• Organisation
  • SERVICE PROVIDER

South London and Maudsley NHS Foundation Trust

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

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

Latest inspection summary

On this page

Overall inspection

Good

Updated 20 August 2021

We carried out this announced comprehensive inspection of the acute wards for adults of working age and psychiatric intensive care unit (PICU) and community services for adults of working age services provided by this trust as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the provider as good.

We also inspected the well-led key question for the trust overall. We inspected two services, inspected and rated one as good (acute and PICU) and one as requires improvement (community mental health services for adults). Overall, we rated effective, caring, responsive, and well-led as 'good' but safe was rated as 'requires improvement'.

The trust serves a population of 1.3 million people across the London boroughs of Croydon, Lambeth, Lewisham and Southwark, and employs more than 5,000 staff. Staff provide services to around 41,000 patients in the community and in 716 inpatient beds across 52 inpatient wards. The trust has a turnover of £503 million and broke even in 2020/2021.

The trust provides the following core services:    

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

Long stay/rehabilitation mental health wards for working age adults 

Wards for older people with mental health problems 

Child and adolescent mental health wards 

Forensic inpatient/secure wards 

Wards for people with learning disabilities or autism  

Mental health crisis services and health-based places of safety 

Community-based mental health services for older people 

Community-based mental health services for adults of working age 

Community services for people with learning disabilities or autism 

Specialist community mental health services for children and young people 

The trust also provides the following specialist services: 

Specialist eating disorder services  

Specialist neuropsychiatric services

Substance misuse services

Other national specialist services

We did not inspect long stay/rehabilitation mental health wards for working age adults (previously rated requires improvement) because the services had not had time to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection. We are monitoring the progress of improvements to services and will re-inspect them when appropriate.

Our rating of services stayed the same. We rated them as good because:

We rated effective, caring and responsive as good and we rated safe as requires improvement. We rated well-led for the trust overall as good.

We rated acute wards for adults of working age and psychiatric intensive care unit as good and community-based mental health services for adults of working age as requires improvement. In rating the trust, we included the existing ratings of the fourteen previously inspected services.

Since the last inspection there had been significant changes to the executive leadership team at the trust and the new members had settled into their roles and were working together effectively. The trust had appointed a chief executive, chief operating officer, chief nurse, and director of communications, stakeholder engagement and public affairs. The trust had also appointed a new board level director of corporate affairs. The trust reviewed leadership capability and capacity on an ongoing basis. The new appointments had given them an opportunity to review how they carried out business and make further improvements.

Since the last inspection the board had a new chair and one new non-executive director. At this inspection we found the trust had an ambitious board, with a wide range of skills and experience who demonstrated dedication and commitment to improving the care delivered to patients by the trust. The non-executive directors all had experience as senior leaders in a range of organisations and brought skills such as a knowledge of finance and investment, strategic development, research, population health, working in partnership and transforming services. The non-executive directors were well supported and challenged effectively by the team of governors.

Board members had completed board development days to better understand and further develop each person’s roles and responsibilities in relation to the strategic direction of the trust. The board understood the plans for the development of the trust both internally and externally and recognised the complexity of achieving their strategic aims.

There was high quality, effective leadership at all levels of the organisation. There were regular board visits to services. Senior staff across the trust modelled open and transparent behaviour. Staff we spoke with during the core service inspections felt supported, valued and respected. Staff spoke about improvements in the culture and felt the trust leaders were more visible and present since we last inspected the trust in 2019.

The trust leadership demonstrated a high level of awareness of the priorities and challenges facing the trust and how these were being addressed. The trust leadership had demonstrated an ability to adapt at a fast-changing pace during the COVID-19 national pandemic. The trust had developed a very pro-active vaccination programme with a high uptake from staff and patients. At the time of the inspection over 85% of all staff had received their first vaccine. Staff provided information and advice to eligible patients regarding the COVID-19 vaccines to alleviate concerns and encourage uptake.

Since the last inspection the trust had embedded the divisional structures and borough-based working for local services. This had strengthened their multi-disciplinary working within each of the trust directorates. They had also further developed their ability to work in partnership with other stakeholders to meet the healthcare needs of the local populations and develop new responsive models of care.

The trust had also strengthened its input into the South London Mental Health and Community Partnership (SLP). The SLP focused on delivering mental health services across south London in partnership with two other NHS trusts. The three trusts collaborated effectively to improve the quality of services, learn from each other, and share functions to maximise the effective use of resources. The SLP had been successful in developing new models of care and ensuring patients were treated in services closer to their homes. The SLP was also involved in provider collaboratives for forensic services, CAMHS, and specialist eating disorder services in south London. The provider collaboratives were responsible for commissioning these services for the population of south London, including from the independent health sector.

The trust collaborated effectively with a range of external partners. The trust worked within a very complex landscape across four London boroughs, four clinical commissioning groups, local alliances, and two integrated care systems. The chief executive had recently led a London-wide project looking at emergency department admissions for children and young people in crisis.

Leaders spoke with insight about the need to work collaboratively to improve existing services. There was a high level of awareness of the need to improve access and flow for a number of its community and inpatient services. It recognised that while the trust could make changes within its own services, long term solutions would only be achieved through partnership working. Managers engaged actively with other local health and social care providers alongside other stakeholders to ensure that an integrated health and care system was commissioned and provided to meet the needs of the local population. For example, the trust was supporting GPs to develop the skills to manage shared care arrangements. The trust was also working within boroughs to support partners in the development of housing, employment and other services to enable people with mental health needs to live successfully in the community.

The trust was committed to working with the local communities. The trust was leading a national piece of work to eliminate the unacceptable racial disparity for patients in terms of access to services, experience of service, and clinical outcomes through the development of the Patient and Carer Race Equality Framework (PCREF). Once developed this will be rolled out across all the mental health trusts. To address patients’ social and digital exclusion during the pandemic, the trust had worked with the Maudsley Charity to provide digital support and equipment where possible and had set up a telephone befriending service provided by volunteers.

