inpatient wards each patient had their own bedroom and could keep their personal belongings safe. There were quiet areas for privacy. However, we did hear from some community team staff about the lack of space for them to work in the office.
  • The food on inpatient wards was generally of a good quality and patients could make hot drinks and snacks at any time. However, patients on the learning disability ward said the food was unappetising but were working with the caterers to suggest improvements.
  • The services met the needs of all patients who used the service – including those with a protected characteristic. Staff helped patients with communication, advocacy, cultural and spiritual support.
  • The trust continued to manage responding to concerns and complaints well. They largely responded to complaints within the appropriate timescales. The responses were of a good standard. The trust used the themes from complaints to make improvements.
  • Referral criteria for community mental health services for adults and children and young people did not exclude patients who would have benefitted from care. Staff assessed and treated patients who required urgent care promptly. Staff followed up patients who missed appointments.
  • The service ensured that patients, who would benefit from care from another agency, made a smooth transition. This included ensuring that transitions to adult mental health services took place without any disruption to the patient’s care.
  • There were some excellent examples of working with other providers or in an innovative manner to ensure people received the range of services needed to promote their recovery. For example, the forensic ward maintained excellent links with the community and engaged patients in a range of activities seven days a week. This included local college attendance, work experience on a farm and attending a ‘coping through football programme’ with the local professional football team. Since the last inspection the ward had developed one of its gardens to provide an innovative programme where patients looked after a range of small livestock, including chickens and rabbits.

However:

  • The trust was not adequately monitoring the responsiveness of the health-based place of safety (HBPoS). For example, they did not collect the data to monitor the number of times when the HBPoS was full and patients needed to be taken to another trust. In addition, the trust did not routinely gather data to show the number of patients who had stayed in the HBPoS for more than 24 hours, or the reasons why.
  • The community mental health services for children and young people in Kent still had some significant waiting lists. Across Kent, there were 4143 young people at the end of May 2019 who had been waiting over 16 weeks for treatment following referral. Of these, 3372 were waiting for treatment through the neuro-diverse pathway and 771 were waiting for treatment through the other pathways available. Some families in Kent, fed back that they had been frustrated by some of the waits and that they were not consistently given information about the length of time they would be waiting for services to start. The trust was working with local commissioners to continue to make improvements.

Well-led

Requires improvement

Updated 6 September 2019

Our rating for well led went down. We rated well led for the trust overall as requires improvement because:

  • Staff engagement was mixed, and some staff described an unhealthy culture. Whilst the trust had achieved positive staff survey results and most staff we spoke to were very enthusiastic about working for the trust, there were still some pockets of unhappy staff who did not feel adequately engaged. The most significant examples were the junior doctors and some consultants working in the mental health services. They described how they had tried to escalate concerns but had not received a timely or adequate response. They explained how their professional views were not adequately respected and how when things went wrong there was a culture of blame rather than learning.
  • The senior executive leadership team was not working together in a cohesive manner. Whilst some external support had been sought to promote an improved working relationship there was still more to do. This was having an impact on the safe delivery of services. For example, whilst an action plan was in place in response to the junior doctor concerns it required collaborative work across the leadership team to make the improvements. Whilst some work had taken place, other significant concerns relating to the admission process to the acute mental health inpatient beds and the broader culture of the inpatient services had not been resolved. Some members of the leadership team recognised the difficulties in working together and expressed a sense of frustration that this was hampering their ability to do their jobs well.

  • Many staff described a trust where they believed decision making was ‘nurse dominated’. The Chief Nurse Group caused the greatest confusion with people describing its role in a variety of ways. There was a lack of clarity in how this group related to the Communities of Practice. We had ongoing concerns about the split Chief Operating Officer role. These related to variations in how the role was carried out by the two post-holders; the impact of this arrangement in terms of staff perception of the unity of the trust and the potential for a lack of clarity in terms of decision making on operational issues.

  • The current governance processes might not provide adequate assurance for the board on workforce and finance. At present, safer staffing data was discussed at each board meeting and a six-monthly workforce report was presented to the Quality Safety Committee and then key points reported to the board. The trust was addressing many complex workforce issues, and this might not provide adequate opportunity for assurance to be gained. Whilst the trust had a positive track record of delivering its financial performance, there were some areas of potential risk identified in financial governance. The trust had a ‘finance matters’ meeting with the non-executive directors which was not a formal sub-committee of the board. There was a potential risk that financial performance might not receive adequate board oversight and that emerging risks and issues may not get escalated appropriately.

  • The trust did not have a separate financial strategy other than delivering the annual financial plan. There was a risk without an overarching financial strategy the trust did not have in place suitable arrangements to deliver a medium and long term, financial plan.

  • Learning and development for team and ward managers did not equip them with the skills to effectively manage staff. Whilst managers were offered training, there had been around 60 contacts this year with the Freedom to Speak Up Guardian to raise concerns relating to the application of trust HR processes. The trust recognised that further leadership development was needed to put this into place. The trust also needs to further reduce the number of disciplinaries and make increased use of mediation. Grievance processes needed to be concluded in a timely manner.

  • The effective use of feedback from the Freedom to Speak Up Guardian needed to be further improved. It was positive to see that a full-time post had been created and growing awareness of staff across the trust of the role. However, feedback tended to focus on numbers of contacts and themes rather than how the issues raised could be addressed. In addition, the feedback gathered had not always been used in a timely manner by the executive team to make improvements such as those raised by the junior doctors.

