• Organisation
  • SERVICE PROVIDER

Oxleas NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

7 February - 20 February 2023

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

Summary

  • This was a focused inspection. We looked at the safe, caring and an aspect of well led domains. We did not rerate the service as a result of this inspection. The rating of this core service remained good.
  • The trust had ongoing recruitment in progress, which had improved vacancy rates. Staff we spoke to were universally positive about the trusts efforts in recruitment to reduce staff vacancies. Staff we spoke to who had been recently recruited felt that they had good support from managers.
  • The trust had various projects on resetting the culture on acute wards to improve staff morale, reduce staff sickness, improve staff retention, reduce incidents of violence and aggression. These projects were in response to concerns raised in January 2022 about the number and nature of incidents, safety, staffing, concerns about the quality and consistency of care on the acute wards.
  • Staff made every attempt to avoid using restraint by using de-escalation techniques. We observed staff effectively intervening and de-escalating situations on different wards when patients started to become distressed or agitated. Staff used the minimum physical interventions necessary to keep a patient safe when de-escalation techniques were not successful.
  • We used the Short Observational Framework for Inspection (SOFI2) to conduct periods of observation on all wards inspected. We observed that staff treated patients with compassion and kindness. We saw staff communicating positively with patients during incidents, responding promptly and using kind words and tones. We observed consistently high-quality interactions between staff and patients on the wards. Staff displayed a great deal of passion for their work.
  • Staff had training in key skills and understood how to protect patients from abuse. Mandatory training completion rates were between 85% and 95%. The trust had an experienced nurse to support staff with inductions, senior nurses to support identify training gaps and liaise with the training department about staff training needs.
  • Staff received additional training to support their roles. This included subjects such as See, Think Act (STA) a relational security training; care certificate for non-registered nurses; reinforce appropriate, implode disruptive (RAID) an approach to working with disturbed and challenging behaviour.
  • Staff facilitated a range of activities and therapies every day. For example, relaxation group, pottery group, addiction/stress management.
  • Managers and staff carried audits such as infection prevention and control and environmental audits.

However:

  • This inspection identified a breach in Regulation 12, safe care and treatment. Staff did not always store medicines safely and correctly and keep records up to date. Medicines management needed to improve on Betts and Goddington wards. Therefore, the rating for safe remained requires improvement.
  • Staff on the psychiatric intensive care unit had not ensured that two hourly reviews had taken place by two registered nurses following commencement of seclusion of a patient as per trust policy.
  • Staff from black and minority ethnic communities did not feel they were not always well supported by the trust, when they experienced racist abuse during incidents.
  • Not all the clinical equipment had been serviced in an appropriate timescale.
  • Staff on Goddington ward had not kept a record of induction for staff.
  • The trust had not ensured that staff on Betts and Goddington Wards had access to working body cameras.

Our findings

Oxleas NHS Foundation Trust provides a range of mental and physical healthcare services for adults and children in South East London, mainly in the London boroughs of Greenwich, Bexley and Bromley. The trust provides forensic mental health services and a range of physical and mental healthcare in prisons across South East London and Kent.

It is the main provider of specialist mental health and adult learning disability health care services in Bexley, Bromley, Greenwich.

This inspection was of acute mental health wards for adults of working age and psychiatric intensive care units. We inspected the following four acute wards Avery, Betts, Goddington, Shrewsbury and one psychiatric intensive care unit The Tarn. These were located at Oxleas House and Green Parks House. Goddington ward had opened in November 2022.

The core service is registered to provide the following regulated activities: treatment of disorder disease or injury; diagnostic and screening procedures; and assessment or medical treatment of person admitted under MHA and nursing care.

We last inspected acute wards for adults of working age and psychiatric intensive care units in January 2019. The overall rating was good with requires improvement in safe; good in effective, responsive, well led and outstanding in caring. We inspected this service to review the regulatory breach in the safe domain and follow up information we had received about the service.

In January 2019 staff did not consistently carry out physical health checks on patients after they received rapid tranquilisation in line with trust policy, this was a breach of Regulation 12 Safe care and treatment (2)(a)(b). We found in this inspection that staff had consistently followed up of physical health checks on patients after rapid tranquilisation.

How we carried out the inspection

To fully understand the experience of people who use services, we asked the following questions of this provider:

Is it safe?

Is it caring?

Is it well led?

Before the inspection visit, we reviewed information that we held about the location.

During the inspection visit, the inspection team:

• visited five wards and observed the safety of the ward environment

• spoke with 17 patients who used the service and 8 carers

• spoke with the ward managers for each of the wards

• spoke with fourteen staff members: including consultant psychiatrist, occupational therapists, registered nurses and healthcare assistants and a pharmacist in person and remotely

• observed coffee and cake group, huddle, ward round and community meetings

• used the Short Observational Framework for Inspection (SOFI2) to conduct periods of observation on Goddington wards and used SOFI2 techniques on Betts, The Tarn and Avery wards

• looked at a range of policies, procedures and other documents relating to the running of the service.

You can find 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 with seventeen patients and 8 carers using the acute and PICU wards.

Patients we spoke to felt safe, staff were always available when needed, well-mannered and kind. Patients and carers reported staff helped them to understand their mental health, medicine and behaviour. Staff and patients valued the role of the lived experience practitioner who helped run groups, meet patients face to face, facilitate escorted leave and personalised activities. Some raised concern that there can be a shortage of staff. Two felt that the quality of food could be improved.

Four carers out of eight felt that staff needed to improve communication, especially for carers that live overseas and four felt that communication was excellent. They felt some staff were more compassionate than others and felt wards needed to provide more variety of activities or trips. Two carers felt updates were not given regularly and on time and there needed to be more advanced planning for patient leave and discharge. A carer valued staff approach to physical health checks, they had updates when they attended ward rounds and care plan reviews, service anytime and they always respond to any requests and valued the encouragement to support patients.

23/02/2023 - 24/02/2023

During an inspection of Forensic inpatient or secure wards

We carried out this unannounced, comprehensive inspection because we had not inspected these services since April 2017

Oxleas NHS Foundation Trust provides forensic services across eight wards, based on two sites. Joydens Ward provides care and treatment for female patients. All the other wards provide care and treatment for male patients. During this inspection, we visited Danson Ward, Crofton Ward, Heath Ward, Joydens Ward and Birchwood Ward. All these wards are at the Bracton Centre. We also visited Greenwood and Hazelwood wards at Memorial Hospital. Whilst our inspection activities focused on these wards, most of the data we reviewed covered all eight wards within this core service.

The previous comprehensive inspection of this core service was in April 2017. At that inspection, we rated the service as good. We rated the service as ‘good’ for the domains of safe, effective, caring and well-led. We rated the service as ‘outstanding’ for responsive.

Oxleas NHS Foundation Trust is registered to provide the following regulated activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983
  • Diagnostic and screening procedures
  • Treatment of disease, disorder or injury.

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

  • The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. The service took a proactive approach to anticipating and managing risks to patients. This was embedded and is recognised as the responsibility of all staff. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding. All staff were open and transparent, and fully committed to reporting incidents and near misses.
  • The service took a holistic approach to assessing, planning and delivering care and treatment to all people who use services. This included addressing, where relevant, their nutrition, hydration and physical health needs. Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. All staff were actively engaged in activities to monitor and improve quality and outcomes
  • The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • People who were detained under the Mental Health Act 1983 (MHA) understood and were empowered to exercise their rights under the Act. The service supported staff to understand and meet the standards in the MHA Code of Practice. Staff worked effectively with others to promote the best outcomes with a focus on recovery for people subject to the MHA.
  • 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. Patients valued their relationships with the staff team and felt that they often go ‘the extra mile’ for them when providing care and support.
  • There is a holistic approach to planning people’s discharge, transfer or transition to other services, which is done at the earliest possible stage. As a result, discharge was rarely delayed for other than a clinical reason. There were innovative approaches to providing integrated person-centred pathways of care that involve other service providers.
  • Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Leaders had an inspiring shared purpose. They strived to deliver and motivate staff to succeed. Governance arrangements are proactively reviewed and reflect best practice. A systematic approach is taken to working with other organisations to improve care outcomes.