On 16 June 2021, following extensive consultation facilitated by voluntary organisations, the trust alongside the two other South London mental health and community trusts, and councillors from the 12 boroughs participated in the South London Listens Summit. They made pledges to help prevent and address a crisis in mental health services. These included support for young people’s and perinatal mental health, better access to services, work and wages, and addressing social isolation. The trusts introduced mental health champions in every borough and forming mental health hubs to talk and share information. There were 350 community leaders trained as champions, and a social isolation, loneliness, and inclusion strategy was being developed.

The trust had begun the process of developing their five-year ambitions for 2021–2026 as their previous strategy was reaching its end. This included a 12-week engagement programme with staff, local communities, and external partners, to identify key ambitions. The engagement programme was also seeking feedback from service users, carers and governors. The trust had identified early strategic themes linked to the needs of the organisation, the local populations and the health and care system. The senior leadership team was confident in its capability to deliver on the development and implementation of the strategy.

The trust had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees and team meetings. The board was operating well with quality being a key focus. Sub-committees were working well and governance throughout the services had improved.

Leaders understood the risks within their services and were able to report them and escalate them where required. The board assurance framework was used actively by the board. The risk registers and board assurance framework clearly described how risks would be mitigated and progress was closely monitored. The senior leadership recognised the need to clearly link the framework to the strategic ambitions of the trust. Risks identified in the inspections were already known by the trust and being addressed. The trust, through its audit committee and board development, reviewed its risk appetite annually, and undertook horizon scanning to identify new and emerging areas of risk. There was a balance between workforce, finance and service performance risks.

The standards of cleanliness and maintenance had improved since the last inspection in 2019. The quality of environmental risk assessments had improved. The trust was working hard to improve the quality of the buildings in which it provided care to patients. This included the development of a new centre for children and young people’s mental health services which would bring together leading experts. The Douglas Bennett House development was due to complete in 2023 and will create eight new adult inpatient wards. The leadership team were aware that The Ladywell Centre was not fit for purpose and some estates work had taken place to improve facilities and safety for patients whilst it remains in use.

The trust had responded positively to the previous inspection and worked to make the necessary improvements. For example, we saw progress on physical health monitoring for inpatients and in the community. The trust continued to be part of the physical healthcare work with the Mind and Body Programme, which was committed to providing a programme of work to join up and deliver excellent mental and physical healthcare, research and education to treat the whole person. The Integrating our Mental and Physical Healthcare Systems project (IMPHS) launched in 2019 and was a three-year project focused on closing the mortality gap for people accessing services by improving the physical healthcare on offer to them. The IMPHS project team worked closely with physical health leads to support the trust’s physical health strategy. We saw examples of where improvements had taken place in supporting patients to manage their physical health. Staff working in the clozapine clinic had access to point of care testing facilities. This ensured that patients could have physical health monitoring completed and medicines supplied within a 20-minute appointment. The trust continued to convey a clear message about ensuring the right physical health care in the right place at the right time delivered by the right person. There was still room for improvement in the recording of physical health monitoring on some inpatient wards.

The trust continued to focus on improving patient safety by reducing violence and aggression and the use of restrictive practices. The promoting safe and therapeutic services (PSTS) redesign was on-going and the trust envisioned this would have an impact in the future. This included community involvement in the development of the programme. Ward staff participated in the trust’s restrictive interventions reduction programme including use of the safety huddles, monitoring of low-level incidents, and the use of the Dynamic Appraisal of Situational Aggression tool. The trust was aiming to eliminate prone restraint of patients by training relevant staff to administer rapid tranquilisation in the deltoid muscle (in the arm). The trust had a quality priority to reduce incidents of violence on all wards by 50% and stop prone restraint. Whilst achieving these targets was proving hard, the work was ongoing and closely monitored. There was also a quality improvement project focused on reducing restrictive practice.

The trust had focused on improving patient and carer involvement since the last inspection. The trust’s 2019/2020 quality report said there had been an increase in the number of patients and carers attending the trust board and sub-committees. All quality improvement workstreams at the trust were coproduced, codesigned or had patient and/or carer involvement in projects. They were supported by the trust’s patient and public involvement (PPI) leads. Patients and carers were able to join the trust’s involvement register with support and opportunities in place to undertake paid tasks. Since the previous inspection, the scope of work undertaken by those on the register had significantly expanded. The trust had committed to improving identification of patient’s carers, and membership of the Triangle of Care scheme (promoting partnership between patients, carers and staff). Patients, staff and carers were able to meet with members of the trust’s leadership team to give feedback. Patient stories were routinely presented at board meetings. 

The trust leadership had actively engaged with staff. The chief executive held regular open meetings with staff and during Covid-19. The chief executive and trust chair had held weekly broadcasts since March 2020, these had been twice weekly during the first national lockdown. These were used to share key messages with staff. In 2020, the trust had introduced the Listening into Action (LiA) programme with the aim of ‘making [the trust] a GREAT place to work’. The LiA programme was focused on quick and positive improvements for staff. The trust had conducted a survey which over 60% of staff completed to identify areas for improvement. They had taken action to address issues raised including reviewing the disciplinary procedure and rewarding staff for their work during the pandemic with an extra annual leave day.

Quality improvement was well embedded across the trust and over 1,000 staff had been trained in the methodology. During the inspection staff spoke about the quality improvement projects taking place within their services. Monthly performance and quality meetings took place for both inpatient and community services and management systems were in place and reported through the various sub-committees to the trust board. However, some further work was needed to ensure learning from quality improvement projects was shared across the four boroughs.

