North East London NHS Foundation Trust

Updated 28 August 2025

With an annual budget of £490 million, North East London NHS Foundation Trust (NELFT) provide care and treatment for a population of around 4.3 million people. They employ approximately 7,500 staff who work across 210 bases. The trust provides services in the London Boroughs of Barking Dagenham, Waltham Forest, Redbridge, Havering and in the counties of Essex and Kent.

The trust predominantly provides community health services for children and adults across its geography; it is also a significant provider of community and inpatient mental health services for children and adults across its patch.

We had previously inspected North East London NHS Foundation Trust in June 2022. At that time, we had rated the trust overall as good and well led as good.

We undertook a trust level (well-led) assessment, which included an onsite visit on the 26 27 March 2025. We also held 17 staff focus groups on site and remotely and observed board and committee meetings between January 2025 and April 2025.

Our previous inspection made some recommendations for improvements and the CQC wanted to see if these had been implemented. Since the last inspection there had been significant changes to the board leadership – both executive and non-executive and the CQC wanted to assess the impact of these changes.

This inspection took place at a time of significant pressures for healthcare services – especially those associated with crisis and acute mental health pathways. The CQC wanted to see how the trust was managing these pressures and working with system partners to support access to services. The CQC monitor serious incidents and wanted to understand how the trust was addressing and learning from these incidents. The inspection team were very conscious of the impact of the ongoing corporate manslaughter trial on staff at the time of our visit.

Prior to the well led review, the CQC had inspected acute wards for adults of working age and psychiatric intensive care units; community health services for adults and specialist community mental health services for children and young people in the Redbridge locality. We followed up themes from these inspections during the well led assessment.

We assessed all eight of the quality statements in the well-led key question used when assessing an NHS trust using our current framework.

Our positive findings from the well led review included:

• The people we spoke with were enthusiastic, committed and focused on people who use services.
• During the well led review people had mostly felt able to be candid and open. People felt able to reflect not only where things were going well but also where there was the need for further improvements. Speaking up arrangements were well understood and working positively.
• People had valued having better access to senior leaders – specifically mentioning the board service visits and the board meetings taking place at different trust sites.
• The introduction of an Executive Director of Allied Health Professions (AHP), Psychological Professions and Social Work who is a board member had been well received and was contributing to alternative ways of approaching challenges such as the AHP apprenticeships.
• The culture of the trust had improved – with staff referring to the just and compassionate programme and the training delivered to trust leaders.
• The trust was valuing diversity – staff spoke about the anti-racism work and the global majority network were very active in the work of the trust. The LEAP (leaders empowered to achieve their potential) programme was valued. However, there was scope to further develop other staff networks.
• Co-production and co-delivery with people who use services, families and carers had progressed significantly since the last inspection and was embedded in much of the trusts work.
• Quality improvement projects had extended across the trust since the last inspection. This was promoting innovation in teams. However, we did hear from staff who struggled to find the time for this work.
• The focus of the trust on working at place was enabling leaders to focus on meeting the needs of local populations and reducing inequalities in partnership with other providers.
• The trust was making good progress with its use of digital technology. The trust was making good use of data, although some staff had to access several platforms and needed support to develop their digital literacy.

We also identified areas for improvement which included:

• The trust needed to strengthen medical leadership especially for directorate leaders. This was identified as an area for improvement at the last inspection. Whilst a review had started this was at an early stage. Some medical staff still felt it was hard to contribute to decision making in their area of work. Also, further work was needed to ensure that medical and nursing staff worked effectively together as part of a multi-disciplinary team on the inpatient mental health wards. For example, in identifying the deteriorating patient and meeting their physical healthcare needs.
• The trust needed to amend its arrangements for reviewing mortality to include an appropriate range of professionals and ensure sufficient capacity to avoid backlogs in this work. At the time of the inspection, we were told there were around 60 cases waiting to be reviewed. The interim medical director had identified this and was implementing the changes needed.
• The trust needed to keep progressing with its work to improve access to the appropriate treatment and support for people experiencing mental ill health and reduce the numbers of people waiting for over 12 hours in acute emergency departments. The trust had been an outlier compared to other London trusts although early improvements could be seen when looking at data for January to March 2025. It was recognised that considerable work was taking place with multiple initiatives developed with system partners. However, at the time of the inspection the 24 hour integrated care assessment hub was not yet fully open (a soft launch was planned). In addition, there was a lack of clarity about when developments were happening and the projected impact on patient flow so that progress could be monitored.
• The trust needed to continue supporting governors to work together to carry out their roles effectively.
• The inspection of the acute mental health inpatient wards showed that while governance arrangements were in place, there was scope to ensure these were applied robustly and consistently to support the delivery of safe care and treatment.

