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Provider: Oxleas NHS Foundation Trust Good

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

Inspection Summary


Overall summary & rating

Good

Updated 26 March 2019

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

  • We rated safe, effective, caring, responsive and well-led as good. We rated all the trust’s services as good. In rating the trust, we took into account the current ratings of the eight services not inspected this time, as well as the six we did inspect.
  • We rated well-led for the trust overall as good.
  • The trust had a committed leadership team with strong values and integrity and had delivered consistently high-quality patient care across the services we inspected. Leaders had a good understanding of services, and were visible and approachable. There were effective processes in place for cascading information between the trust board, senior leadership, clinicians and other staff.
  • Leaders across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose. Staff described good morale within the teams. Staff felt well supported by managers and were confident in their leadership approach and direction. Most staff felt able to raise concerns and were confident they would be taken seriously.
  • Services had enough staff with the right qualifications, skills, training and experience to keep patients safe and to provide the right care and treatment. Staff shortages were responded to promptly and recruitment campaigns were ongoing. The learning and development needs of staff were identified and prioritised through annual appraisals and regular clinical supervision. There were good opportunities for specialist training and development for staff. Lived experience practitioners had been recruited, trained and supported to work with patients from the perspective of someone who had used services in the past.
  • Staff assessed and managed risks to patients well and followed best practice in anticipating and de-escalating volatile situations. There had been a reduction in incidents of violence and aggression across the inpatient wards. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The trust was committed to improving by learning from when things went well and when they went wrong. Staff learned from complaints, incidents and near misses and ensured that lessons learned led to improvements. Managers were aware of the key risks in their services and these were reflected in local risk registers. Risk registers were used effectively to escalate risks and ensure they were addressed.
  • Staff took a person-centred, holistic approach to care and were recovery-oriented. Patients had good access to physical as well as mental healthcare and were supported to live healthier lives. Services took account of patients’ individual needs, including the needs of patients with protected characteristics. On the acute wards and psychiatric intensive care unit there was a high level of patient involvement in running and participating in community meetings.
  • Staff had received training, understood their roles and implemented their responsibilities under the Mental Health Act 1983. The trust was at the forefront nationally of the introduction of non-medical approved clinicians.
  • Services provided care and treatment that was based on national guidance and evidence of its effectiveness. Services monitored the effectiveness of care and treatment and used the findings to make improvements. Most people could access a service when they needed it. Services responded promptly to urgent referrals.
  • The trust collaborated well with local organisations to plan new services and improve existing ones. Partnerships with other organisations across south London had a positive impact on the quality of care and treatment provided to patients including making sure they were cared for closer to home.
  • Leaders understood the importance of sustainability and delivering services within budget. Staff at all levels were actively engaged in this work and always considered the potential impact of possible savings on the quality of patient care.
  • The trust collected, analysed, managed and used information well to support all its activities. Managers had access to the information they needed to provide safe and effective care and used that information to good effect. The trust was making good use of digital technology. This was leading to the effective sharing of patient records with other health providers and simplified the transfer of information.
  • The trust was striving for continuous improvement. The trust used a systematic approach to quality improvement. Over 300 staff had received training in quality improvement methodologies and there were over 40 active quality improvement initiatives across all directorates and trust wide.

However:

  • Staff did not always follow best practice to ensure the safety of patients after they had received rapid tranquillisation. In the acute wards staff did not consistently carry out and record physical health checks on patients following the administration of rapid tranquilisation. Although staff assessed, monitored and maintained medical equipment to ensure it was fit for purpose on most wards, on one ward, despite carrying out regular checks, staff had not identified and replaced expired automated external defibrillator pads, syringes and emergency medicines.
  • Although the trust had appropriate medicines management policies in place staff did not always follow these. Some managers in the community mental health teams for older people did not record the quantity or serial numbers of medicine prescription pads. There was a risk staff would not be aware of any prescription pads or single prescriptions that went missing. Some non-registered staff in the intensive home treatment team for older people administered medicines to patients but had not received training in medicines management and their competency to do so safely had not been checked.
  • Documentation and record keeping was inconsistent across services in terms of the quality of recording and storage on the electronic patient record. This included patient care plans, information about risk and mental capacity assessments. Some records were not updated, did not contain a full risk history or lacked detail to support decisions about patients’ mental capacity. In several services, information was stored in different parts of the patient record by different staff, which could cause delays in finding information when needed.
  • The trust needed to make environmental improvements on some wards to ensure the patient experience was positive and people’s individual needs were met. This included improving environments for patients with autism and people with cognitive impairments. The trust had plans to remove shared bedrooms from two acute wards to improve patients’ privacy and safety.
  • Although most patients could access the services they needed in a timely way some patients in the health-based places of safety had long waits before they could access an in-patient bed. The waiting time for patients to be assessed by the Greenwich memory service had increased to 12 weeks.
  • Whilst the trust had a diverse board that reflected the staff and local community, it did not have an overarching strategy to address equality, diversity and human rights. There were missed opportunities to link pieces of work together and share learning across the organisation. The trust had a strong BME network but other networks were still developing. The trust acknowledged they needed to continue to work to improve the experience of BME staff and staff with lived experience, and fully implement the accessible information standard.
  • The trust board recognised that further work was needed to have a longer-term strategy, articulating the ambitions of the trust. There was a piecemeal approach to co-production work with service users and carers, with plenty of good practice, but little coordination to ensure this was fully embedded in all the trust’s work. Some key areas of work that needed to be signed off by the board had not been clearly presented and approved.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RPG/reports.

Inspection areas

Safe

Good

Updated 26 March 2019

  • Staff delivered services from suitable premises that were visibly clean, well-cared for, and pleasant environments. Environmental risks were regularly assessed and mitigated effectively. Teams had access to well-equipped clinic rooms. There were effective systems for infection prevention and the management of sepsis.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and knew where to get advice when they needed it.
  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff had completed mandatory training in key skills. Where wards and teams had staff vacancies, or posts that were difficult to recruit to, the trust was running active recruitment campaigns. Staff in community mental health teams for older adults and home treatment teams had manageable caseloads. Staffing levels on wards were reviewed daily to keep patients safe. Any staff shortages were responded to promptly.
  • Staff assessed and managed risks to patients well and followed best practice in anticipating and de-escalating violence and aggression. The trust had implemented the Safewards model to improve safety for patients and staff. Interventions had reduced incidents of violence and aggression. Staff used restraint and seclusion only after attempts at de-escalation had failed and were using alternative restraint techniques to reduce the use of prone restraint.
  • There was a culture of reporting and learning from incidents and near misses. When things went wrong, staff apologised and gave patients honest information and suitable support. Services planned for emergencies and staff understood their roles if one should happen. Staff provided debrief sessions to patients involved in or witnessing incidents on the wards. Staff were provided with immediate support and longer-term assistance after adverse incidents.
  • Staff kept appropriate records of patients’ care and treatment. Records were stored and maintained safely and securely. Staff treated patient identifiable information in line with General Data Protection Regulations.