However,

  • The service did not inform patients routinely that body worn cameras were being used by staff.

How we carried out the inspection

During this inspection, the inspection team:

  • visited seven wards
  • conducted a review of the environment on each ward and observed staff supporting patients
  • spoke with 7 ward managers
  • spoke with 27 staff including registered nurses, support workers and activity co-ordinators
  • spoke with the director of forensic services and the head of mental health legislation
  • spoke with 6 doctors
  • spoke with 20 patients
  • reviewed the records for 14 patients
  • reviewed the medication charts for 25 patients
  • attended handover meetings, a safety huddle, a staff meeting, multidisciplinary team meetings and a community meeting
  • reviewed other documents, performance data and policies relating to the running of the service

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

During this inspection, we spoke with 20 patients. Overall, feedback from patients was positive.

Patients felt safe and said there were always enough staff on the wards. Patients spoke positively about staff. They said that staff were caring and supportive. Patients said that they engaged in activities. They told us about activities such as playing table tennis, visiting the library and using the computers. Patients said they met with their psychiatrist and multidisciplinary team every two weeks and felt involved in decisions about their care. They said they found medication, groups and individual therapies helpful in their recovery. Patients who were allowed leave said they valued this. They told us they were able to visit their families, attend activities in the community and go shopping in areas they were familiar with. Patients said that if they did have any concerns, they would talk to staff about this.

A small number of patients were unhappy about being in hospital. There concerns focused on the nature of their detention under the Mental Health Act and the restrictions this placed upon them.

12, 13 and 15 September 2022

During an inspection of Community-based mental health services for adults of working age

We carried out this short notice announced inspection because at our last inspection we rated this service overall as requires improvement.

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 includes:

  • Hubs (previously known as primary care plus (PCP)) directly linked with primary and secondary care services. The hubs provide a single point of access to trust mental health services. Staff focus on telephone triage of patients, providing advice and support to GPs and directing patients to the pathway that meets their needs.
  • 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 bipolar disorder.
  • The early intervention pathway (EIP) for patients aged between 18-65 experiencing psychosis for the first time, or at risk of developing psychosis.

We inspected the following services:

Bexley ICMP

Bexley ADAPT

Bexley hub (PCP)

Bexley EIS

Greenwich West ICMP

Greenwich West ADAPT

Greenwich East ICMP

Greenwich EIP

Greenwich hub (PCP)

Bromley West ICMP

Bromley hub (PCP)

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

Our rating of services stayed the same. We rated community-based mental health teams for adults of working age as requires improvement because:

  • Patients gave some mixed feedback about the care and support received from the teams, particularly when they were in crisis. They reported some difficulty being accepted by some teams and getting through to some services by phone.
  • Risk management or crisis plans were not always updated as patients’ risks changed, although we found some improvement in staff recording patient risks, as required in the last inspection report published in August 2020. We also found some patients at risk of being missed due to gaps in the electronic waiting lists which had recently been introduced.
  • Teams used a zoning system to monitor patients' level of risk, and inform caseload management for staff, but records did not always make clear why patients were allocated to or had changed risk zoning levels and what extra support was needed.
  • Patients were still waiting too long for neurodevelopmental assessments and some psychological therapies. The trust had taken a wide range of actions to address long waits as required at the previous inspection. However, as demand had increased for these services, there were still excessive waiting times for assessment and treatment.
  • There was insufficient oversight of medicines management across the community mental health teams, including some errors in the management of prescription charts for patients.
  • The trust was not monitoring delays in Mental Health Act assessments and Community Treatment Order recalls for patients in the community mental health teams.
  • Staff had improved their systems for collecting feedback from patients, but there was insufficient feedback collected from carers. There was also insufficient communication from the service, about improvements made as a result of patient or carer feedback.
  • Staff were not sufficiently recording the needs of patients with a protected characteristics and how they met these.
  • Some staff including some managers had very high caseload sizes including complex cases on their caseload due to ongoing issues with staff recruitment and retention.
  • Staff were not always clear about the new protocols for recording care plans, particularly staff in the hubs using the new care planning tool for assessments.
  • The teams had taken significant steps to improve monitoring of the physical health needs of patients and make sure that patients who needed an electrocardiogram received them regularly as required at the previous inspection. However, further work was needed to ensure that this continued, particularly when staffing levels were low.

However:

  • Most 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. Patient feedback was particularly positive for the early intervention services, with patients particularly appreciating access to family therapy.
  • Staff provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients.
  • Teams had improved monitoring of patients on waiting lists to detect and respond to increases in their level of risk. They had also provided and were developing more groups for patients waiting for psychology 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 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 followed good personal safety protocols.
  • The teams included or had access to the full range of specialists including peer support workers who met the needs of the patients. The trust employed lived experience practitioners who were able to work with patients from a position of personal experience.
  • There was effective joint working with voluntary sector provision, and staff were embedding roles in GP practices, and a move to a ‘no wrong door’ approach to the services.
  • Staff were strongly motivated, working very hard to meet demand, and felt well supported by their immediate managers. New roles had been created, such as band 4 nursing associates with career pathways, to address gaps in staffing.
  • Leaders had the skills, knowledge and experience to perform their roles and had a good understanding of the services they managed. Staff described strengthened management within the last year with improved processes, and systems and support. Staff reported that the trust promoted equality and diversity in its day-to-day work and in providing opportunities for career progression.
  • Teams were undertaking a wide range of quality improvement projects including projects to improve patients’ physical health, increase patient feedback, working to reduce appointments which patients did not attend, looking at barriers to discharge, and a project led by patients looking at their experience of coming off medicines without discussions with healthcare professionals.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about these services and information requested from the trust. During the inspection visit, the inspection team:

• visited 11 services and looked at the quality of the environment

• spoke with 29 patients and 9 relatives/carers

• spoke with 63 staff including team managers, consultant psychiatrists, registered mental health nurses, psychologists, occupational therapists, social workers and lived experience practitioners

• attended and observed 9 meetings, including zoning, bed management, referral screening, and cases of concern meetings

• reviewed 50 care and treatment records

• reviewed medicines management including over 60 prescription charts

• looked at a range of policies, procedures and other documents relating to the running of the service

• met with 6 senior managers within the service by video conference

• contacted 6 local GP practices, and 3 advocacy services, to request feedback, but we did not receive any feedback from them

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

Patients said staff treated them well and behaved kindly. Although some patients and relatives expressed concerns about waiting times, almost all spoke positively about the individual staff supporting them. Patients described staff as reliable, respectful, caring, and listening to them. Some patients spoke positively about regular contact with staff, offering emotional support and advice when they needed it, helping them to manage stress, and supporting them with practical tasks such as benefit claims, and housing issues. Most patients said staff were compassionate. A small number of patients did not always feel respected and listened to by staff working with them.

Patients valued therapeutic groups and other activities arranged by staff such as walking groups, and a picnic. Patients were very aware of staff shortages in the teams, and some felt this had impacted on the frequency at which they were seen, and the amount of time staff had to speak with them on each occasion. Several patients said that it was hard to get accepted by the teams on referral. Some patients noted that it could be hard to get through on the phone to the Heights office base.

