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Provider: South West London and St George's Mental Health NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 12 June 2018

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

We rated all six services we inspected as good. Following this inspection all the trust’s services were rated good overall.

  • We rated well-led for the trust overall as good.

  • The trust had made considerable improvements since the last comprehensive inspection in March 2016. The community-based mental health services for working age adults, long stay/rehabilitation mental health wards for working age adults and child and adolescent mental health wards had all improved their ratings overall and/or in individual key questions. The trust had met all requirement notices made following the March 2016 inspection and a focused inspection in September 2017 in those services we inspected.

  • Whilst there had been a number of changes in executive directors, the trust was well-led and the senior team were committed to improving services to meet the mental health needs of local communities. The trust had an open and transparent culture and staff were able to raise concerns. Staff were committed to the working for the trust and felt well supported by their managers and colleagues. An award winning intranet provided accessible information to staff and supported overall engagement.

  • The trust was outward looking and engaged well with external partners and stakeholders. The trust was working well with the two other South London mental health trusts through the South London Partnership and this was supporting the introduction of new models of care. The trust was actively engaged in the work of the sustainability and transformation partnership.

  • The trust encouraged innovation to improve patient care. Recent developments included a service aimed at preventing admission to hospital, and the introduction of crisis cafes, which were very well liked by service users. More than 40 quality improvement initiatives had been completed by staff or were under way across the trust.

  • The trust had effective structures, systems and processes in place to support the governance of the trust, including financial governance. Managers had easy access to performance information to enable them to make improvements. Staff could add local risks to service line risk registers. Risk registers reflected the risks staff told us about. Senior leaders had good oversight of risks. There was an open and positive culture in respect of reporting incidents. Lessons learned were disseminated to staff and used to improve services.
  • The trust was making good progress with the recruitment and retention of staff. A detailed review of staffing levels on inpatient wards had led to an increase in staffing on most wards. A caseload weighting tool in the community mental health teams was helping to ensure caseloads for individual staff were manageable.
  • The trust had a focus on equality and diversity and was supporting the development of staff diversity networks. The trust provided effective communication support to deaf service users through the employment of deaf nursing staff, the provision of British Sign Language interpreters and videos on the trust website. The trust worked well with local communities, including black and minority ethnic communities and schools, to promote and support mental health initiatives. The trust board had a diverse membership. The trust had set up an expert working group to look at the disproportionate number of black men detained under the Mental Health Act.

However:

  • Staff did not always follow best practice to ensure the safety of patients after they had received rapid tranquillisation. When patients declined checks of their clinical vital signs, staff did not always return to make further attempts to record these observations. When staff carried out routine checks of patients’ vital signs, they did not always escalate results to senior nursing staff or a doctor when indicated by the scoring tool or record why they had not done so.

  • Staff did not always store information on patient electronic records consistently so that it could be found easily by others. The patient records system in the substance misuse service was difficult to navigate and staff stored information in different places, which made it difficult to find. The electronic patient record system in the CAMHS community teams was difficult for staff to use and it was easy to input information into the wrong place. Staff in community teams reported regularly being unable to access patient records when the server was down for short periods. Clinical staff found IT support was not always timely and accessible.

  • The trust had not consulted effectively with staff around changes to mental health rehabilitation services that had been made. Staff were unhappy with the and the way they had been involved in discussions about the changes. They continued to be anxious about the future of the service and morale was low.

  • Some trust services missed an opportunity to learn from informal or local complaints as they did not keep a record of the complaints to support managers to identify patterns and trends.

  • The trust needed to continue to work on the new trust strategy that would provide clear direction and underpin the delivery of high quality sustainable care. Further work was needed to fully implement the leadership development programme for ward and team leaders and managers.
Inspection areas

Safe

Good

Updated 12 June 2018

Our rating of safe improved. We rated it as good because:

  • We rated five of the six services core services that we inspected as good for safe.
  • The trust had taken action to ensure that its services had a sufficient number of staff. The trust had increased staffing levels in the mental health wards, which enabled staff to facilitate patient leave and hold one to one meetings with patients to discuss their care more consistently. The new staffing establishments and shift patterns were based on a detailed analysis on information including incidents and acuity levels. Staff in a community team had developed a caseload weighting tool that was to be rolled out to other teams to help ensure care co-ordinators had manageable caseloads. The trust was making good progress in the recruitment and retention of staff, although this proved a constant challenge in community-based teams for working age adults in some boroughs.
  • The trust had effective systems to report and learn from serious incidents, including deaths. Staff reported incidents and they were investigated appropriately. Lessons learned were shared with teams in meetings and at specific events so as to reduce the risk of similar incidents happening again. Staff reporting of incidents involving the restraint of patients had increased as a result of a positive reporting culture. The trust had introduced strategies to reduce violence, aggression and restrictive practices.

  • Staff managed medicines safely. The implementation of electronic prescribing and administration records had led to a reduction in medicine errors. Staff in the community-based mental health teams transported medicines safely. This was an improvement since the last inspection in March 2016.

  • The majority of staff had completed mandatory training across all of the wards and teams. Shortfalls in training in risk assessment, which had been recently introduced, and in medicines management training for allied health professionals were being addressed.

  • Since the last comprehensive inspection in March 2016, there had been improvements in staff understanding of what constituted seclusion in the child and adolescent mental health wards. Lone working and personal safety protocols were now well embedded in the community teams.