However:

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

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

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

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

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

Checks on specific services

Wards for older people with mental health problems

Good

Updated 3 November 2017

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

  • The trust had made improvements since the previous inspection in April 2016. At our previous inspection of wards for older people in April 2016, we found that the trust was in breach of Health and Social Care regulations. These breaches were in relation to safety, dignity and respect and staffing. At this inspection, we found that the trust had taken appropriate action to improve the service.

  • There was now a robust system in place to reduce the risk of falls. Patients were now able to access their bedrooms at any time as they wished. The trust had improved ward premises. The wards had been redecorated, there was new furniture and the risk to patients from ligature points had been reduced. Patients on all wards now had easily accessible call bells to alert staff if they needed support. Staff understood the legal requirements of the Mental Health Act. Patient privacy and dignity was promoted.

  • Staff thoroughly assessed patients in relation to their physical and mental health when they were admitted to the ward. Staff screened patients for risks in relation to falls, skin care, continence and nutrition. Staff worked in partnership with the patient and their carer to develop care plans which reflected the patient’s choices. Staff liaised with a geriatrician and other clinical specialists to ensure care and treatment was effective.

  • Staff checked the physical health of patients each day and took action to address any deterioration in the patient’s health. Multidisciplinary team work was effective and care plans addressed patients social and rehabilitation needs. Staff were experienced and well-trained.

  • Patients were encouraged to be as independent as possible. There was a range of activities available on the ward. Discharge planning was effective for almost all patients. The trust worked with other agencies to manage delayed transfers of care.

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

However:

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

  • Some ward layouts did not allow staff to readily observe all areas and whilst the risks associated with this were mitigated through observations, the trust had not considered the use of aids such as convex mirrors to improve visibility.

  • Whilst the take up of mandatory training averaged over 80% in most areas, there were two exceptions. Ward managers were taking action to ensure staff attended any courses they had not yet completed. We did not see that lower compliance levels with these mandatory training courses had impacted upon the quality and safety of care and treatment being provided.

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

Mental health crisis services and health-based places of safety

Inadequate

Updated 9 January 2020

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

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

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

  • The trust had acted to promote the safety of patients and staff. Patients were no longer left unsupervised at Sunflowers Court whilst they waited to be assessed, were being assessed, or waited to be admitted to the hospital. The trust had introduced robust arrangements to ensure patients were supervised at all times whilst waiting and appropriate waiting and assessment areas were now available.

  • Improvements had been made to the way the acute crisis assessment team accessed staff with the necessary range of professional skills and experience, including doctors, when undertaking assessments of patients. This meant staff working in the acute crisis assessment team could now access appropriate multi-disciplinary staff for all assessments.

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

However:

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

Specialist community mental health services for children and young people

Requires improvement

Updated 6 September 2019

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

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

However:

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

Wards for people with a learning disability or autism

Good

Updated 6 September 2019

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

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

However:

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

Community mental health services with learning disabilities or autism

Good

Updated 6 September 2019

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

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

However:

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

Forensic inpatient or secure wards

Good

Updated 6 September 2019

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

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

However:

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

Community-based mental health services for adults of working age

Requires improvement

Updated 6 September 2019

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

However:

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

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

Requires improvement

Updated 6 September 2019

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

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

However:

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

Community health services for adults

Good

Updated 9 January 2018

Overall rating for this core service: Good

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

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

Overall we rated adult community health services as good because:

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

However:

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

Community health services for children, young people and families

Good

Updated 9 January 2018

Overall rating for this core service is good because:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

However:

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

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

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

Community end of life care

Good

Updated 9 January 2018

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

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

However, we also found:

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

Information about the service

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

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

Mayfield inpatient unit provides two specialist palliative care inpatient beds.

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

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

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

Child and adolescent mental health wards

Outstanding

Updated 14 November 2017

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

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

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

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

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

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

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

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

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

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

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

However:

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

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

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

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

Community health inpatient services

Good

Updated 27 September 2016

  • Overall we rated this service as good.

  • This was because we found a good culture for the timely reporting of incidents and the trust were able to identify themes and trends among community inpatient services. Safeguarding processes had a level of profile that enabled the identification of possible abuse and encouraged reporting. Processes for the safe administration of medication were in place and the overall standard of documentation was good. Wards were clean and staff were trained in infection prevention and control. Premises and equipment were largely well maintained and managed. However, we also found that equipment had not been serviced and space available for meaningful therapeutic activity compromised the service provided to patients.

  • Community inpatient services were operating with a substantial nurse vacancy rate and on the whole we found this had been largely well managed. However, we found a number of examples where rehabilitation therapy staffing and facilities had led to a basic provision of rehabilitation service. Patients received timely pain relief and received adequate assistance to eat and drink. Staff were also able to access key skills training appropriate to their role. We found good examples of integrated and multidisciplinary working. Patient discharge was appropriately planned and managed.

  • Staff understood their roles with consent and capacity. We also observed staff to be caring in their interactions. All patients we spoke with told us that staff were kind and treated them with respect. We did not come across any examples where this was not the case. Patients and relatives felt involved and included in care and treatment. Services were meeting the needs of vulnerable people. Assessments for wound management were completed and reviewed in accordance with the stated frequency. Community therapy assessments had taken place and case notes showed updates on preparation for discharge. Patients reported to us that their care and treatment needs were being met.

  • Staff reported to us that they had confidence in their leadership, who they found responsive. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of the service.

Community-based mental health services for older people

Good

Updated 27 September 2016

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

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

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

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

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

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

However:

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

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

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