However:

  • Staff did not consistently carry out and record physical health checks on patients following the administration of rapid tranquilisation. This was contrary to national guidelines and trust policy. Patients receiving rapid tranquilisation are at risk of seizures, airway obstruction, excessive sedation and cardiac arrest. The failure to carry out checks in line with national guidelines and trust policy put patients at risk of avoidable harm. Staff at the health-based place of safety did not always clearly record when patients refused their physical health observations following receipt of medication by rapid tranquilisation.
  • Although staff assessed, monitored and maintained medical equipment to ensure it was fit for purpose on nearly all wards, staff on Sheperdleas Ward, despite carrying out regular checks, had not identified and replaced expired automated external defibrillator pads, syringes and emergency medicines.
  • Some staff in the community mental health teams for older people did not record the quantity or serial numbers of medicine prescription pads, contrary to trust policy and national guidance. There was a risk staff would not be aware of any prescription pads or single prescriptions that went missing. Some non-registered staff in the home treatment team for older people administered medicines to patients without training or a check of their competence to do so safely. Doctors had not signed medicine administration records to indicate changes to medicines that had been prescribed for three out of ten patients on Shepherdleas Ward.
  • Whilst staff had a good understanding of individual patient risk, in the wards for older people with mental health problems staff had not updated patient risk assessments in a third of patient records we reviewed. Staff, on Betts and Norman wards, did not always record a full history of patients’ risk incidents, changes to patients’ risk status, or new relevant incidents on their risk assessments. Staff in the community mental health teams for older adults did not record information about patients in a consistent manner. This could cause delays in finding information when needed.
  • At Oxleas House, there was a blanket restriction of removing all patients’ shoelaces, and cords from hooded tops on admission, instead of conducting prompt individualised risk assessments on admission.

Effective

Good

Updated 26 March 2019

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

  • Staff assessed the physical and mental health needs of all patients holistically. They developed individual care plans, which were reviewed regularly through multidisciplinary discussion and updated as needed. Staff took a person-centred approach to care and were recovery-oriented. Staff ensured that patients had good access to physical healthcare and supported patients to live healthier lives. The community-based mental health services for older people took a proactive approach to improving patients’ physical health through the provision of structured activity sessions. The home treatment teams ran a weekly physical health clinic to support patients’ physical health needs.
  • Services provided care and treatment that was based on national guidance and evidence of its effectiveness. Staff had access to policies and standard operating procedures through the trust’s intranet. Patients had access to evidence-based psychological therapies and clinically indicated medicines. Staff used innovative approaches to care. On Holbrook Ward staff used the Kitwood person-centred care model to support patients with dementia and mental health needs. The community mental health team for older adults provided an enhanced dementia service, which included caring for people at the end of life. Staff on acute mental health wards used the Broset Violence Checklist to help reduce incidents of violence and aggression. Patients in the intermediate care wards received adequate pain relief in line with the Core Standards for Pain Management Services in the UK (2015).
  • Staff provided patients with enough food and drinks to meet their needs and improve their health. Patients had access to specialist dietetic services when required. Services took account of patients’ religious, cultural and other preferences in terms of the meals provided.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. Staff used recognised rating scales to measure outcomes for patients. Clinical audits were used to measure the effectiveness of treatments. Where concerns about performance were highlighted, managers evaluated practice to identify opportunities for improvement.
  • Most services made sure staff were competent for their roles. The learning and development needs of staff were identified through a system of appraisals and regular supervision meetings. Staff used reflective practice meetings to consider their response to the complex needs of patients. Staff had access to specialist training to meet their professional learning needs. Local services provided new and temporary staff with an appropriate induction.
  • Staff of different disciplines worked collaboratively to benefit patients. The trust proactively employed lived experience practitioners who were valued members of their teams. Services had good working relationships with other teams and agencies both within the trust and externally, to meet the needs of patients. Staff in the health-based place of safety met regularly with the police. Staff in community mental health teams for older people worked with specific care homes in their local area and with patients’ GPs. Acute wards worked closely with local drug and alcohol support services.
  • Staff had access to up-to-date and accurate information on patients’ care and treatment. All staff had access to an electronic records system that they could update. Staff on the acute wards used visual boards to record patient information. This tool was successful in ensuring that patients’ needs in all areas were met. Staff referred to the boards at each handover and multidisciplinary meeting. Bexley and Bromley home treatment teams used a spreadsheet to collate comprehensive information about each patient’s needs, at a glance. This information was updated at every handover so the team always had the most recent information available to them.
  • Staff had received training and understood their roles and responsibilities under the Mental Health Act 1983. Staff ensured patients understood their rights under the Act. The trust was at the forefront nationally of the introduction of non-medical approved clinicians.

However:

  • Although staff understood the trust’s policy in relation to the Mental Capacity Act 2005 and supported patients to make decisions for themselves, the recording and storing of mental capacity assessments was inconsistent. Records of mental capacity assessments of patients were not readily available in some teams and wards and many assessments lacked supporting detail.
  • Patients were occasionally kept at the health-based places of safety beyond the lawful period of their detention whilst staff identified a suitable bed for the patient to be admitted to. Although staff sought patients consent to remain at the facility informally when this happened, on 19 occasions patients had not agreed to stay at the facility beyond 24 hours. The trust was actively working to reduce the number of such incidents.
  • In the acute wards, patient care plans varied in terms of how well they addressed patients identified needs and how often they were reviewed by staff. New staff working with patients might not have all the information they needed to support patients appropriately. In the health-based place of safety staff did not routinely audit the completeness and quality of patient records.
  • Not all staff in the Greenwich home treatment team felt confident in being able to provide support to patients from the lesbian, bisexual, gay and transgender (LGBT+) community.