Staff provided care that was personalised, holistic and recovery orientated. Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. Staff tried to proactively involve families and carers in patient care although this had proved challenging during the COVID-19 restrictions. Staff understood how to protect patients from abuse and the services worked with other agencies to do so.

Processes for identifying and managing financial risk were well understood by the board. The board had a track record of ensuring financial control totals were delivered. The finance department was considered to have strength and was resilient. The trust had received bridging capital from the NHS, to funds its two large estate modernisation projects pending the sale of other trust assets. At the time of the inspection the trust told us that it had not yet finalised the terms and timing of the repayments. However, the formal loan agreement was signed following the inspection. In addition, the trust was planning to invest £12m capital in 2021- 2022 on digital and smaller estates maintenance and development projects.

At a national and international level there was a strong research base and system-leading research was taking place. Opportunities for research were explored and supported. Staff at the trust were heavily involved in innovative research and development work and were regularly published in clinical journals. The Pears Maudsley Centre for Children and Young Peoples was bringing together leading experts in care and research from the trust and another leading organisation in the field. The two organisations were working together to create a centre of care for young people. There was a focus on the potential of research to identify mental health difficulties early and transform treatment and care of children and young people in the UK and internationally.

However:

Due to the COVID-19 pandemic some face-to-face mandatory training had not been delivered. This resulted in trust-wide poor compliance for certain short courses which could impact on patient safety. The trust leadership were aware of this and had various mitigating actions in place to improve compliance by July 2021.

Whilst the trust had a workforce strategy and the executive team had succeeded in reducing the trust-wide vacancy rate, staff recruitment and retention was still an issue. There were a high number of nursing vacancies (21.3%) and staff turnover was also high (11%). Some staff on the acute wards told us escorted patients’ leave was sometimes cancelled or postponed due to staff shortages although the frequency was not accurately monitored.

At the time of the inspection there were significant bed pressures across the trust. Patient flow remained a significant challenge for the trust and the trust had appointed a flow director and flow leads who had daily contact with the inpatient wards. The trust had significantly reduced out-of-area placements as part of the multi-year patient flow programme although these had started to increase again. Whilst male patients in the psychiatric intensive care units were now moving to an acute ward when this was clinically appropriate, there were still challenges for female patients. There was a quality improvement project in place to address this and these moves were being prioritised.

Within community services some teams reported high caseloads, waiting lists for non-urgent referrals and some long waits for some individual psychological therapies. However, the community services were implementing a redesign programme which aligned to the NHS Mental Health Implementation Plan. Staff were enthusiastic about the change programme and could see the value of the intended outcome and how this aligned with their work. The aim of this service redesign was to speed up patient access and flow through services, reduce staff vacancies, increase multidisciplinary teams (MDTs) and improve outcomes for patients and patient experience.

Within most teams, staff completed risk assessments for each patient using the trust’s risk assessment tool and reviewed this regularly, including after any incident. Information was detailed and up-to-date and showed evidence of patient involvement. However, we found examples where patient records were not up-to-date and risk assessments were not reviewed. Team managers were aware of the issues with recording and updating risk assessments and providing support to improve the performance of staff and this was reported at the directorate’s performance and quality meetings.

The trust had improved waits for Mental Health Act assessments since 2019 and had built strong relationships with the police, ambulance services and approved mental health professionals. However, many services still reported long waits for assessment with an average of 12 days. The trust held regular forums with the associated police borough commanders where this issue was continually reviewed. Within the service redesign there was a crisis care programme which included a workstream focusing on improving the MHA assessment pathway. The trust was leading on a system-wide MHA assessment summit in summer 2021 with a goal to develop an action plan to further review and address MHA assessment delays.

The trust was working to improve its culture but recognised there was more work to do. Despite the trust’s equalities strategy, the commitment from the trust leadership for the organisation to be anti-racist, a race equality conference taking place, the progress with staff networks and many other actions there still was considerable ongoing work required to improve the experience of some Black, Asian and Minority Ethnic (BAME) staff working for the trust. One of the trust’s key actions from the Workforce and Organisational Development Strategy (2020 to 2023) was to establish a BAME Leadership Academy Programme specifically focusing on talent management, succession planning and career development for staff from a BAME background. The aim of the programme was to create greater levels of sustainable inclusion by addressing the social, organisational and psychological barriers restricting BAME staff from progressing. The trust had made improvements in the results of the Work Force Equality Standard (WRES) and NHS Staff Survey but there was more to do. In particular BAME staff were still overrepresented in comparison to white staff in formal disciplinary procedures.

Incidents and complaints were investigated, and lessons were shared with staff to minimise the risk of them happening again. However, the quality of the serious incident reports was variable; some were well written, others were less well written and lacked clear terms of reference.

The trust had a learning from deaths process in place and this was led by a member of the executive. Staff in services told us that learning from deaths and serious incidents was shared. The documented findings presented to the board were brief and it was not always clear whether learning had taken place. There were plans to strengthen this and share the learning more widely.

Compliance with the duty of candour could be improved, as the trust's own internal audit found that only 37% of letters to patients and families following incidents included a clear documented apology. In response to this the trust was planning an animated film regarding duty of candour with the communications team and a bulletin on the topic had been issued to staff in April 2020. There were plans for a re-audit to take place in October 2021. Staff told us they knew how to deliver duty of candour and were supported to do so when required.

Some staff experienced problems with IT equipment, such as mobile telephones and laptop computers, and significant delays in having these issues addressed. Staff also reported new starters had long waiting times for equipment and access to the trust’s electronic systems.

How we carried out the inspection

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

We visited 10 out of the trust’s 47 community based mental health teams which included a mix of assessment and liaison, early intervention and promoting recovery teams. For adults of working age and psychiatric intensive care units (PICUs) we also used a sampling approach. We inspected 10 of the 22 wards operational at the time of the inspection.