Patients’ feedback was mixed about the service overall, with suggestions for improvement in waiting times, responses from the crisis team, more frequent reassessment, and improving transition from children to adult services.

Patients told us that it was not always clear how their feedback was used to improve services.

13 to 14 April 2021

During an inspection of Wards for older people with mental health problems

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.

09 October to 10 October 2020

During an inspection of Wards for older people with mental health problems

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 carried out are treatment of disease, disorder or injury and assessment or medical treatment for persons detained under the Mental Health Act 1983

We undertook an unannounced focused inspection of all four wards for older people with mental health problems following an unexpected death of a patient who died following the use of a ligature on Scadbury Ward in February 2020 and the unexpected death of a patient who died following the use of a ligature on Shepherdleas Ward in May 2019. As this was a focused inspection, we only looked at specific areas concerning assessing and managing ligature risks to patients, learning from serious incidents and the governance arrangements for implementing and monitoring actions plans following serious incidents.

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. The remainder of our inspection activity was conducted off-site. This included staff interviews over the telephone and analysis of evidence and documents.

During the inspection visit, the inspection team:

  • visited all four wards and observed the safety of the ward environment;
  • spoke with the managers or acting managers for each of the wards;
  • spoke with two matrons covering the wards;
  • spoke with eight other staff members; including nurses and healthcare assistants;
  • looked at a range of policies, procedures and other documents relating to the running of the service

Overall Summary

We re-rated this core service following this inspection. The overall rating went down and was limited to Inadequate for the safe and well led key questions, due to breaches of regulations. Due to the serious nature of the concerns we had after the inspection, we served a Warning Notice on the trust, requiring them to make significant improvements. This was because we were concerned about the assessment and management of ligature risks to patients and the governance arrangements from board to ward of implementing and monitoring action plans resulting from serious incident investigations.

We rated this service as inadequate because:

  • Staff did not adequately assess the risk of all high-risk ligature points, particularly on Scadbury Ward. Staff used an assessment tool to score all ligature points on the wards based on level of severity. It was not clear how some high-risk ligature points had been assessed as a lower score than others.
  • Staff did not regularly update the ligature risk assessments of the ward areas. Staff on all four wards had not updated or reviewed their ligature risk assessment immediately or soon after a serious incident had occurred on Scadbury Ward.
  • Staff did not clearly put mitigations in place to reduce the risk of ligature anchor points on both Shepherdleas Ward and Scadbury Ward. Environmental ligature reduction works were not due to start on both these wards until March 2021. Ligature risk assessments showed that staff had identified ligature risks without clearly stating what the risk management would be in the meantime.
  • Managers did not share lessons learned from a serious incident that occurred on Scadbury Ward with the whole team and the wider service. The trust set out recommendations for staff across the core service to follow after a serious incident. Staff had not implemented these recommendations on the wards.
  • Our findings from this inspection demonstrated that governance processes did not operate effectively from directorate to ward level, particularly in relation to the implementation of serious incident action plans. An action plan put in place following a serious incident investigation did not clearly set out who was responsible for the implementation of all actions arising from the investigation at ward, directorate and senior management level. This resulted in a failure to carry out required actions to protect patients from avoidable harm.
  • There was not a clear framework of what must be discussed at a ward and directorate level. This did not ensure that essential information, such as learning from incidents and implementing actions plans was shared with staff at ward level. Staff did not keep up to date records of their staff team meetings.
  • New staff were not made aware of the ligature risks on the wards. The new staff induction on Scadbury Ward, did not include the assessment and management of the risk of ligature points.
  • Staff could not observe patients in all parts of the wards. On Scadbury Ward, three patient bedrooms and a communal bathroom were located on a corridor behind a corner away from the nurses’ station and other communal parts of the ward.

However,

  • Staff on Scadbury had received a debrief facilitated by a psychologist after a serious incident had occurred on the ward.
  • Patients had easy access to nurse call alarm bells to call for help in an emergency.

05 August 2020

During an inspection of Community-based mental health services for adults of working age

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.

03 August 2020

During an inspection of Community health inpatient services

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.

15 August 2019

During an inspection of Mental health crisis services and health-based places of safety

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.

21 November to 11 January 2019

During a routine inspection

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.

21 November to 11 January 2019

During an inspection of Wards for older people with mental health problems

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

  • The wards provided clean and safe environments and there were safe staffing levels across the service.
  • Staff completed a comprehensive assessment and provided a range of evidence-based treatments that reflected patients’ physical and mental health needs including specialist dementia care. Three out of the four wards had dementia friendly environments, which supported the patient group. Holbrook Ward deserved particular mention for its good practice in meeting the needs of the patients.
  • Staff managed risks effectively including the risk of falls and pressure sores. Staff managed patients’ physical health well and made prompt referrals to specialists when necessary. There was a low incidence of incidents across the service. Managers investigated serious incidents and identified learning.
  • Staff were caring and compassionate in their approach. Patients spoke positively about the support they received. Carers and relatives were involved in patients’ care and treatment plans. Patients were supported to make decisions about their care and treatment. When there were concerns about a patient’s mental capacity staff would ensure that a capacity assessment was completed.
  • Appropriate arrangements were in place for access and discharge. Bed management meetings took place weekly and a bed was available locally to a patient when needed.
  • The provider had employed “lived experience” practitioners, who had experience of mental health issues and they supported patients on the wards.
  • Staff were positive about working for the provider and had opportunities for training and leadership courses. Staff received regular supervision and appraisal to support them in their roles. Staff felt respected and valued, and found their managers to be supportive and visible. Staff felt able to raise concerns without the fear of retribution.
  • Senior leaders had the skills and experience to manage the service. The trust had trained some staff in quality improvement.

However:

  • On Shepherdleas ward staff had not completed accurate checks of equipment. Some potentially life-saving equipment was three months past the expiry date. Doctors had not signed changes to prescribed medicines on three out of 10 medicines administration records.
  • A patient who was given rapid tranquilisation whilst subject to a section 5 (2) of the Mental Health Act 1983 had no recorded capacity assessment or legal justification for this.
  • The environment on Oaktree Lodge was not dementia friendly, despite admitting patients with cognitive impairment.
  • On all four wards we found that patients’ dignity and privacy was compromised because they could not independently close the observation panels in their bedroom doors. Staff left the panels open and expected patients to ask if they wanted them closed.
  • Whilst staff had a good understanding of individual patients risks they had not updated risk assessment records with all relevant information in seven out of 23 records.
  • Whilst each ward learnt from incidents, this learning was not always shared across the wards.

21 November to 11 January 2019

During an inspection of Wards for people with a learning disability or autism

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.

21 November to 11 January 2019

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

  • 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.

21 November to 11 January 2019

During an inspection of Mental health crisis services and health-based places of safety

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

  • Staff assessed and managed patient risk well. Staff demonstrated a sound understanding of patients’ risk and kept them under continuous review at twice daily team meetings. Staff completed full risk assessments, physical health assessments and crisis plans where appropriate, and completed them to a good standard.

  • Bexley and Bromley home treatment teams used a comprehensive spreadsheet that collated key information about each patient on the team caseload at a glance. This included the current risk profile, physical and mental health, medicines, as well as social needs. This information was updated at every handover so the team always had the most recent information available to them.

  • The service had good working relationships with other teams both within the trust and externally, to meet the needs of patients in crisis. This included community mental health teams (CMHT), inpatient wards, day treatment teams, child and adolescent mental health services, police, local authorities, and accident and emergency departments. Home treatment teams had regular face to face meetings with CMHTs and inpatient wards to help ensure smooth transition of care between teams.