Updated 20 January 2025

We undertook this short notice announced inspection of Redbridge Emotional Well Being and Mental Health Service as part of our continual checks on the safety and quality of healthcare services. Our inspection focused on areas highlighted in the recommendations of a Regulation 28 Prevention of Future Deaths report issued by the coroner following the unexpected death of a young person referred to the service in 2022. We also followed up on whistleblowing concerns shared with us about the service in 2024. We visited Redbridge Emotional Well Being and Mental Health Service on 3 and 4 March 2025.

Redbridge Emotional Well Being and Mental Health Service is a specialist community mental health (CAMHS) team providing support to children, young people and their families in the London Borough of Redbridge. It is run by North-East London NHS Foundation Trust (NELFT). The service is available to families with children and young people from birth to their 18th birthday.

As part of our inspection, we spoke with 12 relatives/carers of children and young people accessing the service. We spoke with 19 staff, including multidisciplinary team and senior leaders. We reviewed 12 patient treatment and care records, attended 4 meetings and observed 3 patient appointments. We also sought feedback from 4 partner agencies regularly working with the service.

We previously comprehensively inspected the trust’s CAMHS services in 2019. We rated the safe, responsive and well led domains as requires improvement. We rated the effective and caring domains as good. Overall, we rated the service as requires improvement. The provider was in breach of Regulation 17 Good governance, Regulation 12 Safe care and treatment and Regulation 18 Safe staffing.

We did not re-rate the service on this occasion, as we did not visit the CAMHS services NELFT provides in three other North-East London boroughs or in Kent. During this inspection we focused on selected quality statements under the safe, effective, caring, responsive and well led key questions.

During this inspection we saw that whilst the service had made some improvements in response to the coroner’s Prevention of Future Deaths report (Regulation 28), whistleblowing concerns and previous inspection findings, there was more to do. We had concerns about the long waiting times for assessment and treatment, how risk for people who waited was kept under review and the high caseloads held by some staff. These were breaches of Regulation 12 Safe care and treatment. Not all governance processes operated effectively, which was a breach of Regulation 17 Good governance.

• Children and young people did not access care in a timely way. Over 60% were waiting for either initial telephone triage following referral, or for initial assessment or treatment. One hundred and eighty-two young people were waiting for initial telephone triage. Eight hundred and twenty-three young people had been initially telephone triaged and were waiting for initial assessment. A further seven hundred and eighty-five young people were waiting for treatment, with 361 (46%) waiting over 18 weeks.

• As a result of high demand for services, children and young people experienced delays from when they were referred to starting their treatment. There was a group of young people on the waiting list who were about to turn 18, or had turned 18, and had not yet had an initial assessment, affecting their transition to adult services.

• Caseloads varied across pathways and were highest among staff working in triage. Some staff reported individual caseloads over 90 and one said theirs could reach 110.

• Systems to keep young people safe while they waited for treatment required improvement as they did not always work effectively. Systems to identify, manage and mitigate risks for children and young people who were receiving treatment also needed improving.

• Governance systems and processes needed to be strengthened. Audits were not always properly completed, blank prescription forms were not managed appropriately and the team risk register did not capture all identified risks.

However,

• Most carers described the staff as kind, caring and respectful. Staff attitudes and behaviours when interacting with patients and carers showed they were respectful and responsive, and provided support and advice when needed. Staff held regular multidisciplinary meetings where they shared information about patients.

• Most care plans were personalised, holistic and recovery orientated. People using the service knew how to complain. Staff handled complaints appropriately. Staff ensured that patients and carers could easily access information on a range of topics, including local services, helplines, how to complain, healthy eating and safeguarding.

• Leaders were working hard to improve staff morale and wellbeing. Most staff we spoke with said the leaders were visible and approachable. Staff reported a friendly, open and supportive culture between peers and the leadership team.

Updated 19 September 2024

We carried out short notice announced inspection of community health services for adults as part of our continual checks on the safety and quality of healthcare services. We visited community health services for adults in Havering, Barking and Dagenham, Redbridge and across Essex. We visited 9 district nursing teams, 2 tissue viability/leg ulcer services, 1 respiratory service and 1 diabetes long-term conditions team. We were on site inspecting these services over on the 19, 20, 21, 26, 27 28 November 2024. We gave verbal feedback which we confirmed in a letter to the trust shortly after our inspection.

As part of the inspection, we visited 9 district nursing teams, 4 specialist teams, the tissue viability clinic, leg ulcer services, respiratory services, and the diabetes clinic – long-term conditions team. We spoke to 38 patients, 7 carers and relatives and received 22 comment cards from patients. We reviewed 49 patients’ care and treatment records. We attended home visits with district nurses, physiotherapists and tissue viability nurses, including observing medication administration. We carried out a tour of the environment at each site we visited. We observed handover meetings, a patient safety meeting, pressure ulcer meeting, monthly shared learning meeting, risk meetings, safety huddles, and integrated case management meetings. We also spoke with 61 staff members, including Integrated care managers, community matrons, community therapy team, associate director of nursing services, single point of access triage practitioner, non-medical prescribers, operational managers, team leaders, deputy clinical nurse, occupational therapists, support workers, health care assistants, respiratory nurses, tissue viability nurses and diabetes specialist nurses, pathway coordinator and band 3-7 nurses.