However:

  • Following the administration of rapid tranquilisation to a patient, staff did not keep adequate records of how often they had attempted to take patients’ physical observations. This was contrary to trust policy and national guidance. When a patient’s physical health observations were outside of the normal range, staff did not always escalate this to senior nursing or medical staff or record that they had done so. This increased the risk that patients’ physical health problems may have gone undetected or not been addressed appropriately. The trust took action to address these issues immediately following the inspection.

  • The trust did not always ensure that clinical staff had easy access to important patient information. Inconsistent storage of clinical information on the electronic patient record meant that meant staff could not easily access all information held about a patient’s physical health and other care related matters. The patient records system in the substance misuse service was difficult to navigate. Similarly in the CAMHS community teams, staff found the records system was difficult for staff to use and it was easy to input information into the wrong place. Staff in community teams reported regularly being unable to access patient records when the server was down for short periods.

  • In community-based services for working age adults, more than 80% of patient risk assessments were of good quality and accurate. This was an improvement since the last inspection, in March 2016. However, some risk assessments had not been reviewed after incidents or when a patient was transferred from another team. Caseloads in the Wandsworth Early Intervention team were higher than nationally recommended levels.

  • Staff did not use and share crisis information with young people and families as well as they could have as the resources were still in development. CAMHS had developed ‘what if’ plans to use for young people who might need support if their mental health deteriorated, but these were not often used by staff.

Effective

Good

Updated 12 June 2018

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

  • We rated all six services core services that we inspected as good for effective.

  • Staff demonstrated excellent working relationships with teams and agencies both internal and external to the trust. This ensured a smooth and clear pathway of care for patients, particularly in the acute care pathway and community-based mental health services for adults of working age. The trust was working with the two other south London mental health trusts in the South London Partnership to the benefit of forensic and child and adolescent inpatient services.

  • The trust had made improvements to ensure that staff received regular clinical and managerial supervision to support them to deliver effective services and develop professionally. The rehabilitation ward had improved staff supervision by 40% since the last inspection in March 2016. The completion of planned staff supervision was high in most areas. Supervision records were saved electronically, easy to find and used to inform future sessions.

  • Staff worked with patients to develop person-centred, holistic and recovery oriented plans of care. Services delivered a range of evidence-based therapeutic interventions. Phoenix Ward, the rehabilitation service, had introduced more therapeutic activities aimed at improving patients’ individual skills and maximising independence.

  • Staff ensured that patients received an assessment of both their physical and mental health needs. A quality improvement initiative had led to an increase in the number of patient cardio metabolic assessments carried out by community staff. Patients had good access to specialists for their physical health needs. Staff had undertaken placements at the local acute hospital to improve their physical health nursing skills.

  • Staff received support to fulfil their responsibilities in respect of the Mental Health Act (MHA) and associated code of practice, and the Mental Capacity Act. Staff had received training, understood the requirements of the legislation and acted in accordance with requirements in their day to day work. MHA administrators were knowledgeable and had effective systems in place to monitor the implementation of the MHA. Associate hospital managers had good understanding of their responsibilities.

However:

  • Doctors did not always document in detail, discussions with patients about treatment options when obtaining consent to treatment.

  • On Lavender Ward, some patients were prescribed medicines to aid sleep for several weeks without evidence of a review by a doctor.
  • In the substance misuse service staff had not reviewed the trust’s prescribing protocols following the publication of new clinical guidance in July 2017.
  • Staff in community-based mental health services for working age adults did not always record when they had explained to patients on a Community Treatment Order, their rights and the conditions of the order.
  • Patients in the acute wards for working age adults and psychiatric intensive care unit had limited access to a clinical psychologist. The trust had recognised this and was actively recruiting more clinical psychologists.

Caring

Good

Updated 12 June 2018

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

  • We rated all six services core services that we inspected as good for caring.

  • Staff treated patients with kindness and compassion. They were caring and supportive and treated patients and carers with dignity and respect. Feedback from patients and relatives was mostly very positive even in community teams for working age adults that were experiencing staffing difficulties and other challenges.

  • Staff provided dedicated support to carers. Two wards ran weekly family clinics to support patients and carers. Lavender Ward had a full time carer support worker. The rehabilitation ward held a group for carers every month. Staff showed good understanding of individual patients’ needs.

  • Staff involved patients and, where appropriate carers and relatives, in care and treatment decisions, although this was not always documented in care records. The trust was co-producing a service user and carer development and involvement plan. This included increasing service user and carer influence on service delivery through participation in staff recruitment and delivering training. Young people were involved in the refurbishment of a waiting area for patients and families. The trust offered volunteer and employment opportunities to people with lived experience and planned to extend this work to harder to reach communities.

  • Patients were able to give feedback about their experiences of services via a real-time feedback machine. Staff responded positively to feedback and looked for ways to improve services.

However:

  • The child and adolescent inpatient wards did not provide an advocacy service to informal patients. Young people, who were not detained under the Mental Health Act, did not have access to an independent voice to represent their views. Staff in specialist community mental health services for young people did not always clearly record the wishes and views of young people in care records.

Responsive

Good

Updated 12 June 2018

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

  • We rated all six services core services that we inspected as good for responsive.