  • Safeguarding was integral to the teams’ daily practice. Care records demonstrated that staff clearly recorded safeguarding decisions and made appropriate safeguarding referrals where necessary. Staff were aware of the team and trust safeguarding lead.

  • Provider premises were visibly clean and staff had access to well-equipped clinic rooms to carry out necessary physical health examinations. Staff ensured patients’ physical healthcare needs were met. Staff ran weekly physical health clinics and provided psychoeducation on improving health and lifestyle factors.

  • Staff were competent and skilled to deliver care. Staff had received mandatory training in key skills. One hundred percent of staff had received an appraisal and regular supervision. Managers ensured staff had access to regular team meetings.

  • Patients’ care plans were personalised, holistic and recovery-oriented. Staff considered goals and interventions with patients, reflecting their employment, education, housing, relationships and financial needs.

  • Staff cared for patients with compassion and had a good understanding of their individual needs. Staff demonstrated examples where they went the extra mile in the care they delivered. For one patient, staff arranged a voluntary driver to transport them to provider premises due to their fear of public transport.

  • Teams signposted patients to other appropriate facilities to support their care and treatment. For example, in Bexley home treatment team, staff signposted patients to the Bexley crisis café, where mental health professionals provided support to people in distress during the evenings.

  • Managers had the right skills, knowledge and experience to lead the teams. Managers had access to information to support them with their management role and promoted a positive team culture. Staff said they enjoyed working for the teams, and described good team morale. There were low staff vacancies and turnover across the teams.

  • Lived experience practitioners were part of the teams. They were staff members with lived experience of mental health illness.

  • The home treatment teams were responsive to referrals for assessment. Teams met the 24-hour target time to assess referrals received from primary care plus (PCP). PCP was the single point of access for referrals from GPs. The teams tried to engage with people who found it difficult or reluctant to engage with the service to ensure their safety.

  • Staff were proactive in improving services. Staff were involved in quality improvement projects in Bromley and Greenwich home treatment teams, and were looking at ways to reduce paperwork and increase patient contact time in one project, and improving clinicians access to medical doctors during home visits via the use of technology in another. Bromley and Greenwich home treatment teams had received Home Treatment Team Accreditation from the Royal College of Psychiatrists.

However:

  • In Bexley home treatment team meetings did not follow a clear framework to ensure learning from incidents, complaints, and safeguarding concerns were shared and discussed between the team. Since the home treatment teams changed to operating as a borough-based model, staff reported that there was a lack of sharing key information between the teams.
  • The emergency alarm system at Greenwich health-based place of safety had a fault. When it was activated, staff were wrongly alerted to an incident at the PICU ward in the building, presenting a risk that staff may not respond to emergencies as quickly as possible.
  • 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.
  • Not all staff in the Greenwich home treatment felt confident in being able to provide support to patients from the lesbian, bisexual, gay and transgender (LGBT+) community.
  • Four per cent of patients detained under Section 136 since January 2018 had been detained unlawfully. This was due to their Section 136 expiring often due to staff not being able to find an appropriate bed in a timely manner. Some patients had long waits before they could access a bed. Between January and October 2018, 31 patients waited longer than the 24-hour limit for a Mental Health Act assessment because staff could not identify a suitable bed for the patient to move on to.
  • Although monitoring information relating to the use of Section 136 and timeliness of assessments was collected, staff did not routinely complete clinical audits to assess the completeness and quality of clinical records. This included timeliness and quality of risk assessments and management plans.

21 November to 11 January 2019

During an inspection of Community-based mental health services for older people

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.

21 November to 11 January 2019

During an inspection of Community health inpatient services

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

  • Feedback from patients and people who are close to them was consistently positive. Those we spoke with felt that staff often went the extra mile and the care they received exceeded their expectations.
  • There was a strong and visible person-centred approach to care. Staff and leaders valued and promoted caring and supportive relationships between staff, patients, and those close to them.
  • Patients’ individual needs were highly respected by staff and embedded in their care and treatment.
  • Staff had a good understanding of managing individual patient needs and helping patients living with dementia.
  • Governance arrangements were proactively reviewed and reflected best practice.
  • Leaders had an inspiring and shared purpose. There were comprehensive leadership strategies in place to develop the desired culture.
  • There was a positive culture amongst staff across all wards and departments. Staff and managers appeared receptive of our review of services. Any concerns we identified during our inspection were recorded, shared with relevant staff, and acted upon immediately.
  • Staff were patient-focussed, proud of the work that they carried out and shared responsibility to achieve positive outcome for the patients.
  • There was clear accountability and reporting from ward to board.
  • There was an improved culture of shared learning across the organisation following incidents and near misses.
  • There were effective systems for infection prevention and control and the management of sepsis.
  • Staffing levels were planned and reviewed to keep people safe, with any staff shortages responded to quickly. Staff had the skills and competence to carry out their roles effectively and in line with best practice.
  • Dementia screening and training had improved.
  • Collaborative multi-disciplinary working enabled patients’ independence and supported evidence-based care.

However:

  • Staff working at the Greenwich Intermediate Care Unit did not always understand the nuances of seeking informed consent from patients.
  • Opportunities for shared learning between the two community inpatient services could be enhanced.
  • The monitoring of the performance of the services by the trust could be developed further.

20 June 2018

During an inspection of Wards for older people with mental health problems

As this was a focussed inspection of one ward, we did not change the ratings of this core service.

Our findings from this inspection were:

  • At the April 2018 inspection, we found that staff did not follow the trust’s policy and national best practice guidance regarding ‘do not resuscitate’ decisions for patients. Staff did not record that they reviewed these decisions, completed capacity assessments for patients, or involved Independent Mental Capacity Advocates (IMCA) in the decision. At this inspection, staff had reviewed ‘do not resuscitate’ decisions and completed capacity assessments for patients. IMCAs had also been involved in the decisions. However, one patients’ capacity assessment was not sufficiently detailed, and for one patient the IMCA was involved after the decision had been reviewed and confirmed.

  • At this inspection we found that an informal patient who did not think they were unwell was recorded as consenting to take medicines. There was no record that they had a capacity assessment regarding the decision to take medicines. It was possible that the patient did not provide informed consent.

  • At the April 2018 inspection, we found that staff did not always complete risk assessments for patients when they were admitted, and did not always update patient risk assessments when required. On this inspection, staff had reviewed and updated patients’ risk assessments. No new patients had been admitted to the ward.

  • At the April 2018 inspection, we found that patients’ care plans were not always detailed, specific or met patients’ needs. Patients’ care plans did not always include patients’ preferences and did not show that patients had been involved in developing them. When the visiting GPs assessed and recommended treatment for patients’ physical health problems, they did not always record this in the patients’ care and treatment records. At this inspection, patients’ care plans were detailed, specific and addressed all the patients’ needs. Patients’ involvement and preferences were reflected in their care plans. Visiting GPs recorded their assessments and treatment recommendations in patients’ care and treatment records.

  • At the inspection in April 2018, we found that staff were preoccupied with routine and tasks, and spent more time talking with each other than with patients. Staff communication with patients was not always therapeutic. There were few activities for patients to undertake, and patients were largely unoccupied. The outcome of a safeguarding investigation into the standard of care provided to a patient had not led to more widespread learning. At this inspection, staff spent most of their time with patients. There were a range of purposeful activities for patients, patients were smiling, and staff supported them with activities. Staff treated patients with dignity and respect. The additional input from senior managers had supported staff to become more self-aware and more focused on improving care for patients.

  • At the April 2018 inspection, the ward leadership team did not effectively monitor and improve good standards of care and treatment for all patients. At this inspection, the additional support of senior managers had provided clear leadership to the staff team, supporting staff to implement changes and addressing issues with team dynamics. The ward was introducing an improved system of quality and performance monitoring to ensure that standards of care and treatment were monitored and improved.