We had previously inspected community health services for adults in October 2017. As a result of that inspection, we had rated the safe domain as requires improvement. The provider was in breach of Regulation 18, as staff did not have regular clinical supervision or appraisals. We had rated the effective, caring, responsive and well led domains as good. Our overall rating was good.

At this inspection our ratings changed. Our rating for safe improved, this domain was rated as good and there was no longer a breach in regulation. Ratings for effective, caring, responsive and well led stayed the same and were rated as good. Our overall rating stayed the same and the service was rated as good.

• We found improvements with staff being consistently supervised, appraised and their competences assessed. Compliance with mandatory training was high and staff could access a range of specialist training appropriate to their role. Staff were suitably trained and competent to administer medicines. Staff were committed to continually learning and improving services. Staff used quality improvement methods to make improvements in care and the quality of services provided.
• Feedback from patients and carers about the service they received was mostly very positive. They were treated with dignity and respect. Patients and carers said they found staff helpful and kind and said their treatment was clearly explained. Where a patient’s condition deteriorated, patients told us that staff responded promptly and appropriately.
• Managers investigated incidents and shared lessons learned with the whole team and the wider service. Staff were able to give examples of learning from incidents. Staff completed comprehensive risk assessments which were regularly reviewed. Identified risks were managed or mitigated appropriately. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• People we spoke to felt involved in their care planning. Staff we spoke to understood peoples’ strengths, abilities, aspirations, culture and unique backgrounds and protected characteristics. The service displayed information leaflets in various languages, reflective of their local communities. Team bases had information displayed about chaperones and staff made sure patients were aware they could request a chaperone. The trust listened to people who were most likely to experience inequity and aimed to develop services to address this. People working in services reflected the diversity of the communities they worked in.
• Patients were encouraged to feedback on services and engage in their development through local and trust wide engagement networks. The service treated concerns and complaints seriously, investigated them and learned lessons. Patients, relatives and carers knew how to complain or raise concerns.
• Governance processes operated effectively at team level and performance and risk were managed well. There were robust structures, processes, and systems of accountability in place to monitor the performance of the service. Staff adhered to infection control principles and where appropriate used personal protective equipment. Managers and staff carried out a comprehensive programme of regular audits to check compliance and improvement over time to support the delivery of care. Staff in specialist clinics had systems to follow up patients who did not attend. Deferred visits rarely happened.

However:

• Some patients (15%) commented that communication could be improved. They said telephone messages were not always passed on or responded to. For a small number of patients who did not share a language with the person delivering a care, an appropriate interpreter was not always booked. Other patients commented that staff changes could impact upon consistency of care.
• Improvements were needed in the policies and processes in place for the management of medicines and secure stationary kept in staff’s homes. Improvements were also needed to ensure that peoples drug allergy information was accurately and consistently recorded.

Updated 23 September 2024

We carried out this short notice announced inspection of acute wards for adults of working age and psychiatric intensive care units as part of our continual checks on the safety and quality of healthcare services. We visited the acute wards for adults of working age and psychiatric intensive care units at Sunflowers Court over three days on the 15, 16 21 October 2024. We gave verbal feedback which we confirmed in a letter to the trust shortly after our inspection.

As part of the inspection, we spoke with 24 patients. We also spoke with 63 staff members including doctors, ward managers, clinical leads, registered and non-registered nurses, student nurses, occupational therapists and assistants, psychologists, social workers, pharmacists, and administrators. We looked at 42 patient care and treatment records, and 28 medicines administration records, including 8 rapid tranquilisation records. We examined the environment on each ward, and attended 8 ward meetings including community meetings, safety huddles, and moderate harm meetings. During and following the inspection we spoke with 30 carers/relatives of patients using the service. Following the inspection we also spoke with the Integrated Care Director, Associate Director of Nursing and Quality and Deputy Director of Nursing.

We had previously inspected acute wards for adults of working age and psychiatric intensive care units in August 2022. As a result of that inspection, we had rated the safe, effective, caring, responsive and well led domains as good. Our overall rating was good.

As a result of this inspection our ratings changed. We rated safe and caring as requires improvement. Our ratings for effective, responsive and well-led were good. Overall, our rating for acute wards for adults of working age and psychiatric intensive care units went down from good to requires improvement.