  • The trust had clear criteria for people accessing its services and had created clear admission and discharge pathways. Staff mostly met targets to assess and treat patients. Emergency referrals to CAMHS were seen quickly by dedicated, skilled practitioners. Patients in the community had short waits to see a clinical psychologist, although access to psychology for patient in acute wards was more difficult. The trust was recruiting more clinical psychologists to increase psychology provision to inpatients in acute wards.

  • Staff worked actively to discharge patients safely and appropriately and avoid delayed transfers of care. In daily bed management meetings managers described any barriers to patient discharge and how they were being addressed. Senior staff supported ward and community staff to facilitate patient discharges and intervened to reduce delays. Despite the pressures on the acute care pathways the trust had placed relatively few patients in beds outside the trust in the last year.

  • Patients knew how to complain. The trust met targets for complaint responses in most cases. Young people felt listened to when they raised concerns.

  • The services offered interventions to improve patients’ social networks, education and employment. Patients attended courses at the recovery college. The trust provided two community-based recovery cafes that were open in the evenings and at weekends, in partnership with a third sector provider. The cafes were well used and highly valued by services users.

  • Services were recovery oriented and offered a range of meaningful and therapeutic activities. Staff actively followed up patients who did not attend appointments

  • Staff enquired about, considered and acted on the diverse needs of patients and their families. Some teams had an LGBT champion and signposted LGBT+ patients to relevant local groups and useful websites. Staff worked closely with a specialist local authority team to support young people from the local South Korean community referred to CAMHS. Staff on inpatient wards asked about patients’ cultural and religious needs and supported patients with the provision of appropriate meal menus and access to spiritual support. Staff in the East Wandsworth CMHT worked closely with the local mosques. The trust provided effective communication support to deaf service users through the employment of deaf nursing staff, the provision of British Sign Language (BSL) interpreters, and BSL videos on the trust website. Premises were accessible to people with physical disabilities. The trust worked well with local communities, including BME communities, to promote and support mental health initiatives.

However:

  • The rehabilitation ward did not record and track complaints at a ward level. In the child and adolescent inpatient wards and substance misuse service staff did not routinely record local or informal complaints. These may have been missed opportunities for learning. Complaint response letters to patients tended to be written in over formal language, even when responding to young people. Responses could have shown more empathy.

  • Patients using community mental health teams for working age adults, particularly in Kingston, Richmond and Merton, reported that they often struggled to get through to staff when they telephoned the trust’s contact centre.

  • Some children and young people said the hospital food was of a poor quality and not very appetising. The soundproofing of therapy rooms in the substance misuse service was not adequate and conversations could be overheard.

Well-led

Good

Updated 12 June 2018

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

  • Whilst there had been a number of changes in executive directors, the trust was well-led and the senior team were committed to improving services to meet the mental health needs of local communities. The changes in the chief operating officer and director of HR had led to some areas of work taking longer than anticipated.

  • The culture of the organisation was open and transparent. Staff felt able to raise concerns and acknowledge areas for improvement. Most staff enjoyed working for the trust and felt well supported by their managers and teams. Staff engagement was enhanced by an award winning intranet, which provided very accessible information.

  • The trust was outward looking and engaged well with external partners and stakeholders. The trust was working well with the two other South London mental health trusts through the South London Partnership and this was supporting the introduction of new models of care as well as facilitating learning and sharing functions to maximise the use of resources. The trust was actively engaged across five boroughs in the work of the sustainability and transformation partnership.

  • The trust encouraged innovative solutions to improve patient care. This included the development of the Lotus Suite, a service aimed at supporting people intensively for a short period of time, thus preventing an admission to hospital. The trust had also commissioned crisis cafes with third sector partners, which were well liked by the people using them. The quality improvement programme, whilst still in its early stages was supporting staff to develop ideas to improve trust services. For example, a focus on cardio-metabolic assessment in the community was supporting patients with their physical health needs.

  • The trust had effective structures, systems and processes in place to support the governance of the trust including financial governance. This included board sub-committees, service line committees and team meetings. There was a clear trust risk register monitoring how risks were mitigated and staff at all levels could contribute to this. The quality of data had improved and team managers had access to local dashboards to help inform their work. However, the volume of data was very high and front line staff said inputting data could take too long.

  • The trust was co-producing a service user and carer development and involvement plan. Whilst this was still being finalised it included aspirational but also realistic proposals for the extension of co-production across the trust services. This included increasing service user and carer influence and control through participation in recruitment and delivering training. It also provided personal opportunities such as access to volunteering and employment opportunities. There were plans to extend the work with harder to reach communities.

  • The trust had systems in place to report and learn from serious incidents including patient deaths. However, further work was needed to improve the timescales for incidents being investigated.

  • The trust was making good progress with the recruitment and retention of staff. The time to recruit was taking an average of just six weeks. A number of nurse development programmes were taking place or in progress, which were providing attractive job opportunities with career progression. A detailed review of staffing levels on inpatient wards had led to an increase in staffing on most wards. Changes resulting from the review included an increase in staff on 9-5 shifts, increased supernumerary shifts for band 6 nurses, backfill for band 7 nurses on leave and an increase in band 4 staff.

  • The trust was undertaking a large estates modernisation programme. Plans for the redevelopment took into account the need to maintain patient safety and patient experience while building works took place.