9 April 2018

During an inspection of Wards for older people with mental health problems

As this was a focussed inspection of one ward we did not change the ratings of this core service.

Following this inspection we issued Oxleas NHS Foundation Trust with a Warning Notice.

On this inspection, we found:

  • Two patients had full risk assessments completed a significant time after they were admitted to the ward. One was completed after 19 days, the other after 10 weeks. This meant staff were not aware of actual and potential risks when patients were admitted.

  • Staff interactions with patients were brief. Patients sat in the communal areas of the ward with little to occupy them. Staff appeared to spend more time talking with each other than with patients.

  • The recording of patients’ capacity to make decisions was poor, particularly when decisions were made not to resuscitate a patient if their heart stopped. There was no record that patients’ had been assisted to make such decisions, or that these decisions were reviewed.

  • Staff communication with patients was not always therapeutic. We observed a member of staff telling a patient she would be ‘jabbed’ if she did not take her medicines.

  • Two patients said that staff did not spend time with them. Other people said the same, and said that staff were sometimes dismissive of patients and were preoccupied with routine and tasks.

  • The quality of patients’ care plans varied and some patients did not have care plans that met all of their needs. Some care plans were not detailed and specific to the patient.

  • There was a lack of activities on the ward. Activities were not always designed to meet patients’ needs and did not follow best practice.

  • A patient was significantly underweight and had not been referred to a dietitian. The patient’s care plan recommended staff refer the patient to a dietitian if they were concerned about the patient’s weight but this had not been done.

  • The nursing team had discussed the findings of a recent safeguarding investigation. There had not been more widespread learning to ensure other patients were not affected. Other patients on the ward experienced poor care.

  • The leadership team on the ward were unable to monitor and maintain good standards of care and treatment for all patients.

  • The systems to monitor and improve quality and safety for patients on the ward had not been effective.

However:

  • When patients were at risk of falls staff completed a falls risk assessment. Patients at risk of pressure ulcers were assessed using a recognised assessment tool.

  • Specialist staff, including dietitians, physiotherapists and district nurses came to the ward following a referral. The palliative care team also attended the ward when this was necessary.

  • All patients had an annual physical health check.

24 - 26 April 2017

During an inspection of Forensic inpatient or secure wards

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.

27 February - 1 March 2017

During an inspection of Mental health crisis services and health-based places of safety

We rated mental health crisis services and health-based places of safety as good overall because:

  • Following our inspection in April 2016, we rated the service as good for caring.

  • During this most recent inspection, we found that the service had addressed the issues that had caused us to rate safe as inadequate and effective, responsive and well-led as requires improvement, following the April 2016 inspection.

  • The mental health crisis services and health-based places of safety were now meeting Regulations 9, 10 and 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

9 March 2017

During an inspection of Community health services for children, young people and families

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.

27 February - 2 March 2017 and 9 March

During an inspection looking at part of the service

After the inspection in February/March 2017, we have changed the overall rating for the trust from requires improvement to good because:

  • In April 2016, we rated 10 of the 14 core services as good.

  • In response to the February/March 2017 inspection findings, we have changed the ratings for one core service from inadequate to good. This is the core service for acute wards for adults of working age and psychiatric intensive care units. In addition, we have changed the ratings for two core services from requires improvement to good. These are the core services for mental health crisis services and health-based places of safety and community health services for children, young people and families.

After the February/March 2017 inspection, we have changed ratings of the following key questions from inadequate to good:

  • The safe key question for acute wards for adults of working age and psychiatric intensive care units and mental health crisis services and health-based places of safety.

  • The responsive key question for acute wards for adults of working age and psychiatric intensive care units.

  • The well-led key question for acute wards for adults of working age and psychiatric intensive care units.

Also we have changed ratings of the following key questions from requires improvement to good:

  • The safe key question for community health services for children, young people and families.

  • The effective key question for mental health crisis services and health-based places of safety.

  • The responsive key question for mental health crisis services and health-based places of safety.

  • The well-led key question for mental health crisis services and health-based places of safety and community health services for children, young people and families.

  • In the services we inspected, the trust had acted to meet the requirement notices we issued after our inspection in April 2016.

  • We also carried out a ‘well led’ review and found that the trust had continued to strengthen leadership of the trust and refine the trust governance processes.

However:

  • Staff on the acute wards and psychiatric intensive care unit restrained patients in a prone position on many occasions, which put patients at an increased risk of avoidable harm. The trust was rolling out improved training to address this but not all ward staff had yet completed the training.

  • Doctors had not always carried out a review of patients’ prescriptions of ‘as required’ medicines in a timely manner.

  • Staff removed the shoelaces and hooded top cords from all patients admitted to acute wards. This practice did not reflect individual patient risk assessments.

  • In the community services for children, young people and families, although health visitors completed most mandated checks in the ‘Healthy Child Programme’ to an appropriate level, the ante-natal mandated check for mothers with specific needs was low.

  • Following the April 2016 inspection, we rated one other core service as requires improvement, the forensic inpatient/secure wards. The trust has provided clear action plans explaining the changes taking place over a longer timescale. The Care Quality Commission will return at a later date to re-inspect these services.

The full report of the inspection carried out in April 2016 can be found here at http://www.cqc.org.uk/provider/RPG

27 February - 1 March 2017

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

We re-rated acute wards for working age adults and psychiatric intensive care units as good because:

  • Following our inspection in April 2016, we rated the services as good for effective and caring.

  • During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe, responsive and well led as inadequate following the April 2016 inspection.

  • The acute wards for adults of working age and psychiatric intensive care units were now meeting Regulations 9, 10 and 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

26 - 28 April 2016

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

We rated acute wards for adults of working age and psychiatric intensive care units as inadequate because:

  • Wards were admitting new patients before being able to discharge existing patients. This meant that patients were frequently moved to make maximum use of beds. However, we heard of three occurrences where patients had to sleep on sofas or mattresses for one night because of the lack of beds.

  • Ligature audits concentrated on areas where observations where not taking place and did not include the whole ward, communal areas were left out. There had been five suicides linked to the core service, the latest of which was in May 2016. Staff awareness of environmental risks was not consistent across the core service.

  • The trust had mixed gender wards. At times, the same sex accommodation rules were breached by having male patients in female only corridors.

  • Medication cards were physically in poor condition and there was inconsistent recording and reviewing of people’s medicines. Patient allergies were not documented on the medication cards therefore staff were not aware of any medication that should not be given to patients.

  • Not all patients received copies of their care plans.

  • The trust did not implement local risk registers that highlighted risks pertinent to individual wards.

However;

  • The ward environments were clean, bright and the décor and furniture were well maintained.

  • Patients received comprehensive assessments during the admission process and received information on the service.

  • Physical health examinations were carried out within a 24-hour period and checks were ongoing during the patient’s admission in hospital.

  • Psychological interventions were available for patients as part of a group session; one to one sessions were also available.

  • Patients were given opportunities to provide feedback on the services they received, such as through tablets and patient experience groups.

  • Staff were kind, caring and polite.

26 - 28 April 2016

During an inspection of Forensic inpatient or secure wards

We rated forensic inpatient services as requires improvement overall because:

  • Only two staff were allocated to work on Birchwood. Staff told us one member of staff would often work alone on the ward if the other member of staff was facilitating patient leaves. The service implemented a lone working policy and staff used this. Sanctioning lone working on a secure inpatient ward risked the safety of staff.