During this inspection we had concerns how the trust ensured dignity and respect for all patients which was a breach of Regulation 10 Dignity and respect. We also had concerns in relation to patient safety and found the trust to be in breach of Regulation 12 Safe care and treatment. Improvements were also needed in relation to governance and we additionally found the trust to be in breach of Regulation 17 Good governance under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

• We found that some patients did not have risk assessments and care plans in place for physical health conditions. Many of the patients had complex physical health conditions and nursing staff did not always feel confident in the management of these conditions.

• There were some safety concerns in relation to the environments on Ogura, Picasso and Kahlo wards. Following the inspection the trust advised that they had taken action to address the environmental concerns on Ogura and Picasso wards but further environmental improvements were needed.

• Improvements were needed in the way that restraint and subsequent debriefs were recorded so that the use of restraint could be appropriately monitored.

• Some staff were undertaking intermittent observations at regular intervals, making them predictable. Following the inspection, the trust updated their policy on observations to reflect the need to vary times of observations. Changes in staff practice would need to be embedded.

• We found some issues with medicines administration including medicines prescribed as needed. We also found instances when controlled drugs were administered with only one signature.

• Patients on all the wards said that they did not have direct access to hot drinks and snacks. We observed, and patients reported having to wait a long time for staff to provide these. Following the inspection, senior managers in the trust said that they were taking steps to address this.

• There were limited rooms available on the wards to facilitate private meeting between carers and their family members if several visitors arrived at the same time. Some carers were unhappy with the facilities for visiting patients and said they could not meet patients in private each time. Most carers reported problems getting through to the wards by telephone especially at night.

• Some patients were not receiving their halal and vegetarian meals as these were being taken by other patients. The service reported that since this was reported, staff were being more vigilant in the allocation of meals to patients.

• Whilst governance systems were in place, these needed some further refining and embedding to ensure services were delivered consistently appropriately and safely.

However, we also saw improvements:

• Staff learnt from incidents. Staff on each ward were able to tell us about how they had taken steps to incorporate learning from incidents and there were action plans in place for all serious incidents.

• Appropriate environmental checks were in place and works to roll out patient call bells was underway. The wards were visibly clean, with regular hand washing and infection control audits in place.

• Staff were clear about how the trust’s safeguarding procedures to protect patients from abuse.

• There had been significant recruitment to the wards although all wards had vacancies for permanent consultant psychiatrists, with locum consultants covering. The trust was working hard to address this.
• Mandatory training rates were quite high across the wards and staff described good opportunities for professional development within the trust.

• Staff provided a range of care and treatment suitable for the patients in the service consistent with national guidance.

• Staff ensured that patients had access to physical healthcare input and supported them to live healthier lives. For example, physical health and substance misuse specialists visited the wards and provided professional advice as needed.

• Supervision for clinical staff was mostly provided monthly, although there were inconsistencies in provision between the wards. Levels of appraisals still needed to improve for some wards.

• Staff were involved in several quality improvement projects and working towards accreditation with the Royal College of Psychiatrists.

• Multidisciplinary staff met with patients weekly to discuss their support and treatment. Patients could give feedback on the service. Staff carefully planned patients’ discharge and worked with care managers and coordinators to make sure this went well.

• Most staff felt respected, supported and valued, and said that the trust promoted equality and diversity in daily work and provided opportunities for development and career progression. Following the most recent staff survey from 2023 the trust had an action plan including introducing long service awards and opening a café in the hospital building.

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.

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 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.

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.

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.

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.

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.

Updated 26 August 2022

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.

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.

Updated 27 September 2016

We rated long stay/rehabilitation mental health wards for working age adults as good because:

• There was evidence of good medicine management and patients medicine records were clear and accurate. The pharmacy team reviewed medicine charts including antipsychotic medication. Staff recorded patients allergy status on the prescription charts. Staff recorded where patients self administered medicines.
• Comprehensive and holistic care plans demonstrated patient involvement. Patients and carers were involved in care planning and care plans were written in a person centred way.
• Patients’ physical health was assessed and regularly monitored by staff. Patients’ physical health was discussed and reviewed during ward rounds.
• We saw kind and caring interactions between staff and patients. Patients told us that staff were polite and respectful. Staff were knowledgeable about patient needs. There was evidence of family and carer involvement in care planning.
• There was evidence of discharge planning in patient records. Staff discussed discharge planning with patients, familes, carers and community services.
• Staff received regular supervision and appraisals. Staff received monthly supervision which could be increased if appropriate or requested. We saw evidence that all staff had completed their annual appraisal within the preceding 12 months.

However:

• We saw high use of bank staff, although regular bank staff was used where possible.
• There was no dedicated psychology input on the ward. However, staff could refer patients for psychological interventions. Staff told us there was a long waiting list and referrals were not based on wards although patients were fast tracked where possible.
• Patients were unable to make a drink or snack as required.
• Staff and patients expressed anxiety regarding the planned ward closure.

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.

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.