Caring

Good

Updated 26 March 2019

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

  • Staff cared for patients with compassion and kindness and were mindful of their privacy and dignity. Patients were respected and valued as individuals and had their privacy protected. We observed positive, caring and supportive interactions between staff and patients throughout the inspection. Staff provided patients with help, emotional support and advice at the time they needed it. When patients were distressed, staff supported them in a calm and sensitive manner, using de-escalation techniques effectively. Most patients and carers told us that staff understood their needs and supported them to understand and manage their care, treatment and condition.
  • Staff involved patients in decisions about their care and treatment. Staff involved patients in care planning, crisis planning and risk assessment. Patients had easy access to independent mental health and mental capacity advocates. On the acute wards and psychiatric intensive care unit there was a high level of staff and patient involvement in running and participating in community meetings. On some wards patients facilitated and made presentations to the meetings.
  • Staff involved carers and relatives in all aspects of care with the patient’s agreement. Staff were proactive in explaining to families how they could be involved in the patient’s recovery and discharge. On Scadbury, a ward for older people with mental health problems, all patients had a family involvement plan. Staff routinely invited carers and patients into ward rounds and care planning meetings. In some wards staff using video calling to include relatives and carers who lived abroad in ward rounds. In the community mental health teams for older people staff involved carers in cognitive stimulation therapy and post-diagnostic support groups. A carers’ liaison worker from an external organisation facilitated a carers’ support group for relatives of patients on Lesney and Millbrook wards. Green Parks House held a weekly drop in session for families and carers whose relative was a patient on the wards.
  • Staff enabled patients and those close to them to give feedback about the service they received. Staff used the results of surveys and feedback to inform service improvement. The trust gave patients a questionnaire to report their views on the quality of the service when they were discharged. The results of the previous month’s survey were displayed on each ward’s notice board. Patients were asked about the choice of food, helpfulness of staff, discharge arrangements and their overall care. The wards had a ‘you told us, so we did’ board, which highlighted any requests or suggestions that patients or carers had made and what actions had been completed in response.
  • Lived experience practitioners had been recruited, trained and supported to work with patients on the wards, supporting them from the perspective of someone who had used services in the past.

Responsive

Good

Updated 26 March 2019

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

  • Most people could access a service when they needed it. Services responded promptly to urgent referrals. With the exception of health-based places of safety and one memory clinic, services met waiting time targets for assessment and treatment. For the three months prior to the inspection, there were no breaches of the 24-hour referral to assessment target in all three home treatment teams. Despite great pressures staff managed beds well. A bed was usually available when needed and patients were not moved between wards unless it was for their benefit.
  • Delayed discharges or transfers of care were monitored closely in bed management meetings. Barriers to patients being discharged were identified at admission, and addressed as early as possible to prevent patients staying in hospital longer than they needed to. Staff were proactive in addressing barriers to discharge. In the wards for older people staff had developed close links with local commissioners and local authorities to help identify future placements for patients.
  • Staff supported people who found it difficult to engage with services through building relationships and responding positively to the things that were important to the patient. Missed community appointments were discussed during staff handover meetings and there was a clear escalation process to address patients’ non-engagement with community services.
  • Services took account of patients’ individual needs, including the needs of patients with protected characteristics. Services enabled access for people with physical disabilities, took account of patients’ cultural and religious needs and provided information in accessible formats. The Greenwich Memory Service had carried out a quality improvement programme to increase referrals for people from Black African communities, who were under-represented in the service. Information displayed in waiting rooms made clear that the trust viewed discussions about sexuality positively and that homophobia was unacceptable. Reasonable adjustments were made to ensure people with additional needs such as visual and hearing impairments, and people who required interpreting and translation services could access and use services on an equal basis to others.
  • Most wards for older people with mental health needs and the intermediate care wards took account of the needs of patients with dementia and cognitive difficulties. The environment on Holbrook Ward was specifically designed for patients with dementia. The ward decoration, pictures, accessories, dementia-friendly kitchen and a newly opened sensory garden, all contributed to a calming, therapeutic ward environment and supported patients’ memories. Scadbury and Shepherdleas had also made changes to the ward environments to make them more appropriate for patients with dementia.
  • Food was generally of good quality and patients could make hot drinks and snacks at any time. Meal choices took account of patients’ dietary requirements and religious, cultural and other preferences. On the acute wards, patients had varying views of the quality and choice of meals and portion sizes. There was ongoing liaison between staff, patients and the contracted caterer to improve patient satisfaction with food on these wards.
  • Staff treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff. Information about making complaints was clearly accessible on the wards, and provided to new patients as part of their orientation to their ward.

However:

  • Although most patients could access the service they needed in a timely way some patients in the health-based place of safety had long waits before they could access an in-patient bed. Between January and October 2018, 31 patients waited in the place of safety longer than the 24-hour limit. Following a decrease in service funding the waiting time for patients to be assessed by the memory service in Greenwich had increased to 12 weeks, above the target of six weeks.
  • The trust needed to make improvements in some ward environments to ensure the patient experience was positive and met people’s individual needs. At Atlas House, a ward for people with learning disabilities, the environment did not fully address the sensory needs of patients with autism. Oaktree Lodge, a ward that admitted patients with cognitive impairment was not designed in a way that was dementia-friendly. The trust had plans to remove shared bedrooms from Lesney and Millbrook wards and consequently improve patients’ privacy and safety. Patients on some wards for older people could not close privacy panels in their bedrooms doors independently and relied on staff to remember to close them.

Well-led

Good

Updated 26 March 2019

Our rating of well-led stayed the same. We rated it as good because:

  • The trust had managers at all levels with the right skills and experience to run a service providing high-quality sustainable care. Managers had good understanding of the services they managed, were visible in the service and approachable for patients and staff. Senior leaders visited the wards and teams regularly and were known to staff.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff in all services were caring, compassionate and patient-focused.
  • Staff described good morale within the teams and worked well together. Staff felt well supported by managers and were confident in their leadership approach and direction. Most staff felt able to raise concerns and were confident they would be taken seriously. Staff who had long service in the trust were recognised. They felt proud to work for the trust.
  • Services had effective systems for identifying risks, and planning to eliminate or reduce them. Senior managers were committed to improving by learning from when things went well and when they went wrong, and supporting staff training and professional development. Staff learned from complaints, incidents and near misses and ensured that lessons learned led to improvements. Managers were aware of the key risks in their services and these were reflected in local risk registers. Risk registers were used effectively to escalate risks.
  • The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems. Managers had access to the information they needed to provide safe and effective care and used that information to good effect.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Staff were very positive about and committed to working for the trust. Partnerships with other organisations locally and across south London had had a great impact on the care provided to many patients, many of whom were now treated much closer to home.
  • The governance systems in place ensured that services were delivered to a good standard. There were effective processes in place for cascading information between the trust board, senior managers, clinicians and other staff working in services.
  • The trust used a systematic approach to continually improve the quality of its services. Staff had received training in quality improvement methodologies. Services were implementing quality improvement initiatives in care delivery. Projects included the provision of an evidence-based programme of activities for patients on the psychiatric intensive care unit and a project to offer patients the opportunity to have time with their named-nurse in a more relaxed environment away from the ward. Similarly, projects were underway in Bromley and Greenwich home treatment teams looking at ways to improve service delivery and patient care. The trust piloted improvement initiatives and introduced them trust wide if they were successful. Some teams had achieved accreditation from the Royal College of Psychiatrists, such as Bromley and Greenwich home treatment teams and the memory services in Bexley and Bromley.