  • The trust was supporting the development of staff equality and diversity networks. As a provider of national mental health services for deaf children and adults the trust provided effective communication support to deaf service users through the employment of deaf nursing staff, the provision of British Sign Language (BSL) interpreters, and BSL videos on the trust website. The trust supported hearing staff working in deaf services to learn BSL. The trust worked well with local communities, including BME communities, to promote and support mental health initiatives. Diversity was encouraged on the trust board.
Checks on specific services

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

Good

Updated 12 June 2018

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

  • Wards were led by skilled, knowledgeable and experienced managers. Ward managers had easy access to detailed information about the performance of their ward that helped identify shortfalls and supported their commitment to drive improvements in patient care. Staff took part in quality improvement initiatives aimed at reducing waste, reducing violence and aggression on the wards and improving the physical health and well-being of patients.

  • Staff treated patients with kindness and compassion and offered support to carers. Patients described staff in positive terms highlighting their caring, friendly and supportive approach. Two wards ran weekly family clinics to support patients and carers and Lavender Ward had a full time carer support worker in post. Staff enabled patients to give feedback about their care and experience via real time feedback devices and in regular community meetings. Staff acted on feedback.

  • Staff came from diverse backgrounds and offered support to patients that took account of their spiritual, cultural and religious needs. Some staff wore rainbow lanyards, which showed the wards were trying to be inclusive and supported patients to discuss their sexuality. A former transgender patient provided training for staff on Lilacs Ward on how to care for transgender patients.

  • Staffing levels had been increased across all wards to make them safer and ensure that patients could go on leave and have regular one to one time with staff. Staff planned patient discharges proactively.

  • The wards had improved reporting of incidents and restraints and had introduced strategies to reduce violence and aggression and restrictive practices on the wards. Staff learned from complaints and serious incidents and made improvements so as to reduce the risk of reoccurrence.

  • Patients had a comprehensive physical health assessment shortly after admission. Staff promoted healthier lives and supported patients to stop smoking and improve levels of exercise and diet.

  • On Rose Ward, patients were provided with coloured cards that they could use to indicate to staff how distressed they felt and what could help them. The cards helped patients who were unable to verbalise their distress and risks.

However:

  • Staff did not always record patients’ physical observations, or attempts to take clinical observations, after rapid tranquilisation had been administered, in line with trust policy and national guidance. Staff on the PICU recorded patient refusals to have physical observations but did not record revisiting the patient and trying to complete these observations a second time.

  • Staff did not always record patients’ physical health observations with the correct frequency and when scores were elevated did not always escalate the concern to a senior nurse or medical staff.

  • Five wards had 23 beds, more than the 18 beds recommended by the Royal College of Psychiatrists.

  • Although most patients’ risk assessments were detailed and updated following risk events; nine of the 36 we reviewed were not.

  • Medicines were not always stored at the correct temperature. When this was identified, staff did not record whether they had escalated this to a pharmacist or were taking steps to address it.
  • Some staff had not yet completed mandatory training related to risk assessment (RATE training) and medicines management (for allied health professionals). There were low staff appraisal rates for nursing staff on Ward 1 and Ward 3.
  • Staff stored clinical information, particularly in relation to patients’ physical health, in different places on the electronic patient record, which meant that it could be difficult for staff to find it when they needed to. Doctors did not document discussions with patients about treatment options in detail when obtaining consent to treatment from patients.
  • On Lavender Ward, some patients were prescribed medicines to aid sleep for several weeks. There was no record that these ‘as required’ medicines were reviewed frequently enough, in line with trust policy and best practice guidance, and continued to be required by the patient.
  • Although the trust was actively recruiting more clinical psychologists, in the meantime patients had limited access to a clinical psychologist.

  • Very few staff in this core service said they were aware of the Freedom to Speak Up Guardian service and how to make contact.

Child and adolescent mental health wards

Good

Updated 12 June 2018

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

  • Staff kept appropriate records of patients’ care and treatment. Risk assessments were completed on admission and reviewed regularly and care plans were up to date. At the last inspection in March 2016, on Aquarius Ward, a new template for care planning had been introduced, but was not fully embedded. During this inspection, we found the team had fully embedded the new care plan template.

  • Staff used de-escalation techniques before restraint was used. Staff ensured physical health observations were carried out following rapid tranquilisation, in line with national guidance. There was excellent recording of this by staff on Aquarius Ward.

  • Staff participated in regular clinical audits, which helped ensure the quality of the services delivered on the wards. Staff received regular supervision and appraisals. At the last inspection in March 2016, on Aquarius Ward, records of supervision sessions were not kept securely or consistently. During this inspection, we saw evidence that supervision records were stored securely and consistently on the trust’s electronic database.

  • Feedback from patients and carers was generally positive. Young people and carers felt involved in their care and treatment.

  • Staff and patients had access to the full range of rooms and equipment to support treatment and care, including an outdoor area and an onsite school. The trust had onsite accommodation, near to but separate from the ward, where parents and carers could stay when visiting their child, as some lived far away from the units.

  • Ward managers created a culture in which staff felt supported. Staff told us they felt respected, supported and valued by their team. Staff were committed to delivering quality improvements in the wards.

  • At the last inspection in March 2016, staff did not recognise that using the low stimulus room and preventing young people from leaving was seclusion. The necessary safeguards were not in place for young people. During this inspection, we found this was no longer the case. Staff followed trust policy and ensured the necessary safeguards and reviews of seclusion were completed in these circumstances.