During the community services inspection, the inspection team:

  • observed a handover meeting for one community-based team
  • observed a zoning meeting for one community-based team
  • observed a referral meeting for one community-based team
  • observed a team meeting for one community-based team
  • conducted a tour of the environment for seven community-based teams
  • conducted a tour of the clinic rooms for three community-based teams
  • spoke with one occupational therapist, five registered nurses and two social workers, three care coordinators, and four senior practitioners
  • spoke with a psychotherapist and three clinical psychologists
  • spoke with a senior clinical pharmacist and a pharmacy technician
  • spoke with the four mental health advocates
  • spoke with five consultant psychiatrists and one GP trainee
  • spoke with five team managers, three team leaders, three modern matrons, three clinical service leads, one general manager of services and one deputy director
  • spoke with 31 patients and 10 carers over the 10 teams
  • looked at 55 patient care and treatment records
  • reviewed documents relating to the running of the service
  • carried out an anonymous staff survey for all staff in the teams inspected, for which we received 12 responses.

For the adults of working age and PICUs inspection, the inspection team:

  • visited 10 inpatient wards, and looked at the environment, medicines and observed interactions between staff and patients
  • attended staff handover meetings on eight wards
  • spoke with 23 patients by telephone and met with 6 patients in person
  • spoke with nine relatives/carers of patients on the wards
  • spoke with 46 members of staff in person or by telephone or video conference, including ward managers, registered and non-registered nurses, doctors, occupational therapists, psychologists, domestic staff, an activities coordinator, a psychotherapist and a pharmacist
  • carried out an anonymous staff survey for all staff on the wards inspected, for which we received 36 responses
  • looked at the care records of 69 patients
  • looked at 53 medicines administration records for patients
  • reviewed the recent incident reports for this service
  • reviewed specific policies and documentation relevant to this core service

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

What people who use the service say

Patients told us that staff treated them with compassion and kindness. They said that staff respected patients’ privacy and dignity. Patients said staff were attentive, non-judgemental and caring and tailored care to individual needs. Patients also reported staff provided help, emotional support and advice when they needed it. Patients said staff treated them well and were responsive to their needs.

Child and adolescent mental health wards

Good

Updated 8 January 2016

We gave an overall rating for child and adolescent inpatient mental health services of good because:

  • Staff were kind and treated the children and young people with dignity and respect.
  • Young people were able to actively participate in decisions about their care and in decisions regarding the running of the ward.
  • Most young people were risk assessed and received a comprehensive assessment of their needs on admission to ward and monitored throughout their stay.
  • The wards had clear systems in place to mitigate risks to young people, such as with regards to medication and safeguarding.
  • Staffing numbers were usually enough to meet the needs of the children and young people.
  • Incidents were reported, reviewed and lessons learned through feedback to staff.
  • Treatment and monitoring were based upon best practice from appropriate bodies, such as the National Institute for Health and Care Excellence (NICE). Young people had access to a range of therapies.
  • All wards had wide-ranging multi-disciplinary teams and staff were well trained and supported.
  • Young people were supported to meet their religious, cultural and sexuality needs.
  • Complaints were responded to and acted upon appropriately.
  • Regular information was collected and reviewed to measure the quality of the service. Young people were able to give their views on the service.
  • Staff were committed to improving the service they were delivering. Many staff were undertaking work to try and review and improve care for young people.

However

  • The trust had high levels of staff vacancies, especially at Woodland House and Acorn Lodge although on a day to day basis they were taking the necessary steps to ensure the children and young people received the necessary care.
  • Not all records at Acorn Lodge showed up-to-date care plans and risk assessments.
  • Having two wards co-located in one space at Woodland House made it hard for staff to manage the ward.
  • Not all staff had received regular one-to-one formal supervision.

Services for people with acquired brain injury

Good

Updated 23 October 2018

We rated it as good because:

  • Staff completed a comprehensive mental and physical health assessment on each patient shortly after they were admitted. Care plans were personalised, holistic and recovery oriented, and included patients’ views and multi-disciplinary input from the ward team. Staff completed patient risk assessments promptly when patients were admitted to the ward, and put in place detailed management plans. These were updated after incidents.
  • Staff interacted with patients in a positive, respectful and discreet manner, and there was a calm and relaxed atmosphere on the ward. Most patients reported that staff treated them well and described staff as friendly, caring and supportive.
  • Staff were clear about the criteria for admission to the unit and actively planned for patients’ discharge from the time of admission. They worked collaboratively with community mental health teams, rehabilitation teams and local social services. Delayed discharges were monitored and escalated when necessary.
  • Although there remained staff vacancies on the ward, the trust had undertaken a recruitment campaign to attract nurses with a range of different skills to work on the ward and ensure safe staffing levels. The trust had recruited learning disability nurses, physical health nurses and registered mental health nurses. Multidisciplinary staff received the specialist training they needed to provide effective care and treatment to patients. The staff team had an in-depth knowledge of the patient group. It was anticipated that the ward would be fully staffed by September 2018.
  • Staff stored medicines securely and administered them in accordance with national guidelines. They recognised, reported and investigated medicines incidents, and shared learning from incidents to reduce the number of future medicines errors.
  • The service-controlled infection risk well. Staff kept equipment and the premises clean. The ward was visibly clean, tidy and well maintained.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff. Patients knew how to make a complaint.
  • Governance structures in the service helped ensure that learning from incidents and complaints was shared effectively with staff and information was passed from ward to trust board and vice versa. Managers maintained oversight of the quality of the service.

