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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.

Reports


Inspection carried out on 14 May to 26 June 2019

During a routine inspection

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.


CQC inspections of services

Service reports published 9 January 2020
Inspection carried out on 17 and 18 October 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Service reports published 6 September 2019
Inspection carried out on 14 May to 26 June 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 14 May to 26 June 2019 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 14 May to 26 June 2019 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Inspection carried out on 14 May to 26 June 2019 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Inspection carried out on 14 May to 26 June 2019 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Inspection carried out on 14 May to 26 June 2019 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Inspection carried out on 14 May to 26 June 2019 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
See more service reports published 6 September 2019
Service reports published 9 January 2018
Inspection carried out on 10, 11, 12 October 2017 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 10 to 12 October 2017 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 10 October to 12 October 2017 During an inspection of Community end of life care Download report PDF (opens in a new tab)
See more service reports published 9 January 2018
Service reports published 14 November 2017
Inspection carried out on 15 – 17 August 2017 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Service reports published 13 November 2017
Inspection carried out on 15-17 August 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Service reports published 3 November 2017
Inspection carried out on 15 -17 August 2017 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 15 to 17 August 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Service reports published 8 March 2017
Inspection carried out on 27th and 28th October 2016 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Service reports published 27 September 2016
Inspection carried out on 5 – 8 April 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
Inspection carried out on 4 - 8 April 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 4 - 8 April 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF (opens in a new tab)
Inspection carried out on 04 – 08 April 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF (opens in a new tab)
Inspection carried out on 4-8 April 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 5 – 7 and 14 April 2016 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Inspection carried out on 4-8 April 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 5 - 7 April 2016 During an inspection of Community-based mental health services for older people Download report PDF (opens in a new tab)
Inspection carried out on 4 - 7 April 2016 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 4 – 8 April 2016 During an inspection of Wards for people with a learning disability or autism Download report PDF (opens in a new tab)
Inspection carried out on 6 April 2016 During an inspection of Forensic inpatient or secure wards Download report PDF (opens in a new tab)
Inspection carried out on 6 - 7 April 2016 During an inspection of Community mental health services with learning disabilities or autism Download report PDF (opens in a new tab)
Inspection carried out on 5 - 7 April 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 5 – 8 April 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
See more service reports published 27 September 2016
Service reports published 26 January 2016
Inspection carried out on 21 October 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF (opens in a new tab)
Inspection carried out on 20 October 2015 During an inspection of Wards for older people with mental health problems Download report PDF (opens in a new tab)
Inspection carried out on 30 October to 3 November 2017

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

After this most recent inspection we have changed the overall rating for the trust to good because:

  • Following the last inspection in April 2016, the trust had implemented a comprehensive improvement plan and had taken action to meet the requirement notices and enforcement action taken after the inspection in April 2016. In addition the majority of recommendations had also been put into practice.

  • Following this most recent inspection, only one of the fifteen core services remains rated as requires improvement (wards for adults of working age and psychiatric intensive care unit). The rest are rated as good and one core service (child and adolescent mental health wards) is now rated outstanding.

  • The most significant improvement was for child and adolescent mental health inpatient wards where, in an 18 month period, the ratings for the service had improved from inadequate to outstanding. The trust had shown vision and strong leadership in reviewing the model of the service being provided.

  • In addition the trust had stable leadership through the board and the executive leadership team who had an appropriate range of skills, knowledge and experience.

  • The trust was making good use of IT and promoting mobile working. The systems also promoted access at different levels of the organisation to timely information on performance.

  • The trust had a strong track record in terms of its equality and diversity achievements and had made good progress with their workforce race equality standard results from 2016 whilst recognising there was more to do particularly in relation to some of the other protected characteristics.

  • The trust was working to ensure a good balance between providing assurance and promoting quality improvement. The first year of adopting a formal quality improvement methodology had gone well and was producing positive results.

However:

  • The safe key question remains rated as requires improvement and there are further improvements that the trust must make in six of the core services. This includes addressing areas such as ensuring staff had completed mandatory training, hand-washing, fire safety, medicines management, use of prone restraint, updating risk assessments and maintaining clinical equipment. The trust must address these as a matter of urgency.

  • There is also scope for the trust to improve leadership and management further. This included reviewing the capacity of the executive leadership team, having a clear strategy for the trust, strengthening board visits and the feedback from these, supporting governors to perform their duties, strengthening the freedom to speak up guardian role and completing the review of some of the key documents used by the board as part of their assurance process.

Inspection carried out on 4 – 8 and 14 April 2016

During a routine inspection

We rated North East London NHS Foundation Trust as requires improvement for the following reasons:

  • The child and adolescent mental health wards were a particular of concern, where we identified concerns in relation to a number of areas including staffing, restrictive practices, lack of incident reporting and lack of recovery orientated care planning. On this ward, and that of the acute wards for adults of working age and older people mental health wards risks were not always mitigated in relation to the needs of the patients. The environment of the acute wards for adults of working age and older people mental health wards were not safe as the trust had failed to ensure that the risks to patients from ligature anchor points were identified, assessed and appropriate works to address them scheduled. We served a Warning Notice on the trust in relation to these areas.
  • In the community health services there were major staffing shortages and recruitment challenges across all staff groups and localities. There were high caseloads for staff, high use of agency and bank staff, all which had an impact on the delivery of the services.
  • The trust had not demonstrated appropriate learning from incidents and not taken appropriate steps across all of the mental health services to ensure that risks to patients from ligature anchor points had been taken to minimise the risks these might pose to patients.

  • Training in the Mental Health Act was not part of the mandatory training for staff in the mental health services which could lead to staff not working effectively with patients at risk of harm to themselves or others.
  • There was a lack of consistent recording of patient risk across the services to ensure these were captured and plans made to minimise risks.
  • Improvements were needed in the rate of supervision and appraisals of staff across the trust.
  • Improvements were needed in the capturing of information about people who use the services as diversity information was not routinely recorded across services.
  • The trust did not have a Patient Advice and Liaison Service (PALS) and so this advice was not available to people. This meant that patients and users of the service had to contact the service directly and go through complaints procedures without the additional support of an advice and liaison service. This might deter people from raising concerns or complaints.
  • The board did not have assurance that all clinical risks, including those linked to regulatory compliance had been addressed. The trust governance structures had not been fully embedded and did not ensure consistency across services.
  • The trust quality assurance processes had not identified if learning from incidents were implemented or that services were deteriorating.
  • The trust did not meet the fit and proper persons’ requirement for directors and was not compliant with the law. Also, there was a lack of robust induction or training for the trust governors, which meant they might not be as effective as they could be in their role.

However:

  • The trust had good overall systems and processes for managing safeguarding children and adults at risk.
  • There was good access to physical healthcare across the services and this was kept under regular review.
  • Directors and managers demonstrated commitment and enthusiasm to the trust and spoke passionately of the work being undertaken to develop services.
  • The trust had taken positive action in response to the recent NHS staff survey to involve and engage staff more in the development of the trust.
  • There was a well-established patient experience partnership group with direct links to the board to enable strategic developments for people using services.
  • Staff well-being, particularly through the black and minority ethnic network has worked to address inequalities, which has been recognised at a national level. The workforce race equality standards have been met.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.