  • At the last inspection in March 2016, the ward manager on Aquarius Ward was unable to provide accurate figures for compliance with mandatory training. During this inspection, we found this was no longer the case. The ward’s mandatory training compliance rate was 87%.

However:

  • The wards did not provide an advocacy service to informal patients. This meant that the young people who were not detained under the Mental Health Act did not have access to an independent voice to represent their views and wishes on the wards.

  • Some patients said the food was of a poor quality and was not appetising. For example, patients on Corner House said meals were often overcooked or undercooked, and the portions were small.

  • Ward staff did not keep a log of local, informal complaints, which could have made it more difficult to identify trends, and was a missed opportunity for learning.

  • Staff on Corner House felt that communication with the onsite school staff could be improved to the benefit of the children and young people.

Community mental health services for people with learning disabilities or autism

Good

Updated 16 June 2016

Community mental health services for people with learning disabilities were good because:-

People who used services and carers told us that staff were kind, caring and helpful. Staff had a very good awareness of the individual needs of people who used services and this was reflected in comprehensive, detailed and individualised care plans and thorough risk assessments which involved people who use services and reflected the communication needs of people who used the services.

Staff had a good understanding of how to report incidents and were able to give examples of incidents in the service and reflect learning from incidents and complaints. Staff undertook a wide range of clinical and non-clinical audits within the teams and worked to improve outcomes through these.

There were no waiting lists for the service. People referred to the service were seen in a timely manner and had access to out of hours emergency support if necessary.

Staff were very positive about the local leadership both from their line managers and from the consultants within the team and this was the basis of positive team work in a multidisciplinary setting.

However, the team manager post for Wandsworth community mental health learning disability team was vacant and had been vacant for 15 months at the time of our inspection. This post was being covered by the manager of the Merton and Sutton team. Efforts had continuously been made to recruit into this post but it did leave both teams without a full time manager on site.

Community-based mental health services for adults of working age

Good

Updated 12 June 2018

Our rating of this service improved. We rated it as good because:

  • During this inspection, we found that services had addressed the issues that caused us to rate it as requires improvement following the March 2016 inspection.

  • The services had embedded systems to support staff to remain safe whilst carrying out their work. Staff assessed risks for patients and worked with them to manage these risks. Staff knew when to report incidents and when to make vulnerable adult and children safeguarding referrals. Medicines management within the teams had improved since our last inspection, in March 2016. Staff safely transported, stored and administered medicines to patients.

  • The trust continually worked towards recruiting sufficient staff to support patients, but this proved more difficult in some boroughs. Staff were skilled in their roles and received specialist training, especially in caring for patients with a personality disorder, from the psychology teams. Staff supervision within the teams had improved since our last inspection, in March 2016. Staff received regular management and clinical supervision to develop their skills and check their wellbeing.

  • Staff demonstrated excellent working relationships with teams, both internal and external to the trust, to ensure a smooth, holistic pathway of care for patients. Staff offered interventions aimed at improving patients’ social networks, education and employment. Patients attended the recovery college provided by the trust to complete courses such as mindfulness and understanding self-harm. Patients also attended the recovery cafés in Merton and Wandsworth to meet with their peers in the evenings and weekends.

  • Staff worked with some patients to develop care plans that were holistic, person-centred and recovery focused. The teams provided care and treatments based on national guidance that promoted patients’ holistic care and included receiving psychological therapies. Staff worked to improve the physical health of patients and actively monitored the effects of medicines.

  • Patients praised clinical psychologists, psychiatrists and care coordinators within the teams. For example, patients said that they would not be able to cope without the staff in the teams. Staff spoke with patients in a meaningful way and could calm patients down when in distress. Staff involved patients and, when appropriate, carers in decisions about care.

  • The services had clear acceptance and referral criteria for who they would offer a service to and clear care pathways for patients depending on their mental health needs. Most teams met waiting time standards. When patients did not attend their appointments, staff actively followed them up.

  • Staff described the trust’s vision and strategy and understood how this applied in their work. Most staff were positive about the teams that they worked for. They felt confident in the leadership of the community teams. Managers could easily access information about their teams and use this to drive improvement. Senior management regularly monitored the safety and quality of services.

However:

  • At the last inspection in March 2016, we found that the trust did not ensure staff updated patient risk assessments regularly and after incidents. At this inspection, although we found that this had improved, staff did not always fully review and update risk assessments after a transfer from another team or after an incident in 19% of records we reviewed.
  • Patients reported that when they rang the trust’s contact centre to speak to their care coordinator they often struggled to get through. This was especially an issue in Kingston, Richmond and Merton. As a result, patients may not have been able to get hold of their care coordinator quickly.
  • Caseloads in the Wandsworth early intervention service were higher than nationally recommended levels.

  • Staff did not always keep records of when they had explained to patients their rights and conditions in respect of Community Treatment Orders.

Community-based mental health services for older people

Good

Updated 2 December 2016

We rated community-based mental health services for older people as good overall because:

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

  • During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe and responsive as requires improvement following the March 2016 inspection.

  • The community based mental health services older people were now meeting Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Forensic inpatient/secure wards

Good

Updated 16 June 2016

We rated South West London and St George’s Mental Health NHS Trust forensic inpatient wards as good because:

The wards were clean and safe. Procedures and practices were in place for the management of infection control. Staff of all disciplines had a good understanding of relational security and staff were committed to minimising the use of restraint and seclusion in the service.