However:

  • Although staff told us that they were receiving regular supervision, there were many gaps in records of their clinical supervision, indicating that they did not always receive the support needed in carrying out their duties effectively. This may have impacted on the quality of care provided to patients.
  • Although the service had suitable premises and equipment, some areas of the ward, identified as a risk due to poor visibility, were not consistently monitored by staff to mitigate the risks to patients. Staff had not identified expired items in one of the ward’s clinic rooms, indicating that staff were not checking these regularly. It should be noted that almost all patients on this ward were informal, and would not normally be considered at high risk of suicide or self-harm.
  • No patients were given keys to their bedrooms on the ward, which meant that they had to rely on staff to lock and unlock their rooms.
  • There were limited opportunities for patients and their family members to give feedback about the service they received. This was a missed opportunity to involve patients and carers in making improvements to the patient experience.
  • Incidents relating to the service were not always categorised accurately, to ensure that appropriate learning was shared with staff within the trust.

Specialist community mental health services for children and young people

Good

Updated 18 December 2020

South London and Maudsley NHS Foundation Trust provide specialist child and adolescent mental health services (CAMHS) community teams for children and young people up to the age of 18 across the boroughs of Southwark, Lewisham, Lambeth and Croydon. The trust provides a diverse range of specialist outpatient services some of which are national specialist services supporting children and young people with a wide range of disorders including autism, learning disabilities, eating disorders, self-harm, substance abuse and emotional disorders.

This inspection primarily focussed on the specialist community teams supporting children, young people and their families from the four local boroughs, crisis services, and National and Specialist services for people with complex autism associated neurodevelopmental disorders (SCAAND).

Following the last CQC inspection of this core service in January 2016, this core service was rated Goodacross all domains. However, SCAAND and centralised crisis services were not included. The current responsive focussed inspection, only includes ratings for Caring, Responsive, and Well-Led for this core service, as we did not inspect all areas of the other two domains. We used CQC’s interim methodology for monitoring services during the COVID -19 pandemic.

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

As part of this inspection, we:

• Visited one CAMHS service office in the London borough of Lewisham, to look at 34 care records of young people currently using, or recently discharged from CAMHS services (including seven from SCAAND services, six from crisis services, and 21 from the four local borough teams).

• Had telephone conversations with 12 young people who were currently or had recently been using the local borough services.

• Had telephone conversations with 47 parents/carers of young people who were currently or had recently been using the services (38 from local borough services, and nine from SCAAND services).

• Had telephone/video conversations with 75 multidisciplinary staff (25 from local borough teams, 21 from crisis services, and 29 from SCAAND teams). These included doctors, nurses, psychologists, therapists (including psychotherapists, family, behavioural, occupational and speech and language therapists), trainees, and administrators.

• Had video conversations with 13 senior managers/directors with responsibility for

these services.

• Had telephone/video conversations with seven Special Education Needs Coordinators (SENCO workers) working in schools in the local boroughs.

The Service for Complex Autism & Associated Neurodevelopmental Disorders (SCAAND) is a national service. It is commissioned by NHS England with some Clinical Commissioning Group (CCG) contracts. Patients tend to have multiple co-morbidities. There are four clinical service ‘streams’ and a senior leadership team. Referrals are jointly screened and allocated to one of four streams. These are Neuropsychiatry, Intellectual Disabilities (IDT), Autism and Related Disorders (ARD) and the Autism and Intellectual Disabilities Intensive Intervention Team (AID-IIT).

The SLAM CAMHS Crisis Hub, a centralised team in place for approximately 18 months, includes four services. These are a Response team, Enhanced Treatment Service, Crisis Line, and CAMHS Bed Management team. They are in place to enhance the quality of crisis intervention within the boroughs of Southwark, Lambeth, Lewisham and Croydon. They provide a range of short-term community-based assessment and treatment options for up to two weeks and advice and support to parents/carers in partnership with various internal and external agencies.

We did not re-rate Safe and Effective for this core service as this was a focussed inspection which did not look at all sections within those domains. The rating of Good from the previous inspection across those two domains still applies.

  • The service provided safe care. The number of children and young people on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each young person the time they needed. For young people who required urgent care, staff managed access well to ensure they were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved children, young people, families and carers in care decisions. Children, young people and parents/carers were involved in the design and delivery of the service.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the children and young people. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of children and young people under their care. Staff from different disciplines worked together as a team to benefit children and young people. Managers ensured that these staff received training, supervision and appraisal. The teams had effective working relationships with other relevant teams within and outside of the trust.
  • Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
  • The enhanced treatment service had developed an alternative model to young people being admitted to hospital, published in various professional publications. It demonstrated creative ways of working with young people, involving them in the service, and in training CAMHS staff.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • The service was well-led and the governance processes ensured that procedures relating to the work of the service ran smoothly.
  • Leaders had the skills, knowledge and experience to perform their roles. Most staff said they felt respected, supported and valued, and that they had received appropriate support in adapting to new ways of working during the COVID-19 pandemic.

However:

  • Some children and young people had significant waits for assessment and treatment. There were long waits for treatment of trauma, obsessive compulsive disorder, attention deficit hyperactivity disorder and for autism assessments (which had been exacerbated by COVID-19 restrictions).

  • Many parents/carers told us that they had not received communication or support whilst waiting for assessment or treatment. Staff were aware of this and had taken steps to contact people on the waiting list in recent months.
  • Parents/carers told us that they were not always given enough support or signposted to support available to them outside of working hours.
  • There was a lack of consistency in where staff recorded information about children and young people’s care and treatment in care records. This could lead to delay in locating the most up-to-date information by a team member if needed promptly.

  • Although young people said staff discussed care with them, we did not find evidence of the child or young person’s views documented in the care records.

  • Some teams were struggling with ongoing staff recruitment and retention issues and insufficient funding to meet the needs of children and young people living in their area. Croydon teams in particular had experienced recent disinvestment. Some staff spoke of their frustration in having limited resources to focus on prevention and early identification of mental health issues in children and young people.

