North East London NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well led - this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question requires improvement. We did not re-rate the service as a result of this inspection.

We found not all governance processes operated effectively. The service did not manage prescriptions safely, in line with national guidance and trust’s own policy. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

• 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 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.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service team was led by a Head of Service who was supported by a local leadership team. Leaders were mostly knowledgeable about issues and priorities for the service. For example, they had developed an action plan for the service which focused on the areas they had identified for improvement. These included the clinical offering, care environment and staff wellbeing and engagement. This work was ongoing at the time of our inspection. There was a transformation lead in post who supported this work.

The leaders shared information about the service in a range of meetings and other forums, including away days and listening events for staff.

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.

The leaders had started a number of improvement initiatives in response to the concerns outlined in the Regulation 28 Prevention of Future Deaths (PFD) report and the subsequent whistleblowing concerns. The senior staff we spoke with were aware of areas where improvements could be made. Although progress had been made in a number of areas, others required strengthening. For example, there were still significant delays from referral to treatment and shortfalls in managing risk and record keeping.

The service undertook a number of audits and the leaders monitored their findings. However, it was not always clear if this resulted in timely improvements to practice. For example, the audits had identified a number of gaps in the completion of risk assessments, care plans and clinical harm reviews (CHR), but did not outline actions taken or to be taken to address these, nor a timeframe for doing so.

The service did not have a system to manage prescriptions safely in line with the national guidance and trust’s own policy. Although most prescriptions were printed securely through the provider’s electronic prescribing system, the service did not monitor the use of blank prescription forms and did not store them securely. Staff also had access to blank prescription pads which they kept in a safe shared with other services in the building. Staff told us the prescription serial numbers were recorded; however, we found this record was last updated in October 2024 and the numbers on it did not match the pads we saw. We escalated this concern during our visit.

There was no system to manage void prescriptions - prescriptions that are not to be used for any reason, for example due to being spoilt. Best practice guidance advises these should be retained for local auditing purposes for a short period prior to being destroyed securely. However, we found 2 prescriptions issued in 2023. This created the risk of avoidable harm due to misuse or diversion of controlled stationery items in the community or a patient receiving a prescription in error. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We raised these concerns with the leaders. Additionally, the trust’s policy for safe management of prescriptions expired in November 2024 and had not been reviewed.

The service risk register was limited to one item and had not been updated. It was not clear whether the leaders had considered a wider range of known service-specific risks and reviewed them regularly.

However, a number of governance processes worked more effectively. The service had a business continuity plan for emergencies. Staff understood the arrangements for working with other teams, both within the provider and external, to meet the needs of the patients. Staff had access to the equipment and information technology needed to do their work. The care environment was safe and well-managed.