However:

  • Some services lacked effective structures for sharing information and key learning from incidents, complaints and safeguarding concerns cross-borough. Although some wards and teams were similar in terms of service specification they did not always maximise learning opportunities. This was a missed opportunity to share lessons learned and identify improvements.
Checks on specific services

Community health inpatient services

Good

Updated 9 October 2020

Oxleas NHS Foundation Trust provides community inpatient services in two locations. These are Greenwich Intermediate Care Unit, which is based at Eltham Community Hospital in Eltham, and Meadowview, which is based at Queen Mary’s Hospital in Sidcup. Inpatient services provided include intermediate care, and rehabilitation. Patients are admitted to community inpatient services from their own homes, or from acute hospitals.

The regulated activities carried out are treatment of disease, disorder or injury and diagnostic and screening procedures. During this inspection we visited the following location;

Greenwich Intermediate Care Unit, which is a 30 bedded unit (17 patients were on the unit at the time of inspection).

This was a focused inspection we undertook to investigate specific concerns raised to us in respect of three key questions; is the service safe? are staff caring? and is the service well-led?

The information we received suggested there were concerns on the unit in relation to:

  • Personal protective equipment was not available
  • Patients’ needs were not responded to at night
  • Poor infection control practice
  • Physical health concerns not escalated appropriately
  • Staff did not treat patients with dignity and respect

As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent on the wards to prevent cross infection. Two inspectors and a CQC specialist advisor visited the unit on 3 August 2020 for half a day to complete essential checks. Whilst on site we wore the appropriate personal protective equipment and followed local infection control procedures. The remainder of our inspection activity was conducted off-site. This included staff interviews over the telephone and analysis of evidence and documents. Our final telephone staff interview was completed on the 11 August 2020.

This was an unannounced inspection and, in order to see how the service operated outside office hours, the site visit started at 5:00am.

During the inspection visit, the inspection team:

  • visited the unit and observed the quality of the ward environment and how staff were caring for patients
  • spoke with 20 staff members including nurses, health care assistants, domestic staff, occupational therapists, the ward doctor and the matron
  • spoke with four patients
  • spoke with three carers/relatives
  • attended and observed a nurse led hand-over and a multidisciplinary team meeting
  • reviewed three patient care and treatment records
  • looked at a range of policies, procedures and other documents relating to our concerns.

Overall Summary

We did not re-rate the overall service following this inspection. It remained Good overall although we limited the rating for safe to Requires Improvement as we found a breach of regulation. This was a lowering of the rating since the last inspection.

We found:

  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • Staff recognised and reported incidents and near misses. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced.

However:

  • Staff did not clearly document how long patients at risk of skin breakdown spent positioned on each side. There had been a higher number of hospital acquired pressure ulcer incidents in April 2020, although this had improved more recently.
  • Although staff completed and updated risk assessments for each patient and removed or minimised risks, we observed one instance where a patient’s deteriorating physical health measurements were not acted on promptly. This was similar to information of concern shared with us before the inspection.
  • The service mainly controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. Equipment and the premises visibly clean. However, some staff, although maintaining a safe distance from others, were not always wearing the correct personal protective equipment for very short periods of time.
  • Doors to the sluice rooms were left open and the cupboards inside were unlocked, these cupboards contained hazardous materials, such as chlorine tablets.

Wards for older people with mental health problems

Good

Updated 18 June 2021

Oxleas NHS Foundation Trust provides wards for older people with mental health problems across four locations. These are Shepherdleas Ward, based at Oxleas House and Oaktree Lodge, based at Memorial Hospital, both in Greenwich. Scadbury Ward is based at Green Parks House in Bromley and Holbrook Ward based at the Woodlands Unit in Bexley.

Shepherdleas Ward is a 19 bedded ward providing care to people over the age of 65 who have mental health needs.

Scadbury Ward is a 22 bedded ward providing care for people over the age of 65 with functional mental health problems such as depression.

Holbrook Ward is a 22 bedded dementia intensive care unit for people who have complex needs and behaviours related to their dementia.

Oaktree Lodge is a 17 bedded continuing care unit providing care for people over the age of 55, with long term mental health rehabilitation needs.

The regulated activities provided are treatment of disease, disorder or injury and assessment or medical treatment for persons detained under the Mental Health Act 1983.

We carried out this unannounced focused inspection to check whether the trust had made improvements and complied with a Warning Notice served under Section 29A of the Health and Social Care Act (HSCA) 2008 in 2020. The Warning Notice was issued due to concerns about the assessment and management of ligature risks to patients and the governance arrangements, which had led to a failure to implement key safety recommendations from a serious incident investigation. The date for compliance with the Warning Notice was 8 February 2021.

At the previous inspection we identified breaches of Regulation 12 HSCA (RA) Regulations 2014 safe care and treatment and Regulation 17 HSCA (RA) Regulations 2014 good governance. The overall rating for this core service following this inspection in October 2020 went down and was limited to Inadequate for the safe and well led key questions, due to the enforcement action we took. The core service was rated as Inadequate overall.

The current inspection was a focused inspection looking at Safe and Well Led, to review improvements that had been made in all four older adult wards. We inspected all four wards for older people with mental health problems. We inspected the Safe and Well-led key questions in full to enable a re-rating of these areas.

As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent in the service to prevent cross infection. Whilst on site we wore the appropriate personal protective equipment and followed local infection control procedures. This included staff interviews over the telephone and via video and analysis of evidence and documents. Our final video call interview was completed on 15 April 2021.

During the inspection visit, the inspection team:

  • spoke with two patients who used the service and four carers;
  • visited all four wards and observed the safety of the ward environment;
  • spoke with the ward managers for each of the wards;
  • spoke with one healthcare cleaning manager;
  • spoke with one director of estates and facilities and two estates senior facilities managers;
  • spoke with four matrons;
  • spoke with fourteen staff members; including healthcare cleaners, health care cleaning supervisor, consultant psychiatrist, occupational therapists, physiotherapist, registered nurses and healthcare assistants and a pharmacy technician;
  • used the Short Observational Framework for Inspection (SOFI2) to conduct periods of observation on two wards, Holbrook Ward and Oaktree Lodge. SOFI2 is a way of observing care to help us understand the experience of people who cannot talk with us; and
  • looked at a range of policies, procedures and other documents relating to the running of the service.