Community mental health services with learning disabilities or autism

Outstanding

Updated 8 January 2016

We rated South London and Maudsley NHS Foundation Trust community mental health services for people with learning disabilities as outstanding because:

The service was well-resourced with experienced and skilled staff. The service supported staff to develop their knowledge and expertise. The service was linked with the Estia Centre which is a training learning and development resource for adults with learning disabilities and additional mental health needs. This enabled staff to work collaboratively with their peers to develop best practice and work in innovative and pioneering ways.

Staff undertook holistic assessments of people’s needs. They fully took people’s individual learning disabilities and communication needs into account and developed ways of involving them in planning their care and treatment. People’s dignity, independence and confidence in their skills were promoted by the way staff interacted with them and involved them in the process of planning their support.

The service worked in creative ways with people and their carers and made a positive difference to their quality of life. Staff offered people a personalised treatment plan from a wide range of possible pharmacological, psychosocial and psychological interventions. The service monitored how people responded to care and treatment.

Staff worked constructively in partnership with people’s informal carers, relatives and others in their local support network to deliver and develop joined-up care and support to people.

People and their relatives consistently told us staff were kind, polite and sensitive to their needs. Informal carers reported they had received prompt and effective support from the service which had alleviated their stress.

Community-based mental health services for older people

Good

Updated 23 October 2018

Our overall rating for community-based mental health services for older people stayed the same. We rated it as good because:

  • The leadership, governance and culture of the service actively encouraged the delivery of person-centred care. The service had capable managers at all levels with the right skills and abilities to run a service providing high-quality, compassionate, sustainable care.

  • Services were very well-led and allowed staff to be creative and innovative in their approach to care and treatment. Evidence was used to develop new tools and effective services. Quality improvement initiatives and research had led to the development of new ways of working. Innovations had been shared with other health services and professionals both nationally and internationally.

  • Services took account of the diverse needs of patients and carers. The memory service in Lambeth and Southwark was working towards increasing the number of black and minority ethnic people being referred to the service. Staff from the service had piloted an innovative series of sessions on dementia for children in schools as a way of raising awareness among local communities. Staff were sensitive to the needs of LGBT+ patients. Premises were accessible to people with mobility problems and staff saw patients at home when this was more appropriate.

  • Staff worked actively to reduce prescriptions of anti-psychotic medicines and medicines that had an adverse effect on memory.

  • Staff were compassionate, respectful and responsive to the needs of patients and carers. Feedback from patients and carers was very positive and staff were continuing to consider ways in which they could involve patients and carers in decisions about the services.

  • Staff of different kinds worked together as a team to benefit patients. A full range of experienced professionals worked across the teams and were able to provide the necessary interventions to patients. Staff worked well together both within their teams and with other teams to ensure that patients received the support they needed in a timely manner. Teams referred patients to other services when this was appropriate.

  • The service had enough staff with the right, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff had manageable caseloads and were able to respond promptly when an urgent assessment was needed. Work had been done to improve the waiting times for an assessment at Croydon memory service. All memory services were working hard to decrease their referral to diagnosis times, so that they could reach a six-week referral to treatment target by 2020.

  • The service had made improvements to the quality of patient risk assessments since our last inspection in September 2015. Staff used a comprehensive risk assessment tool, which prompted them to cover all areas of risk in sufficient detail including how to safely manage the identified risks. Risk assessments were easily accessible to staff and stored in an appropriate place on the electronic patient record. Teams managed patient risk well. They used regular zoning meetings to identify and focus on patients at high risk.

  • Staff had made improvements to the way they transported medicines and disposed of sharps. Although a few staff in one team did not always follow trust policy in respect of the disposal of clinical waste this was promptly addressed by managers.

  • Similarly, improvements had been made in lone working procedures, the application of the Mental Capacity Act, compliance with safeguarding procedures and to patient waiting areas in Lambeth. Work had also taken place to improve patient crisis plans. These were now in place and patients knew who to contact in an emergency.

However:

  • Whilst the trust was using technology to support mobile working in some teams this had not yet been rolled out across all the teams. Staff told us that they had to return to the office at the end of the day to complete patient care and treatment records, which was not an effective use of their time and may have had a negative impact on the quality of record keeping.’

  • Whilst patient care plans identified all aspect of patients’ care, they were not particularly accessible to patients who were living to dementia. The trust was in the process of improving care plans in terms of accessibility to their patient group during the time of our inspection. Similarly, standard methods for giving feedback about the service did not take into account the particular needs of patients with dementia or offer them suitable alternatives.

  • The recording of staff supervision in Lewisham older adult CMHT was inaccurate and resulted in under reporting. It was difficult for the team manager to be assured about the frequency of supervision taking place in the team without access to full records.

  • Teams were not routinely discussing incidents and complaints at their business meetings as a way of learning and promoting improvements.

Mental health crisis services and health-based places of safety

Good

Updated 23 October 2018

  • During this inspection, we found that services had addressed all of the issues that caused us to rate it as requires improvement in safe following the September 2015 inspection.

  • Staff completed full risk assessments for patients and managed risk well. Staff developed crisis care plans with patients. Staff kept patient risks under continuous review at twice daily team meetings. Staff completed documentation, including initial risk assessments and physical health assessments to a good standard.

  • The service had introduced a purpose-built health-based place of safety since the 2015 inspection, which provided patients with a high-quality environment. There was a dedicated staff team, 24 hours per day and seven days a week. There were good facilities for children and young people and parents could stay overnight.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training in how to recognise and report abuse and they knew how and when to report their safeguarding concerns.

  • Staff supported patients to live healthier lives, and receive support for their physical health. Two nurses ran weekly physical health clinics in each home treatment team. Staff in the health-based place of safety received specialised physical health training to reduce admissions to emergency departments in local acute hospitals.