  • All wards had potential ligature risks in communal patient areas, including areas where patients had unsupervised access such as an unlocked laundry room on Heath. Trust policy did not require staff to assess for ligatures in all areas of the ward environment.

  • The service had a banned item list, which included plastic bags. However, there were plastic bags in all areas of the wards, including areas where patients had unsupervised access such as bathrooms and laundry rooms. Plastic bags posed a risk to patients and staff.

  • The seclusion room on Heath did not meet the guidance set down by the Mental Health Act Code of Practice (2015). There were a number of instances when staff did not routinely advise patients of their rights under section 132 of the Mental Health Act and some patients did not have robust capacity assessments in place to confirm they were able to understand and consent to their treatment. Staff did not routinely complete training and updates on the Mental Health Act Code of Practice (2015).

  • It was difficult for staff to demonstrate links between when they carried out the ward based ligature audit and when the work to remove or modify risks had taken place. Although, the trust was able to evidence how actions arising from ligature audits were logged, managed and actioned.

However:

  • Staff managed risk well and patients told us that the service felt safe. Staff undertook thorough risk assessments for each patient. They were trained in safeguarding adults and safeguarding children procedures. They reported concerns to the local authority when they needed to.

  • Staff knew how to report incidents and managers investigated them; and then shared lessons learnt with staff. The service had safe systems to manage medication. There was an on going recruitment programme to fill vacancies and managers had succeeded in recruiting to all nursing vacancies at the time of the inspection.

  • The wards provided comfortable, safe, modern and suitable facilities for patients. There were secure door entry systems to prevent unwanted visitors and to manage the security level of the environment.

  • Staff provided high quality treatment and care. Different professionals worked well together to assess and plan for the needs of patients. Patients had up-to-date risk assessments and care plans. These focused on treatment plans, recovery and rehabilitation. Staff used specialist tools to assess the needs of patients. Staff routinely supported patients to deal with their physical health needs and developed service-wide initiatives to strengthen this, such as the Food Strategy and the Wellbeing Strategy. Patients could access smoking cessation and drug awareness support.

  • To aid their recovery, patients had access to a wide range of specialist psychology and occupational therapy led therapies. These included art therapy, judo, relaxation, anger management, family therapy and a sex offender’s treatment programme. The service provided patients with access to a wide range of sports activities such as basketball, hockey, swimming and a gym. Patients also had access to fun activities, which included shopping trips, B-B-Qs, trips to the seaside, and trips to local places of interest.

  • Staff ensured patients were fully engaged with their treatment programmes and patients were involved in developing their care plans. The service routinely sought patient and staff feedback. They made changes to the way they did things based on this feedback. There was a strong culture of involving patients in the running of the service and patient’s views were taken seriously.

  • The service invested in, and was responsive to the needs of, its staff. As a result, staff morale was good. Managers listened to staff and provided them with additional resources when they asked for them. Managers routinely held supervision and annual performance reviews with staff and these were up-to-date. Staff had mandatory training, which managers monitored to ensure compliance. Managers supported staff to develop their skills and career by funding external and specialist courses.

  • The service was well led at a local level and managers had good systems in place so they could audit the quality of care. However, senior managers in the trust did not demonstrate that they had sufficient oversight of some audits to determine if they were effective. Ward managers were accessible to their staff. They demonstrated the skills and experience needed to improve the service for patients. Managers and staff were continually looking for ways to improve clinical outcomes for their patients. They encouraged staff to undertake project and research work.

  • The service was part of the Royal College of Psychiatrists’ Quality Network for Forensic Mental Health Services and carried out both self and peer reviews with the network.

26 - 28 April 2016

During an inspection of Long stay or rehabilitation mental health wards for working age adults

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.

26 - 28 April 2016

During an inspection of Wards for older people with mental health problems

We rated Oxleas NHS Foundation Trust as good for older peoples’ mental health wards because:

  • All the wards were well resourced in terms of staff, environments, and activities. The staff teams were consultant psychiatrist led and came from a range of appropriate disciplines. Each environment had older people in mind and were suitably adapted with the right resources. The activities on offer were varied, age appropriate and were rehabilitative in approach.
  • Holbrook ward had been purpose built as a dementia specific ward to meet the specific needs of the patient group. For example, there were bespoke rooms, furniture and even smells to provoke pleasant memories.
  • Oaktree Lodge offered and provided comfort, spiritual and religious support and activities to people with long-term conditions and some who were at the end of life.
  • Staff appraisal, mandatory training and supervision rates were high and there was a commitment from the trust in continuing professional development, career progression and specialist training for their staff.
  • Staff used evidence-based tools to assess, monitor, and manage individual patient needs and risks. Assessment and planning was thorough and considered the patient’s physical and mental health. Family, carers and other professionals were involved in the patients’ treatment.
  • Staff used outcome measures to assess treatment effectiveness.
  • All patients and carers we spoke with were positive about the service’s care and treatment, and patients said they felt well supported. The service had a carers’ support group.
  • Staff had a commitment to quality improvement and innovation. Clinicians took part in audits to improve the quality of care. We saw learning from complaints, concerns and incidents and there was a culture of making service improvements as a result of that learning.

However:

  • None of the wards had clear lines of vision. The layout of the wards meant that there were blind spots.
  • On Scadbury ward we saw that some fire extinguishers were kept in locked cupboards and all staff did not have keys. A more accessible one was kept in the nurses’ station. The trust have provided us with subsequent evidence that this was approved by their fire safety officer and the London fire service.

26 - 28 April 2016

During an inspection of Wards for people with a learning disability or autism

We rated wards for people with Learning Disability and Autism as good because:

  • The ward was visibly clean and tidy. Whilst the ward was mixed gender, men and women were admitted to separate self-contained flats. The ward had a good track record of safety with no serious incidents in the last six months. Staff reported incidents appropriately.
  • The ward was well staffed with a full time modern matron on the ward as well as a ward manager. Any bank staff used were regular and familiar with the ward and patients. Staff were up-to-date with mandatory training and had received an annual appraisal. All staff received training in positive behavioural support which met the needs of the specialist patient group.
  • All patients had a good quality care plan that was personalised to their individual needs. Staff carried out care and treatment reviews regularly. The physical health care needs of patients were assessed and monitored appropriately. All patients had access to music and art therapy on the ward.
  • Clinical staff took part in a range of clinical audits including prescribing observatory for mental health, to monitor the effectiveness of the service provided. Staff carried out general audits on the wards, including audits of completion of patient observations.
  • The ward had an effective multidisciplinary team (MDT), comprising of speech and language therapists, clinical psychologists, therapists and a consultant nurse, all based part time.
  • Feedback from people who had used services and their carers was mainly very positive.
  • There was a full range of equipment on the ward to support patient needs. Therapy sessions were held in rooms specifically allocated to this with essential equipment. The ward had a well-equipped sensory room.
  • Staff morale was high. Staff told us that they felt supported and safe on the ward.
  • Staff had created and implemented easy-read personal profiles for each patient, which contained a wide variety of physical health information about them and their needs and preferences. Patients could take this with them to every health appointment and after discharge.

However:

  • Two fire extinguishers were found stored under the desk of the reception office at the front of the ward. This meant that if they were needed they could not be adequately accessed if there was a fire at the other end of the ward. Another two fire extinguishers were found in a locked food storage cupboard on the main corridor. This would have impacted on patient safety if there was a fire on the ward. The trust has provided us with subsequent evidence that this was approved by their fire safety officer and the London fire service.
  • The communal areas on the ward did not have a ligature risk assessment. The risk was mitigated as the unit operated high patient to staff ratios and service users were never left unsupervised in communal areas.
  • Patients’ bedrooms were not personalised. The bedrooms were not very homely and did not appear to have any colour. Staff attributed this to the fact that some of the current patient cohort did not like pictures or things hanging on the walls.