Our rating of services improved. We rated them as good because:

  • The trust had complied with the Warning Notice. The service had made significant improvements in the safety of the wards. The management of environmental ligature risk assessments had improved. All four wards had an updated live environmental ligature risk assessment that staff could access. Refurbishment work, including the removal of ligature risks had been carried out on all wards. Staff were aware of the remaining ligature risks on the wards and there were clear plans in place to manage these. All environmental ligature risks had been updated following a serious incident. Remaining works to remove ligature risks on the wards were due to be completed by the end of the July 2021.
  • The overall governance of the service had improved. Governance operated effectively from directorate to ward level, particularly in relation to the implementation and monitoring of serious incident action plans on the wards. The trust senior management had introduced a matron with responsibility for and oversight of ligature risks on the wards and the implementation of improvements.
  • All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff maintained good practice in terms of infection prevention and control.
  • The wards had enough nurses, doctors and therapists to keep patients safe. The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received appropriate training, supervision and appraisal.
  • Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing distressed behaviour. Staff minimised the use of restrictive practices.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service through meetings, posters in staff offices, serious incident ‘flash alerts’, individual supervision and directorate meetings. Since our last inspection improvements had been made to ensure staff were aware of and learned from incidents across the services.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s mental and physical health. Staff followed trust policies when administering covert medicines.
  • Staff ensured clear and full documentation of the decisions, reasons, and the discussions that informed do not attempt cardiopulmonary resuscitation (DNACPR) decisions.
  • Staff participated in clinical audits and quality improvement initiatives to monitor the effectiveness of services provided and continuously improve the service provided.
  • Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service and approachable for patients and staff.
  • Staff knew and understood the provider’s vision and values and how they applied to the work of their team. The trust was reviewing their overall strategy and staff had been involved. Staff felt respected, supported and valued. They said the trust promoted equality and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.

However:

  • We found some excess, out of date and used equipment that needed to be removed or disposed of from two clinic rooms in two wards. There was no thermometer to measure room temperature in two clinic rooms meaning the temperature was not monitored or recorded. Two wards had an out of date British National Formulary.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke to two patients who felt safe on the ward, staff were supportive and met their needs.

Community-based mental health services for adults of working age

Requires improvement

Updated 19 October 2020

Oxleas NHS Foundation Trust provides a range of community-based mental health services for adults of working age.

Community mental health teams support patients who have complex mental health and social care needs. They provide medium to longer term support to patients.

The pathway of care consists of primary care plus, which directly links primary and secondary care services. Primary care plus staff focus on telephone triage of patients, provide advice and support to GPs and direct patients to the pathway that meets their needs. Primary care plus provides the single point of access to trust mental health services.

The ADAPT pathway provides focused, therapeutic interventions to patients needing treatment for anxiety, depression, affective disorder, personality disorder and trauma.

The intensive case management for psychosis (ICMP) pathway provides care and treatment for patients diagnosed with schizophrenia and bi-polar disorder.

We inspected the following services:

Bromley West ICMP

Bromley West ADAPT

Bromley PCP

Bexley ICMP

Bexley ADAPT

Greenwich East ICMP

Greenwich East ADAPT

In addition, we collected feedback and information about some of the trust’s other services, including the attention deficit hyperactivity disorder (ADHD) team, commissioned to provide ADHD assessments.

We inspected this service as part of an announced focused inspection. We decided to carry out this inspection following a series of interviews we conducted with patients and carers to gain their view of the service.

As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent in the service to prevent cross infection. One inspection manager visited a team base on 5 August 2020 for half a day to complete essential checks. Whilst on site they wore the appropriate personal protective equipment and followed local infection control procedures. The remainder of our inspection activity was conducted off-site. This included staff, patient and carer interviews over the telephone and analysis of evidence and documents. Our final telephone staff interview was completed on 14 August 2020.

As this was a focused inspection, we only looked at specific areas concerning assessing and managing risk to patients and staff, patients’ access to treatment, patients’ ability to feedback about the service, how the service was running during the Covid-19 pandemic, the wellbeing of staff and patients and the culture within the trust.

During the inspection visit, the inspection team:

  • visited the Bromley West team base at Beckenham Beacon;
  • spoke with 82 patients, relatives and carers who were using the service;
  • spoke with the managers or acting managers for each of the teams;
  • spoke with 36 other staff members; including doctors, nurses, occupational therapists, clinical psychologists and social workers;
  • looked at eight care and treatment records of patients:
  • looked at a range of policies, procedures and other documents relating to the running of the service

Overall Summary

We undertook this focused inspection to look at specific areas concerning assessing and managing risk to patients and staff, patients’ access to treatment, patients’ ability to feedback about the service, how the service was running during the Covid-19 pandemic, the wellbeing of staff and patients and the culture within the trust.

We identified breaches of regulation in this focused inspection and this resulted in the overall rating of this core service going down.

We rated community mental health teams for adults of working age as requires improvement because:

  • Although staff assessed the risks affecting patients they did not consistently put in place or update risk management plans to address these risks.
  • Many patients had not received the physical health checks they needed. The trust could not be assured that patients who required an electrocardiograms (ECGs) to monitor their heart function had received one in the last 12 months. This potentially put patients at risk of avoidable harm.
  • Some pathways within the service were difficult to access. Patients waited a long time to start psychological therapies or receive an assessment for Attention Deficit Hyperactivity Disorder (ADHD). Over a six-month period, most teams did not meet the trust target of 95% of patients to start a psychological therapy within 18 weeks of their referral. In addition, the demand for patients accessing an ADHD assessment had increased and far outstripped capacity, meaning that waits were very long. As of July 2020, across all three boroughs, 362 patients were waiting for an ADHD assessment. The trust had recently started taking steps to address these waiting times, but these were not yet resulting in patients receiving a timely service.
  • Staff did not proactively seek feedback from patients or carers about the care they received from the service. The service needed to do more to inform and involve families and carers appropriately.
  • Patients on the Care Programme Approach (CPA) did not always meet with their full multidisciplinary care team during their reviews. This may have impacted on their ability to be fully involved in decisions about their care.
  • Staff did not always actively address the comprehensive needs of all patients, including those with a protected characteristic. The service could do more to encourage an open and inclusive environment to support patients’ sexual, cultural and spiritual preferences.
  • Individual caseload sizes varied across the teams. The trust aimed for caseloads to be no higher than 35 per clinician. However, some staff reported caseloads higher than this with complex cases on their caseload. The trust needed to do more to embed their new case load weighting tool.