  • The service had enough skilled and experienced staff to support patients in a crisis. Staff of different disciplines worked together as a team for the benefit of patients. The home treatment teams ran a specialist training programme for all staff, which included suicide prevention and family interventions.

  • Patients were positive about staff and the service. For example, patients said staff provided good support when they were experiencing a crisis.

  • Staff did all they could to keep patients at home during a crisis and prevent admission to hospital. The crisis assessment team, consisting of a nurse and a police officer, accepted referrals from the ambulance service and police. They had been successful in reducing admissions to acute hospital emergency departments of patients in crisis.

  • Staff understood arrangements for working with other teams within the trust and externally to meet the needs of patients in crisis. The home treatment teams and health-based place of safety had multi-agency arrangements in place, to monitor and agree the governance of crisis services.

  • Home treatment teams and the health-based place of safety staff worked towards improving quality within the service. Staff had implemented a quality improvement project introducing patient reported outcome measures to incorporate into patients’ care planning.

However:

  • Although staff usually managed patients’ medicines safely, staff sometimes did not package and label the patient’s medicines when they left them at the patient’s home. Staff did not always follow the trust policy for assessing and recording the suitability of the patient’s own medicines before these were administered.

  • Although, there had been a significant decrease in the number of hours patients spent in the health-based place of safety, at the time of the inspection data showed that nearly a quarter of patients had breached the 24-hour target length of stay in May 2018. This was monitored very closely by the trust.

  • The patient section 132 rights poster displayed in the health-based place of safety assessment rooms did not clearly explain patients’ rights and could have been misleading.

  • Capacity assessments for consent to treatment, in the health-based place of safety, lacked detail. Staff did not clearly demonstrate how they had arrived at their decision.

  • Staff in some teams were not aware of the trust’s Freedom to Speak Up Guardian or how to contact them.

Wards for people with a learning disability or autism

Outstanding

Updated 8 January 2016

We rated the South London and Maudsley NHS Foundation Trust wards for people with autism as outstanding because:

Staff working in the service were acknowledged experts in the assessment, care and treatment of the mental health needs of people with autism spectrum disorder. Staff worked constructively with patients to involve them in planning their care and treatment. The service had a track record of success in reducing the incidence of challenging behaviour and the severity of mental illness symptoms in patients who had very complex needs.

The approach of the service was creative. The mult-discipinary team worked effectively to ensure assessments were holistic. The team developed each patient’s care and treatment from a broad range of possible interventions. There was a focus ensuring that patients discharged from the National Autistic Unit were either prescribed no medicines at all or prescribed the least amount of medicines for their mental health needs. Staff interacted with patients in ways which enhanced their dignity, independence and confidence.

Morale was high with staff describing a positive working environment and constructive working relationships with multi-disciplinary team colleagues. Staff worked effectively with commissioners and other agencies from across the country in relation to the admission and discharge of patients.

Specialist eating disorder services

Good

Updated 23 October 2018

  • Staff had made improvements on the ward since our responsive inspection in February 2018 and were no longer in breach of regulations. Staff completed patients’ risk assessments and risk management plans and updated them when required. Staff completed patients’ physical health monitoring charts when required.

  • Since the previous focused inspection in February 2018 the service had made improvements in several areas. This included improvements in systems, which supported the sharing of lessons learned from incidents with all staff; ensuring patients received regular individual time with a nurse; making sure staff were aware of feedback from patient satisfaction surveys; better communication with patients’ care coordinators; and providing more activities for patients at the weekend.

  • The service managed environmental and patient risks well. The trust had completed a new ligature risk assessment for the ward. Staff knew how to manage the identified risks and protect patients from avoidable harm.

  • The service had enough staff to provide the right care and treatment to patients and their families. The service had reduced staff vacancies by recruiting new staff since the previous inspection in February 2018. The trust had made improvements to how bank and agency staff were booked. Bank and agency staff received a better induction when they first worked in the service. The service provided mandatory training in key skills to all staff and made sure they completed it.

  • Patients gave positive feedback about permanent staff. Staff were supportive and kind when interacting with and caring for patients. Records showed patients were involved in decisions about their care. Staff offered families and carers support and skills training.

  • Staff worked to meet the diverse needs of patients on the ward. The ward was accessible to patients with physical disabilities. Staff ensured patients had access to appropriate spiritual support and facilitated access to places of worship. Staff could obtain the support of interpreters when this was needed. Staff supported LGBT+ patients on the ward.

  • Staff were positive about the support they received from their colleagues and the trust. The trust provided staff with training and professional development opportunities. Senior managers were visible in the service.

  • The service was committed to providing high quality evidence-based care to patients. Staff were involved in various quality improvement and research projects and applied findings to practice improving the care delivered to people with eating disorders both on the ward and in community settings. The service was innovative and had devised new models of care for people with eating disorders, which were being rolled out nationally. One community based team had won a national award. The ward was accredited with the Quality Network for Eating Disorders.

However:

  • Although the service provided staff with specific training related to their role, the service did not have a formal eating disorders competency framework for staff. Consequently, there was a risk that staff did not have all of the specialist skills they needed to care for a patient with an eating disorder.

  • Staff did not always record incidents of restraint to include information about the type of restraint, position of restraint, members of staff involved, length of time and that the patient received a physical check for any injuries.

  • The ward had not increased the dietitian and social worker input on the ward since our last inspection. They were reviewing the roles to determine how best to fill any gaps identified.

  • Some staff had not received regular monthly supervision. Although 87% of staff received supervision as planned in March and April 2018, the figure had fallen to 70% in May and 65% in June, below the trust target for clinical supervision compliance of 85%.

  • Some patients felt they were not as involved in their care as they would have liked. Staff did not give all patients a copy of their care plan or an induction to the ward on admission. Some patients said staff did not always respond or act on their feedback about improvements needed to their care or the ward.