26 - 28 April 2016

During an inspection of Mental health crisis services and health-based places of safety

We rated mental health crisis services and health-based places of safety as requires improvement because:

  • The environment of the health-based places of safety and day treatment teams had several ligature anchor points, which posed a high risk to patients. The Bromley and Bexley day treatment team facilities had not completed environmental risk assessments including a ligature assessment in areas where patients would be unsupervised. The service was not aware of the risks, which meant that the risks were not adequately mitigated.

  • The risk assessments completed by the home treatment and day treatment teams demonstrated inconsistencies in how staff documented and managed risks. Care records lacked evidence that patients had person-centred, detailed crisis plans. There was a lack of evidence that physical healthcare monitoring was regularly taking place. The home treatment teams did not always demonstrate that staff carried out an initial physical health screening or full assessment.

  • Staff did not routinely carrying out checks of personal panic alarms, clinical equipment and infection control. One team did not have access to emergency life support equipment including emergency drugs, which meant that staff was unable to attend to patients in an emergency.

  • Bromley HTT and Greenwich day treatment teams had not ensured that all staff had completed all mandatory training courses. Twenty-five percent of staff in Bromley HTT had not completed basic life support training. Thirty-three percent of staff had not all completed breakaway training and 50% of staff had not completed food safety training in the Greenwich day treatment team.

  • Staffing levels varied across the three boroughs. Staff in some teams found it difficult to manage the increasing acuity of the caseload. Staff told us that on occasions joint visits were unable to take place, as there had not been enough staff. Patients were provided with transport in order for them to attend the team base to be seen.

  • Bexley day treatment team had minimal psychology input and was unable to provide specialist psychology support to their patients. After the inspection, the trust advised us that an additional two days per week of psychology input would be provided to the day treatment team starting from October 2016.

  • Trust systems and processes were insufficient in ensuring that the health-based places of safety-protected patient’s safety, privacy and dignity.The entrance doors to the Greenwich place of safety were clear glass and meant passers-by were able see in to the place of safety.One of the places of safety did not provide a comfortable environment for patients, as there was no bed or shower facility available.

  • The trust did not provide staff with specific Mental Health Act (MHA) training in accordance with the new MHA code of practice. Staff lacked knowledge in the application of the MHA and were unable to support patients that remained under the MHA in the community

  • Patients did not have access to information, which related to their rights as a patient and independent mental health advocacy. The information was not clearly displayed in waiting areas and in the health-based places of safety.

  • There was an inconsistent approach in the use of outcome measures. Home treatment teams were using specific measures and the day treatment teams were not. This did not ensure that teams were able to review their clinical effectiveness. However, the trust planned to roll out a new tool that was being piloted by the Bromley HTT.

  • The teams were not ensuring that the systems and procedures that were in place were working effectively. The processes in place to ensure that patients were receiving safe care and treatment, which also protected their privacy and dignity, needed to improve.

However:

  • The trust had plans to review and refurbish the health-based places of safety, although there were no set dates for completion. The trust had responded to and rectified the privacy and dignity issue at the place of safety in Greenwich after the inspection.

  • Staff within the home treatment teams, day treatment teams and health-based places of safety demonstrated good practice in responding to people in crises. Staff were professional, caring and supportive. Teams routinely reflected on incidents and looked at how practice could be improved and lessons learnt.

  • The health-based places of safety were adequately staffed.

26 - 28 April 2016

During an inspection of Community-based mental health services for older people

We rated Oxleas NHS Foundation Trust as good for older peoples’ mental health community- based services because:

High standards of risk assessment and risk management were consistent across all of the services. Potential patient risks were reviewed regularly and patients had individualised crisis plans. In all of the services, there was an ongoing focus on patient safety.

Staff went above and beyond what was expected of them. All grades of staff were accessible, and went beyond service limitations to meet the needs of patients and carers.

The care home project worked with care home staff to effectively support their residents. The memory service also provided an early identification service for residents with suspected dementia.

Following referral, patients waited under six weeks until they were assessed by memory services. Six weeks is the target time for all memory services to achieve by 2020.

The advanced dementia service co-ordinated and provided palliative care to patients with dementia. Staff in the service supported and advocated for patients and carers, including decisions concerning where the patient wished to die.

Complaints were viewed as a learning opportunity. Incidents and complaints were thoroughly investigated. Learning from incidents and complaints was communicated to all services. There was an open and transparent culture.

The strategic direction of the directorate focussed on effective partnership working. Co-operation and collaboration with partners was seen as key to providing a holistic, high quality service to patients and carers.

The senior management team promoted a culture of high standards and continuous improvement. This culture was reflected in each of the services. Standards of care were consistently high across all of the services.

26 - 28 April 2016

During an inspection of Community-based mental health services for adults of working age

We rated the community based mental health services for adults of working age as good because:

  • The services had effective systems for managing risk. Staff reviewed risks to patients at meetings that were held several times a week. Patients had risk assessments and clear risk management plans in place.
  • Most teams had few vacancies. Staff and patients had access to a psychiatrist when they needed one. Managers monitored and adjusted the caseloads of staff so that they could provide safe care and treatment to patients. Teams were piloting a case load weighting tool aimed at ensuring staff caseloads were balanced.
  • Complaints and serious incidents were investigated. The lessons learned were identified and shared with staff in the community teams. Staff made improvements in systems and care to help reduce the chances of the same type of incident or complaint happening again.
  • Teams worked effectively with other trust services such as home treatment teams, child and adolescent mental health teams and employment advisors. Staff worked in partnership with local voluntary sector organisations to provide social inclusion programmes which supported patients’ recovery. The teams were establishing good working relationships with local GPs.
  • Most staff were up to date with mandatory training, received an annual performance appraisal and had regular clinical and managerial supervision.
  • Staff provided care and treatment that was evidence based and in accordance with national guidance. Managers in the early intervention service had been proactive in making sure that staff had the skills to deliver family interventions. Psychologists and psychotherapists were integrated into the teams, which helped improve patient access to therapies.
  • Staff provided caring and compassionate care to patients and carers. They understood the needs of individual patients. Patients were positive about the care and treatment they received.
  • Clear systems of governance supported the teams to learn from incidents and complaints and make improvements in care and treatment. Managers had instant access to key performance information, which helped them monitor and improve the effectiveness of the service, as well as ensuring staff training, supervision and appraisal were up to date.

However:

  • Although the trust provided guidance to staff on issues of patient confidentiality it was not clear that all staff followed the guidance and understood the boundaries. There was a risk that staff were not always maintaining confidentiality and could compromise patients’ privacy, particularly when leaving telephone messages.
  • Waiting times for assessment had improved since the introduction of the re-designed model of care for working age adults in the community. However, the primary care plus teams were inconsistent in terms of how promptly they were able to assess urgent and routine or non-urgent referrals. For example, some teams had assessed over 80% of urgent referrals on the same day and 100% within two weeks. Whereas another team had assessed no urgent patients on the same day and 68% within two weeks in the same time period.
  • Staff did not routinely attend training in the Mental Health Act, this was not mandatory. Some staff said they had limited understanding of the Act and associated code of practice.

25 - 28 April 2016

During an inspection of Community mental health services with learning disabilities or autism

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.