However:

  • Staff worked with patients and their families and carers to develop crisis plans. Staff monitored patients on waiting lists to detect and respond to increases in level of risk. Staff followed good personal safety protocols.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Leaders had the skills, knowledge and experience to perform their roles and had a good understanding of the services they managed. Leaders were visible in the service and approachable for patients and staff during the Covid-19 pandemic.
  • Staff felt respected, supported and valued. Staff reported high morale amongst the teams and felt supported by their senior leadership. They reported that the trust promoted equality and diversity in its day-to-day work and in providing opportunities for career progression in most teams.

Mental health crisis services and health-based places of safety

Good

Updated 1 October 2019

We undertook a focused inspection of the trust’s Pre-Admission Suite (PAS) looking only at responsive key question. The inspection was undertaken following information of concern we received about the length of time patients stayed in the PAS and complaints from patients and relatives. As this was a focused inspection of the PAS, we did not change the rating for this core service.

Following this inspection, we issued a letter of intent to the provider informing it that we proposed to impose conditions on the provider’s registration in accordance with section 31 of the Health and Social Care Act 2008 because of the serious concerns we had about the length of time patients were staying in the PAS, the inadequate facilities provided to patients for lengths of stay beyond 12 hours, and the overly restrictive environment. We asked the trust to take immediate action to address the issues. The provider responded quickly describing the actions it was taking to minimise risks to patients in the service. The trust informed us it had decided to close the PAS as it failed to meet essential standards of quality and safety in respect of length of stay; patient privacy, dignity and comfort; and access to and from the unit for informal patients. The PAS closed on 27 August 2019. Following the closure of the PAS we told the trust we would take no further action in response to the serious concerns we had identified at the time of the inspection.

Our findings from this inspection were:

  • Patients were staying in the Pre-Admission Suite (PAS) for too long. The unit was intended for short stays of under 12 hours, but patients routinely stayed for longer. Between 1 January 2019 – 15 July 2019 151 patients had stayed in the PAS for longer than 12 hours. Sixty-four of these patients had stayed for over 24 hours. Of these, 11 patients had stayed between 2-3 days and 12 patients had waited for 3-8 days. This placed patients at risk of psychological harm. The physical environment and facilities did not meet the needs of people waiting for long periods.
  • Patients privacy, dignity and comfort was compromised. The room only contained upright, non-reclining and armless chairs that were not suitable for spending long periods of time on. There were difficulties in accessing meals, snacks and drinks. No bedding was provided, there was a lack of private space and limited access to shower facilities outside the unit. There was no separation of male and female patients and no safe places to store possessions. This compromised patients’ dignity, privacy, comfort and recovery.
  • The PAS was a potentially overly restrictive environment for patients. The PAS waiting area had restricted access via an entrance door with a key code. Patients could not leave the PAS without permission and when they did leave, staff accompanied them. Patients were not admitted to hospital, not legally detained and had consented to wait in the PAS for admission. Some patients were not happy about the restrictions placed on them, for example not being able to go outside when they wanted to. One person became agitated when he was not allowed to go outside immediately as there was no member of staff available to accompany him at that time.

Wards for people with a learning disability or autism

Good

Updated 26 March 2019

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

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses, doctors and other professionals. 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 could be challenging.
  • 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 cared for in a ward for people with a learning disability and autism and in line with national guidance about best practice. Staff engaged in clinical audit 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 wards. Managers ensured that these staff received training, supervision and appraisals. The ward staff worked well together as a multi-disciplinary team and with external organisations that had a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • Staff planned and managed discharge well. As a result, discharge was rarely delayed for other than a clinical reason and readmission numbers were low.
  • The service was well-led and the governance processes ensured that ward procedures ran smoothly.

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

Good

Updated 26 March 2019

  • Staff completed comprehensive mental and physical health assessments when patients were admitted to the wards. Patients received support from staff of a wide range of relevant mental health disciplines working together as a team. Staff teams provided a wide range of personalised interventions, which included medicines, psychological therapy and a wide range of therapeutic and rehabilitation activities. Patients on some wards had access to psycho-education, a hearing voices group, and talking therapy groups.
  • Staff learned from incidents that had occurred across the service, and ensured that learning from lessons was put in place across the wards, for example, in implementing more frequent searches, and implementing protected time for staff to interact with patients.
  • The trust had effective safeguarding procedures and staff understood how to protect patients from abuse, working with other agencies to do so. Staff had training in how to recognise and report abuse and knew how to apply it in their everyday work.
  • Staff were kind and compassionate. We observed positive, caring and supportive interactions between staff and patients throughout the inspection. There was a high level of staff and patient involvement in community meetings across the service, with systems in place to ensure that patients had opportunities to contribute, and received all relevant information.
  • Staff actively encouraged patients and carers to be involved in care planning and sought their views on a range of aspects of their care and treatment. Staff acted on feedback from patients and carers to make improvements to the service.
  • Lived experience practitioners had been recruited, trained and supported to work with patients on the wards, supporting them from the perspective of someone who has used services in the past.
  • Occupational therapists and the staff teams focused on ensuring patients had meaningful activities, which improved their life skills. Patients had access to a range of therapeutic activities. These included tai-chi, baking, current affairs, drumming, personal grooming, fitness, meditation, music and art.

  • The trust had ensured that environmental risks relating to ligature anchor points, and blind spots were included in environmental risk assessments and that staff were aware of these risks and how to mitigate them.

  • The trust had implemented the Safewards model to improve safety for patients and staff. Interventions had reduced incidents of violence and aggression. They had plans in place to reduce patient restraint, and prone restraint in particular.

  • The trust provided training and support to staff to ensure they had the necessary skills to support patients effectively. Managers held regular supervision meetings with staff to provide support and monitor the effectiveness of their work. Ward managers received support and tools to manage their wards appropriately including dashboards with accurate information including data on staffing, complaints, physical health checks, and incidents.

  • The trust had implemented an ongoing recruitment drive to fill staff vacancies at the service. This was proving effective, although further work was needed to ensure retention of new staff.

  • Staff supported patients to live healthier lives. The trust provided support for patients who wanted to stop smoking. Staff provided appropriate support to patients with physical health needs, and some wards held weekly health and well-being clinics. Staff used a recognised tool to record patients’ physical health observations. Staff prescribed, administered, recorded and stored medicines appropriately.

  • Wards were implementing some quality improvement approaches to care delivery. Projects included the introduction of physical health and well-being clinics, standardised templates to note the actions agreed at ward rounds, support for patients to have time with their named-nurse in a more relaxed environment off the ward, and the use of the Broset Violence Checklist to monitor and address state of agitation before violent incidents occur.

However:

  • Staff did not always carry out physical health checks after administering intra-muscular medicines for rapid tranquilisation. Patients receiving rapid tranquilisation are at risk of seizures, airway obstruction, excessive sedation and cardiac arrest. The failure to carry out checks in line with national guidelines and trust policy put patients at risk of avoidable harm.