Staff assessed risks to patients were on admission, regularly reviewed these and linked them to their plan of care. Staff knew how to protect patients from harm and were knowledgeable about how to recognise signs of potential abuse and the reporting procedures that were in place. There were enough suitably qualified and trained staff to provide care and treatment to a good standard. The multi-disciplinary teams were pro-actively involved in patient care, support and treatment.

Patients had access to a variety of psychological therapies either on a one to one basis or in a group setting. Psychologists, occupational therapists and exercise therapists were part of the multi-disciplinary team and were actively involved as part of their treatment. Both individual clinicians and the senior management team within the service had a good understanding of the effectiveness of the care and treatment, which they delivered.

We saw kind and caring interactions between staff and patients on all the wards. Staff demonstrated a good understanding of patient’s individual needs and preferences. Staff made every effort to maximise people’s dignity. Patients had access to an independent advocacy service. The majority of patients told us they felt safe.

There were different forums for patients to be consulted on their views and to feed back their experiences about how the service was run. Patients spoke positively about the wide range of therapeutic, educational and physical therapies that were offered. There was a robust complaints procedure in place. Patients knew how to complain. Complaints were responded to according to the trust policy.

Staff were provided with regular supervision, annual appraisals and had access to mandatory and specialist training and training provided within the trust.

Staff were aware of and had a good understanding of the trust’s vision and values and how these were implemented in everyday practice. The culture within the service was open and transparent, staff morale was good and Senior managers within the service were visible and accessible to staff and patients.

However:

  • Time management practices being used on Halswell and Turner wards were not recognised as seclusion practices and patients subject to these practices did not meet the safeguards set out in the MHA Code of Practice.
  • Patients on Halswell, Ruby and Turner wards reported that fresh air breaks did not take place regularly, and that on occasions leave was cancelled due to insufficient staff on duty. There was no evidence that this was being monitored or recorded by the staff.

Long stay/rehabilitation mental health wards for working age adults

Good

Updated 12 June 2018

Our rating of this service improved. We rated it as good because:

  • The trust had made improvements since the last inspection.

  • Patients were involved in their care planning and staff supported them to give their views and develop objectives. Patient care plans were personalised and holistic.

  • The ward planned for patients’ discharge and worked well with both internal and external agencies. The ward did not experience delayed discharges and had reduced the average length of stay on the ward considerably in the previous year.

  • Staff were caring and supportive of patients. Patients were allocated a care team and regularly met with named nurses for one-to-one sessions. Staff had a good understanding of the individual needs of patients, including their personal, cultural, social and religious needs.

  • Patients were supported to live healthier lives and had access to physiotherapists and dietitians to help improve fitness and diet.

  • Staff followed good practice in medicines management. Medicines were stored safely. The implementation of electronic prescribing and medicine administration records had led to a significant reduction in omitted medicine doses. Ward areas and furnishings were visibly clean. Clinical equipment was checked, calibrated and kept clean and ready for use.

  • At our previous inspection in March 2016, we identified that staff did not always address identified patient risks in risk management plans. At this inspection we saw improvement. Patients received a comprehensive assessment on admission with effective multi-disciplinary input. The ward assessed risk and physical health on an individualised basis. Plans were in place to address and mitigate risks.

  • At the last inspection in March 2016, we found that the patients were not supported to access programmes of therapeutic activities to promote their rehabilitation. At this inspection, we found significant improvement. The ward supported patients to become more independent and prepare them for discharge into the community. The service provided a wide range of psychological interventions, occupational therapy, leisure and vocational activities. The ward adapted this on a regular basis to meet the needs of patients.

  • At the last inspection in March 2016, we found that the trust had not supported managers to develop the leadership skills to implement a recovery orientated approach to care on all rehabilitation wards. At this inspection, we found the trust supported the ward manager for Phoenix Ward to ensure staff were aware of the aims and objectives for patients across the ward. The manager was attending a development course for black and minority ethnic staff.

  • The ward had made considerable progress in ensuring that all staff received appropriate clinical and managerial supervision. Staff supervision rates had risen by 40% since the last inspection in March 2016. Eighty five per cent of planned supervision took place. All staff had received an annual appraisal.

However:

  • Records of complaints and safeguarding referrals were not kept at a local level. Whilst staff had a good understanding of the trust processes for both, the ward did not have appropriate systems to monitor the progression of these concerns.

  • Staff were unsure about the future of the service and felt this had not been communicated well by senior leaders in the trust. The morale of some staff was low as a consequence.

Mental health crisis services and health-based places of safety

Good

Updated 2 December 2016

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

  • Following our inspection in March 2016, we rated the service as good for safe, caring, responsive and well led.

  • During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective as requires improvement following the March 2016 inspection.

  • The mental health crisis services and health based places of safety were now meeting Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Specialist community mental health services for children and young people

Good

Updated 12 June 2018

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

  • Young people and families said that the services had been helpful to them and this was reflected in feedback surveys that services collected each month. They said that staff provided them with information about what to expect when first using the service and were kind and patient.

  • Services had a range of experienced and qualified staff who were able to deliver interventions in line with national guidance. Staff were trained in safeguarding and followed appropriate steps to keep young people safe. Services had embedded a protocol for assessing and managing people of different risks, including supporting those on the waiting list.