26 – 28 April 2016

During an inspection of Community health inpatient services

Overall rating for this core service

Overall, this core service was rated as ‘Good. This was because:

  • Systems used to identify patients at risk of deterioration were used effectively.
  • Patients received their medicines safely when they were prescribed.
  • Facilities were well maintained in a clean and hygienic condition and staff employed recognised infection control practices.
  • Adequate numbers of suitably qualified and experienced staff met patients’ needs, and kept them safe and patients received adequate medical supervision.
  • Robust systems for assessing and mitigating risks were embedded. When incidents did occur, there were well understood systems for reporting and investigating these, and changes were made to practice in light of the lessons learnt.
  • Patients received care that followed latest published guidance and best practice and outcomes were in line with national averages.
  • Patients received adequate pain relief.
  • Patients were supported to eat and drink suitable food in sufficient quantities. However feedback from patients about the quality of food was mixed.
  • Staff received adequate training to safely undertake their role, and their performance was supervised and appraised.
  • Patients received care from a multidisciplinary team who worked cohesively to deliver care that met their needs.
  • Patients were positive about their experience. They were treated with compassion and their privacy and dignity were respected.
  • The service was well placed to meet the diverse needs of patients and was committed to providing care as close to home as possible.
  • Admissions to the service were well managed to minimise risks to patients. Discharge from the service was well planned to ensure the needs of patients would continue to be met. Delayed discharges were usually beyond the control of the hospitals.
  • Staff shared a vision and philosophy of care within the service, with a strong rehabilitative ethos. Senior leaders were visible and staff were supported by their immediate managers to provide high quality services.

We saw some good practice, including:

  • Compliance with national infection control guidance.
  • A strong ethos of promoting independence and rehabilitation.
  • The implementation of a system called pressure ulcer prevention strategy (Pups) to reduce pressure ulcers.
  • Multidisciplinary team working between nursing, therapy and social care staff.

26 - 28 April 2016

During an inspection of Specialist community mental health services for children and young people

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.

26 - 28 April 2016

During an inspection of Community health services for adults

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.

26 - 28 April 2016

During an inspection of Community end of life care

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.

26 - 28 April 2016

During an inspection of Community health services for children, young people and families

Overall services for children, young people and families were rated as ‘Requires Improvement’. We found community health services for children, young people and families were ‘Requires Improvement’ for safe and well led. We found community health services for children, young people and families were ‘Good’ for effective, caring and responsive.

Our key findings were:

  • There were ongoing incidents related to the electronic system, communication issues and record problems. These were being periodically reviewed but had not been resolved.
  • There were inconsistent methods of recording messages, which meant the trust could not be assured messages had been responded to in a timely manner. Lapses in communication had been identified as a risk when working with vulnerable families.
  • There was no caseload weighting tool to ensure health visitors could deliver an equitable service across the trust. Some caseloads were very high, above the upper limits as set by professional organisations.
  • Allocation meetings where staff allocated work were not recorded consistently. This meant there was no process to review staff allocation. There was no robust system regarding allocation of families and their level of need with the capacity of the staff to meet the need.
  • Some premises were not suitably equipped for families to ensure their safety and infection prevention and control measures were not consistently in place.
  • Data was not robust in relation to health visiting performance and the trust could not be assured it was able to deliver health visiting services to meet people’s needs.
  • School nursing for 2014/15 achieved 100% uptake in the reception year National Child Measurement Programme and 99.9% in year 6. A new healthy weight programme had been introduced for those children classed as overweight to meet the high rate of obesity.
  • The trust delivered care in line with current evidence-based guidance, standards, best practice and legislation. There was good engagement with other providers and across disciplines, we saw some excellent examples of multidisciplinary working.
  • Staff told us they felt respected and valued. All staff said they enjoyed their jobs and liked working in their team and for the trust.
  • Innovation was promoted by the trust.  For example, the use of technology to improve access to health information on sexual health websites for Bexley and Greenwich as well as the electronic application ‘app’ for new parents.

26 – 28 April 2016

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.

We rated Oxleas NHS Foundation Trust as requires improvement overall because:

  • Not all services were safe and the trust needed to take action to address areas of improvement. For example, some wards had fixtures and fittings that people at risk of suicide could use as a ligature anchor point; these potential risks had not been adequately assessed and addressed.

  • The environments at some community based services did not fully promote the privacy, dignity and recovery of patients using these facilities.

  • The governance arrangements in place to take action following serious incidents that required investigation and trust wide learning were limited by the pace of investigations.

  • Concerns regarding the trust wide management of medicines were identified.

  • At Green Parks and Oxleas House mental health acute admission services, each ward had between 16 and 19 beds. In addition to this, they each had one surge bed. Staff said the surge beds were used daily. Records showed us that patients in those rooms had a length of stay ranging from two days to a week. All staff told us bed pressures were the biggest issue, and that the situation had been intense during the previous 12 months. When the demand for beds was high, patients were moved between areas.

  • Across the acute wards, patients were being admitted before discharging existing patients. This meant that patients were frequently moved to make maximum use of beds. However, we heard of three occurrences where patients had to sleep on sofas or mattresses for one night because of the lack of beds. A number of patients had experienced sleeping on sofas and mattresses on the wards waiting for a bed to become available.

  • We were informed and saw evidence that that beds for patients on leave would be used for new admissions and patients were being moved between wards and locations to accommodate new admissions. We were told by patients that having to sleep on other wards during their admission this made them anxious.

  • Front line staff did not receive ‘refresher training’ on the Mental Health Act and the revised code of practice. Some relevant trust wide policies had not been updated to reflect the revised code of practice.

  • The seclusion room on Heath did not meet the guidance set down by the Mental Health Act Code of Practice (2015).

  • There were a number of instances when staff did not routinely advise patients of their rights under the Mental Health Act and some patients did not have robust capacity assessments in place to confirm they were able to understand and consent to their treatment.

  • The trust did not use a weighting tool to ensure health visitors deliver an equitable service across geographical locations.

  • The trust data collection and collation mechanisms were not robust for health visitor service metrics and breastfeeding data at six to eight weeks postnatal.

  • The trust did not complete initial health assessments within 20 days.

  • The trust did not make arrangements to ensure that all the child health clinics were suitably equipped for families and children to ensure their safety.

However:

  •  Staff provided high quality care throughout the trust. We found examples of staff providing a high level of patient centred care and providing positive emotional support to patients who were distressed.
  • In community health services we found that there were arrangements to ensure that patients were safe, and that there were systems to report, investigate and learn from safety incidents.
  • We saw good multidisciplinary working and generally people’s needs, including physical healthcare needs, were assessed and care and treatment was planned to meet them.
  • Services were clean with good infection control practices.
  • In community health services, patients received adequate pain relief and were supported to eat and drink suitable food in sufficient quantities.
  • The trust was meetings its obligations under the Duty of Candour and the fit and proper persons requirement regulations.
  • The trust had robust processes in place to identify and report serious incidents.
  • Front line staff received appropriate training, supervision and professional development. Some staff told us they had been given a lot of support to learn new skills or update their skills.
  • Complaint information was available for patients and staff had a good knowledge of the complaints process.
  • In community health services admissions were well managed to minimise risks to patients. Discharge from the service was well planned to ensure the needs of patients would continue to be met. Delayed discharges were usually beyond the control of the hospitals.
  • The trust held bed mental health bed management meetings once a week and two daily telephone conferences. These meetings included managers from the inpatient and crisis teams. The attendees provided up-to-date information on bed status, a review of admissions waiting for beds, accelerated discharges to accommodate new admissions and patients that were in beds outside of the trust area and possible return dates. Any patients moved between wards were recorded on the trust electronic system as an incident.
  • The trust had participated in a range of patient outcome audits, research and accreditation schemes. Prompt actions had been taken when concerns were identified by audits.
  • The trust has a number of effective initiatives to engage more effectively with users and carers.
  • Trust wide leadership was visible and proactive to front line staff.

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.

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.