  • The trust retained a blanket restriction at Oxleas House of removing all patients’ shoelaces, and cords from hooded tops on admission, instead of conducting prompt individualised risk assessments on admission.

  • Work was required to remove shared bedrooms from Lesney and Millbrook wards, ensure that all the windows at Oxleas House were made safe, and all patients had access to vision panels that they could adjust, and alarm bells in their bedrooms.

  • Staff, particularly on Betts and Norman wards, did not always record a full history of patients’ risk incidents, changes to patients’ risk status, or new relevant incidents on their risk assessments, to ensure that new staff working on the wards, could access this information without delay. Care plans were variable across the wards, in terms of patient input, addressing all areas of need identified, and regular review.

  • Details of all staff involved in patient restraints were not always recorded. Records of mental capacity assessments were not easily available, and did not always include evidence on which the judgements were based.

Community-based mental health services for older people

Good

Updated 26 March 2019

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

The services provided a comprehensive range of treatments including medicines, clinical psychology and occupational therapy. Treatments reflected patients complex needs in relation to the ways in which physical health can have an impact on patients’ mental health. Services offered treatment, group therapies and activities for patients with anxieties associated with depression.

  • Staff cared about patients. Patients spoke positively about the support they received, describing staff as caring and supportive. Patients said they could contact their care co-ordinator whenever they needed to and that staff always listened to them.
  • The services managed risks effectively. Staff completed a risk assessment for all patients and frequently updated this. Risks were reviewed in multidisciplinary team meeting. If a patient’s risks increased, staff responded promptly by increasing the frequency of visits, reviewing medication or referring the patient to a more intensive support service.
  • Feedback from staff was positive. Staff felt respected and valued, and found their managers to be supportive. Staff said that teams worked well together and that colleagues were always available to provide support.
  • Each service had good links with each other and with other agencies. The intensive home treatment team worked closely with the inpatient services to arrange admissions to hospital and provide support to patients being discharged. In each borough, services worked closely with voluntary organisations that supported older people. Care co-ordinators worked closely with care homes to ensure that residents who may require the service were seen promptly.
  • Most of the services responded promptly to new referrals. Most services saw patients within the target times.
  • Teams took steps to ensure that all people, including those with protected characteristics, could access the services. The Greenwich Memory Service had done work to increase referrals for people from Black African communities, who were under-represented. Information displayed in waiting rooms stated that homophobia was unacceptable, an issue that the trust took seriously. Services made adjustments for patients with physical disabilities so that they could attend appointments.

However:

  • In Bexley, staff did not record the serial numbers of prescription pads. This meant that staff would not be aware of any prescription pads or single prescriptions that went missing. Some non-registered staff supporting patients with their medicines had not yet received formal training or a check of their competence to do so safely.
  • In Greenwich, two safeguarding concerns had not been investigated in a timely manner.
  • Services did not take a consistent approach to recording and storing patients’ care plans, risk assessments and mental capacity assessments. Some patient information was difficult to find on healthcare records.
  • In Greenwich Memory Clinic there were delays to assessments of patients referred to the service, following a reduction in funding to the service. The waiting time for an assessment in this service was 12 weeks rather than the target of six weeks.

Forensic inpatient or secure wards

Good

Updated 6 July 2017

We rated forensic inpatient/secure wards as good because:

  • At the inspection in April 2016, we found that the pre-discharge ward, Birchwood, somethimes had only one staff member on the ward. At the current inspection we found there were at least two staff members on Birchwood at all times. Nurse staffing levels had also been benchmarked with other forensic services. This had resulted in an increase in nursing posts.

  • During the April 2016 inspection, ligature risk assessments were not undertaken for all ward areas. We found plastic bags on the wards. Plastic bags were on the list of banned items for the wards. Risks within the service had not been addressed effectively. At the current inspection, ward ligature risk assessments included all areas of the wards. There were no plastic bags on the wards. There had been significant improvements to most wards by the installation of parabolic and convex mirrors. These enabled staff to see ‘blind spots’ on the wards.The trust had responded in a timely and effective manner to a range of risks that had been highlighted in the previous year. The senior management team were focussed on risks in the service.

  • During the April 2016 inspection, we found that the trust had not followed the Mental Health Act Code of Practice in a number of areas. The seclusion room on Heath did not meet Code of Practice guidance. A number of patients were not routinely advised of their rights in accordance with section 132 of the Mental Health Act. Patients’ ability to understand and consent to treatment was not recorded in detail. Patients were not routinely given copies of their section 17 leave forms. At the current inspection, the seclusion room on Heath was being rebuilt. Almost all patients were regularly informed of their section 132 rights. Patients’ capacity to consent to treatment was recorded in detail and patients had copies of their section 17 leave forms.

  • In April 2016, following changes in the use and purpose of Joydens and Heath, some female patients were waiting to be assessed to determine which level of security would best meet their needs. At the current inspection, all female patients had been assessed and were on the appropriate wards. The same consultant psychiatrists and psychologists worked on Heath and Joydens. This provided continuity of care for patients when they changed wards. This was particularly important for women who had a poor experience of relationships with others.

  • At the April 2016 inspection, we found that audits did not translate into action at ward level.

  • At this inspection, Crofton had piloted the use of the Broset violence checklist (BVC). This is an easily understood tool to predict increasing levels of patients aggression. Part of this pilot involved an audit, which found a 37% decrease in patient incidents after using the BVC. Following the audit all forensic admission wards began using the BVC. Other forensic wards implemented a care zoning tool to reflect patient risks.

  • The service was smoke-free, and a smoking cessation clinic operated seven days per week. The fresh air project on Friday evenings involved a meal and a smoking cessation education session. Patients’ carbon monoxide readings were also taken. In seven months, 63% of patients had lower carbon monoxide readings. This meant these patients were healthier.

  • Occupational therapy staff worked every day of the week and activities took place every day, including bank holidays. There was an exceptional range of individual and group activities during the day and evening. These included cycling, art, bricklaying, literacy and numeracy, sports and exercise groups, a spiritual care group, and design and technology. Patients could gain recognised qualifications and real work opportunities were available, where patients worked for external organisations. This meant they could get work references increasing their chances of future employment.

  • A carer’s telephone line operated week days to provide support for carers.

  • Staff felt supported by their immediate managers. Staff were confident to use the whistleblowing procedure and to raise concerns. There was a strong sense of team working and mutual support.