  • Teams worked well with other services both within the trust and externally to provide a consistent and seamless service to children, young people and their families. Teams had taken a proactive approach to providing information to young people. For example, staff identified that several young people had presented at emergency departments having misused a particular substance during a short period of time. The service worked with external organisations, to notify them and also to put together information packs for young people about the dangers of the substance.

  • Since the last inspection in March 2016, the trust had successfully addressed five areas of improvement. These included, the management of low risk patients, working with commissioners to highlight the need for additional resources to address long waiting times, particularly for psychological therapies and the completion of staff safeguarding training.

  • Staff enquired about, considered and acted on the diverse needs of young people and their families. One team had an LGBT champion and signposted LGBT+ young people to local LGBT+ groups and useful websites. Staff worked closely with a specialist local authority team to support young people from the local South Korean community referred to CAMHS. Premises were accessible to people with physical disabilities.

  • Governance systems supported service managers to access the information they needed to run services effectively and identify areas of development. All services had good systems to report and learn from incidents. Staff met regularly and learning from incidents and complaints was evident.

  • Staff were very positive about their teams, said that they felt supported by colleagues and managers and that everyone was dedicated to supporting young people who accessed their services.

  • The trust had set up a CAMHS emergency care team in response to the level of acuity and pattern of young people presenting to emergency departments in a crisis. Staff were able to offer assessments and appropriate onward referrals to suitable services promptly.

However:

  • Although the recording of patient information by staff had improved since the last inspection in 2016, staff did not always save and record information about patient care in a consistent way in electronic records.

  • Staff had begun implementing the use of crisis information sheets and ‘what if’ plans in order to provide young people and families with information about what to do in a crisis or when their health deteriorated. These were not yet fully developed or embedded in practice.

  • The electronic records system and IT infrastructure did not support staff to carry out their roles as effectively as possible. Staff reported that access to emails and the patient records system was often interrupted and the records system itself did not allow for information to be stored and re-accessed in a clear way.

  • Staff did not always record the wishes and views of young people in care records, so could not demonstrate that young people and families were involved in care as much as they could be.

  • Kingston CAMHS did not have robust systems for recording who was on the premises at any particular time, which had fire safety implications.

Specialist eating disorders services

Good

Updated 11 October 2017

We rated specialist eating disorder services as good overall because

  • Avalon ward had made improvements since our last inspection in October 2015. When the ward was last inspected in 2015, we found that the clinic room was disorganised and unclean. During this inspection we found that the clinic rooms on the ward were clean and well organised.

  • When Avalon ward was last inspected, we found that not all staff had completed their mandatory training. During the current inspection we found, that the staff training completion rate was 90%. Wisteria ward and the Eating Disorders Day Unit the training completion rates were over 80%. Staff had access to a wide range of specialist training.

  • Both Avalon and Wisteria wards admitted patients from across the country and were able to care for patients with complex health needs. Avalon ward had high dependency beds.

  • Avalon and Wisteria wards complied with National Health Service (NHS) guidance on same sex inpatient accommodation.

  • Avalon and Wisteria wards had nursing vacancies and there was regular use of agency staff. There was a low number of unfilled shifts. Managers ensured that the wards were staffed safely. Recruitment was a priority for the trust and there was an ongoing recruitment campaign.

  • The services used a range of outcome measures to determine the efficacy of the care and treatment provided. Managers had regular forums during which they could review the quality and safety of the service.

  • Patients' voices were evident in their care plans.They participated in meetings and received information about their care. Patients were able to give real time feedback about their experience of care and treatment whilst on the wards.

  • Parents of patients on Wisteria ward could attend a parent’s group. Patients were able to personalise their bedrooms and had access to outside space

  • There were doctors available to attend the wards day and night in an emergency. A full range of mental health professionals provided input into the three services. Patients were offered a range of psychological therapies. Patient treatment was evidence based and followed national guidelines.

  • Staff morale in all services was high.

However, we found the following issues that the trust needs to improve:

  • During the current inspection we found that on both Avalon and Wisteria wards, that the temperature of the medicine fridge was not being monitored in line with trust policy. The fridge temperature range on both wards was above the recommended range on a number of occasions. On Avalon ward this had happened on 21 ocasions between January 2017 and February 2017. On Wisteria ward this had happened on 31 occasions during the same time period. Staff could not be assured that medicines had been stored at the optimum temperature at all times.

  • On Avalon ward, results of checks on the physical health of patients were not always up dated promptly in patients’ electronic records.There was a risk that staff would not escalate concerns to medical staff quickly when needed.

  • Staff on Avalon had not always updated patients’ risk assessments after incidents. Nor had they reviewed patients’ risk assessments before they went on leave. The lack of regular updates meant that staff might not be able to respond appropriately.

  • Visitors to Avalon ward found that there were delays in being able to come onto the ward. Visitors pushed a door bell to let staff know they wanted to enter the ward. The door did not open automatically. Out of hours, visitors to the ward had been left outside the building and had waited for an extended period of time before they were allowed into the building.

  • The ligature risk assessment for Avalon and Wisteria ward was not accurate. The assessments had not identified all the potential ligature risks on the wards. This was brought to the attention of the trust on the day of inspection. The trust updated and reviewed the ligature risk assessments for both wards immediately after the inspection.