  • Improvements meant that forensic inpatient/secure wards were now meeting Regulations 9, 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

However:

  • A number of blanket restrictions and practices were in place across all wards. These included room searches and patients’ use of mobile phones. These restrictions and practices were not specific to the groups of patients on individual wards or the level of security.

  • Patients’ care plans varied in quality across the forensic services. While some patients’ care plans were detailed and person centred others were not. Some did not address all the patients’ needs.

  • The patients' telephone on each ward had a privacy hood, but these were not effective and did not enable patients to make private phone calls.

Community health services for children, young people and families

Good

Updated 2 May 2017

We rated service for children, young people and families as good overall because:

  • Following the inspection in April 2016, we rated the service as good for effective, caring and responsive.
  • During the current inspection we found that the service had addressed the issues that had caused us to rate safe and well-led as requires improvement following the April 2016 inspection. The service was now also rated good for safe and well-led.

Specialist community mental health services for children and young people

Good

Updated 13 September 2016

We rated the service as good because:

  • Patients told us they generally felt safe in the service. Staff effectively mitigated individual clinical risks.
  • Staff were positive about working for the trust. Mandatory training rates were high; staff felt supported and accessed regular supervision. The teams consisted of enthusiastic people with patient care as their priority. Services included a range of staff able to deliver psychological therapies recommended by NICE.
  • Parents, carers and young people felt services were welcoming, clean and comfortable and gave very positive feedback about how staff treated them. The trust employed a participation worker who supported engagement with young people and families to support their involvement in service development.
  • Staff regularly assessed and discussed elevated risks. This meant that young people and parents/carers had crisis plans in place if needed.
  • Service waiting times were within the trust maximum target of 13 weeks. Services could offer rapid response in an emergency between 9am and 5pm. Bromley CAMHS was a pilot site for an out-of-hours service and was able to offer an emergency response between 9am and 9pm on weekdays and 8am and 10pm on weekends.
  • Services had developed several helpful resources, such as a physical healthcare clinic and a self-help and referral website called ‘headscape’. This was created with the input of young people and provided information about mental health issues and self-help.

However:

  • Staff did not carry out regular environmental ligature risk assessments. There were several areas where ligature risks were present. For example, in bathrooms where staff were unable to fully mitigate risks.
  • There were several vacancies across teams so there was pressure to meet the demands on the service. A large number of vacant posts had been recruited to and staff were waiting to start. In the interim, agency staff filled a large amount of the vacant posts.
  • Leaflets that were available, for example about the complaints procedure, were only available in English. Information about advocacy services was not displayed clearly across all services.
  • The trust had designated a CAMHS inpatient bed on an adult acute ward for use when an inpatient CAMHS bed was not available. There was a protocol on the use of this bed, which was a shared responsibility between this team and the acute ward concerned; however, we found several examples where CAMHS and other trust staff had not followed procedures appropriately. CAMHS staff had not worked together with other trust staff to ensure that the environment on this ward was appropriate and safe for a young person.
  • We found evidence that feedback and learning from incidents was effective within a borough, but not as effective across services in the three different boroughs.

Community mental health services with learning disabilities or autism

Good

Updated 13 September 2016

We rated Oxleas NHS Foundation Trust community mental health service for people with learning disabilities or autism as good because:

Staff worked in innovative and creative ways to provide people, their families and carers with support, care and treatment that made a positive difference to people’s lives. Staff assessed in detail the personal needs of individuals and provided them with care and treatment plans that were holistic and addressed their needs. As well as a wide range of psychosocial and psychological interventions the service also provided innovative support to people living with anxiety and depression.

People who use servcies, their families and carers consistently told us that the standard of care they received was very high and that it had made a positive difference to the lives of all those who used the service.

The service empowered people to contribute to the development of services giving them the opportunity to formally review staff practices, materials, premises and to actively participate in the recruitment of staff to ensure the service met people’s needs.

Systems were in place to ensure that staff continuously delivered services according to best practice and staff liaised and worked with external agencies to share knowledge of best practice methods and ideas.

We observed that staff treated people with care and respect in every aspect of their work and demonstrated patience and concern about all aspects of their mental and physical health.

Staff ensured that they continuously obtained the feedback of people, their families and carers, providing numerous opportunities for them to give their comments and concerns.

The service was well led with a clear commitment from senior management to ensure that staff were well supported, their ideas encouraged and opportunities provided for their professional development. As a consequence staff morale was high and staff were committed to mutually supporting each other to maintain high standards of care.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 13 September 2016

We rated Oxleas Healthcare NHS Foundation Trust's long stay and rehabilitation wards as good because:

  • Cleanliness was good across all wards. Infection audits showed good levels of controls across the rehabilitation and long stay wards.

  • Staff used evidence-based tools and assessments to measure needs and risk. Clinicians took part in audits to monitor and improve the quality of care. Staff had access to additional training for their role to improve clinical effectiveness.

  • Staffing levels across most of the wards was good except Somerset Villa that operated with lower number. The number of nursing staff each shift on Somerset Villa meant that staff could not do restraints and on nights, there could be one nurse on the ward at any time.

  • Staff treated patients and carers with dignity and respect. Staff were enthusiastic, positive and had understood the needs of patients and how to meet them. All patients and carers we spoke with were positive about the care and treatment they had received.

  • Staff felt well supported and supervised, staff appraisal rates were good. Mandatory training rates met trust requirements.

  • Wards were committed to quality improvement and innovation.

Community end of life care

Good

Updated 13 September 2016

Overall we rated community end of life care services at Oxleas NHS Foundation Trust good.

This was because:

  • We found staff provided focused care for dying and deceased patients and their relatives.

  • Do not attempt cardio-pulmonary resuscitation (DNACPR) forms were generally completed in accordance with national guidance.

  • Community health services had policies, guidelines and training in place to ensure that all staff delivered suitable care and treatment for a patient in the last year of their life.

  • Community health services provided end of life care training for staff which was mandatory for community nursing staff.

  • Community health services fulfilled the World Health Organisation definition of end of life care and met the National Institute of Health and Care Excellence’s (NICE) guidance.

Community health services for adults

Good

Updated 13 September 2016

We judged that Community Adult Services were good. This was because:

  • We found that there were arrangements to ensure that patients were safe, and there were systems to report, investigate and learn from safety incidents.
  • We found that care and treatment was based on current guidance and best practice.
  • Patients told us that they were treated with kindness and empathy and that their dignity was upheld.
  • Services were arranged to respond to patients’ individual needs and could be accessed when they were required.
  • We found that services were well-led; with a positive learning culture which staff were engaged in and identified with.
  • Governance systems were in place to monitor safety and service quality and there was an emphasis on on-going quality improvement.
  • Staff felt supported by their line managers who encouraged staff to innovate and develop their practice.