  • The blood glucose monitoring equipment on Avalon ward had not been calibrated in line with trust policy.

  • On Wisteria ward, patients’ dignity and privacy was not always maintained. There was a whiteboard with patient details in the nurses office that could be seen by visitors to the ward. This was brought to the attention of the trust who said they would take action to remedy this. The patients’ bedroom doors had windows but there were no curtains. One patient bedroom had insufficient privacy film on the window. This meant that anybody who walked past the window could see into the bedroom.

  • On Avalon and Wisteria wards the appropriate Mental Health Act documentation was in place. This information was held electronically. However, staff could not readily access this information because they were held on two separate electronic databases. There were no paper copies of the T2 or T3 forms with the medicine cards. For one patient, there was no up to date copy of the T3 form in the electronic record and for another patient the most recent T2 did not have all the medicines prescribed for the patient noted on it. We asked a member staff to find this authorisation to administer these medicines but were unable to do so. Staff who administer medicine for a mental disorder to a patient detained under the Mental Health Act must be satisfied that there is legal authority to do so.

  • Staff were supposed to have 1-1 supervision sessions with their manager on a monthly basis and were supposed to have an annual appraisal. The supervision rate on Wisteria ward was low (71%). Not all staff on that ward had recieved an annual appraisal. Seventy five per cent of staff on Wisteria ward had received an annual appraisal.

  • The patients and staff expressed concerns regarding the quality of the food that was being served on the wards.

  • The wards did not have information available that reflected the diversity of the patient group. For example, there was no information regarding culture, sexuality, religion or gender on the wards.
  • The MDT (multi-disciplinary team) on Wisteria ward had not had regular business meetings for a period of three months due to staff sickness. This meant that information was not shared easily within the team.

Substance misuse services

Good

Updated 12 June 2018

  • The clinical team were knowledgeable and skilled. They had a wealth of experience. The team was led by managers who were committed to ensuring that high quality care was delivered. The clinical team worked closely with their partner providers to ensure that patients received the care and treatment they required.
  • The service recognised the importance of ensuring that patients were supported to remain in good health. The clinical team had a nurse that specialised in physical health. The service had good links with the local acute hospital’s accident and emergency department. The service ran physical health clinics and the clinical team ensured that they referred patients to these clinics. Patients received a comprehensive physical health assessment.
  • The clinical team monitored patients who were prescribed high dose methadone. The guidance suggests that all patients who are prescribed 100mg or above should have regular cardiac monitoring. The clinical team monitored all patients who were prescribed 70mg or above. Where cardiac abnormalities were detected staff escalated this to colleagues in the acute hospital.
  • Patients were provided with crisis cards, which outlined what they should do if they became concerned that they may relapse.
  • Patients stated that the staff were kind and compassionate. The clinical team had a good understanding of the needs of their patient group.
  • The service had undertaken a needs analysis of the patient group. As a result, the service had made links with the local lesbian, gay, bisexual and transgender (LGBT+) forum. This was to ensure that LGBT+ patients were offered the support when needed.

However:

  • Staff stored clinical information, particularly in relation to patients’ physical health, in different places on the electronic patient record, which meant that it could be difficult for staff to find it when they needed to. This was brought to the attention of the trust who took immediate steps to provide staff with guidance regarding the recording of information on the electronic patient record.
  • It was not clear how recently staff had cleaned the physical health monitoring equipment as this was not recorded. Staff had not labelled the yellow sharps disposal bins correctly. There was a risk that equipment might not have been clean and safe to use.
  • The trust had not reviewed prescribing protocols since the publication of new UK clinical guidance in July 2017. There was no assurance that the prescribing protocols were still in line with best practice.
  • The clinical team did not have mechanisms to monitor informal or local complaints. This was a missed opportunity for learning.
  • The soundproofing in the therapy rooms was poor. Conversations could be heard outside. This had been brought to the attention of the lead provider who was addressing this issue.

Wards for older people with mental health problems

Good

Updated 2 December 2016

We rated wards older people with mental health problems as good overall because:

  • Following our inspection in March 2016, we rated the service as good for safe, caring, responsive and well led.

  • During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective as requires improvement following the March 2016 inspection.

  • The inpatient wards for older people with mental health problems were now meeting Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Other specialist services

Updated 5 July 2016

  • The majority of patients on Bluebell ward came from London and the south of England. The ward had a mix of hearing and deaf staff. All staff were proficient in british sign language (BSL).The staff were skilled and there was high completion rate of mandatory training

  • There were systems in place to ensure that learning from incidents took place throughout the service. The ward had robust systems for dealing with complaints. Patients had complained about the admission of hearing patients onto Bluebell ward due to bed pressures in other parts of the trust. The trust had revised their protocol for admitting hearing patients onto the ward. They had put in additional safeguards.

  • The ward had robust processes to manage medicines.

  • Bluebell ward had nursing vacancies and there was regular use of bank and agency staff. The ward tried to use bank and agency staff who could sign. This meant that bank and agency staff could communicate with the deaf patients and staff.

  • The comments from the patients using the service were generally positive. The patients were partners in their care and their voices were evident in their care plans. They participated in meetings and received information about their care.

  • The staff were responsive to the needs of patients and supported patients to access spiritual support. The ward was able to provide patients with cultural and religion specific foods.