  • Although staff completed weekly audits in a number of key areas, it not clear how staff used audit findings to make improvements.

Forensic inpatient or secure wards

Good

Updated 23 October 2018

  • At the last inspection in September 2015, we rated the service as requires improvement because of concerns about the completion of patient risk assessments and the quality of meals provided to patients. At this inspection, we found that the trust had made improvements and addressed both concerns.

  • The service managed patient risk well. Staff had completed individual patient risk assessments and kept these updated. Staff were aware of areas of the ward where incidents took place and managers adjusted how the ward was run in order to mitigate risks.

  • The service had a strong focus on relational security and staff were committed to minimising the use of restrictive practices such as restraint and seclusion. Staff used the ‘four steps to safety’ approach to reduce incidents of violence and aggression and consequently the need for physical restraint and seclusion.

  • Although patients had somewhat mixed views about the meals provided, there had been an improvement in quality after a new meal provider had been contracted. Patients and staff gave regular feedback to the contractor about meals and their views were considered. Patients on some wards could self-cater and made their own choices about which meals to prepare.

  • The service engaged and involved patients in the care they received. This included a focus on collaborative risk assessments. Staff responded to issues raised by patients in community meetings. Each ward had a patient representative who attended regular meetings with senior managers to discuss issues that mattered to patients on individual wards. As a result of feedback from patients, mobile phone access had been arranged for patients on the wards.

  • The service provided a range of evidence based therapies. Patients had access to social activities and a fully equipped gym and sports hall. Staff supported patients to develop the skills they needed to live independently. Patients had the opportunity to work in the unit shop, café, or library and were paid for this.

  • Patients told us that most staff treated them with respect, kindness and compassion. This was supported by our observations of staff interactions with patients. Staff across the service, including the senior management team, had a good understanding of the individual needs of specific patients. Staff understood safeguarding procedures and took steps to protect patients from possible abuse.

  • The service met the cultural, religious and spiritual needs of patients. Patients had access to interpreters, when needed, and information was available in community languages.

  • Patients and staff spoke positively about the senior management team within the service. Staff reflected the trust values in their work, and recovery was a strong theme of the service.

  • The forensic service was part of the South London Partnership with two neighbouring mental health trusts. The trust had been able to bring back 37 patients to south London from services in other parts of the country, meaning they could receive care closer to their communities, families and friends. Overall, the South London Partnership had repatriated 63 patients to south London from other parts of the country.

However:

  • Although the trust was actively involved in recruiting new staff, some wards had high numbers of vacancies and shifts were not always filled by bank or agency staff. On 22 occasions in a six-month period this led to patients’ leave being cancelled due to staff shortages.

  • Although the number of restraints carried out by staff had reduced considerably, staff did not record patient restraints in sufficient detail to enable further learning and development and keep an accurate record of events.

  • Nursing and support staff on Effra Ward were not invited to the ward’s monthly business meeting. This meant there was a risk they were not effectively learning lessons from incidents that occurred on the ward or in the service as a whole, which were discussed at this meeting.

  • Where clinical audits identified areas for improvement staff had not always put action plans in place to address these areas.

Long stay or rehabilitation mental health wards for working age adults

Requires improvement

Updated 30 July 2019

Our rating of this service went down. We rated it as requires improvement because:

  • Whilst improvements had been made and embedded on each of the units since the previous inspection, more work was required to address some of the concerns from last time and we identified some new concerns.
  • The three inpatient mental health rehabilitation services had not clearly defined the model of rehabilitation they were using and how they would deliver a recovery orientated approach. Whilst they described themselves as being predominantly high dependency rehabilitation units there were varying lengths of stay within each service. However, work was taking place through the South London Partnership to define an integrated complex care pathway and identify models of care to optimise the inpatient rehabilitation service.
  • Patients care plans lacked any meaningful planning for recovery, including achievable goals designed to support patients towards discharge.
  • Governance meetings on each ward were still being embedded so they were used effectively to improve the safety and quality of the service for patients.
  • Whilst staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice they did not always discharge these well. Staff did not always know when they should explain a patients’ rights to them and the recording of this was sporadic. Staff at Heather Close had not ensured that some patients had legally consented to medication prescribed to them or that it had been appropriately authorised by a second opinion doctor.
  • Whilst the wards were working to minimise the use of blanket restrictions, staff at the Tony Hillis Unit were confused about recent reductions in restrictions and how to apply these appropriately to meet the individual needs of each patient.
  • Although work was underway to make improvements, patients were not satisfied with the quality of food or the choices available to them. Patients could be supported further to self-cater.
  • Staff had limited understanding on how to support the needs of patients with protected characteristics and there was little information available to these patients to make them feel welcomed onto the wards.

However:

  • All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Improvements had been made in terms of how ligature risks were managed. Maintenance repairs were reported and undertaken within reasonable timescales. Fire safety arrangements at Heather Close had also been addressed, in terms of signage and ensuring fire doors were not wedged open.
  • Staff assessed and managed risks to patients and themselves. Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. As a result, they used restraint only after attempts at de-escalation had failed and this was very rare. The ward staff participated in the provider’s restrictive interventions reduction programme. We found improvements had been made in the observation arrangements of patients as well as ensuring that adequate precautions were taken if a patient went absent without authorisation.
  • Staff understood how to protect patients from abuse and/or exploitation and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and/or exploitation and they knew how to apply it. The environments were suitable for mixed gender and appropriate security arrangements had been put in place by the trust.
  • Staff assessed the physical and mental health of all patients on admission. Care plans had improved and were reviewed regularly through multidisciplinary discussion and updated as needed.
  • Staff actively engaged with commissioners, GPs, social care organisations and other secondary care services. This ensured that staff could plan, develop and deliver the service to meet the needs of the patients.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Staff involved patients in care planning and risk assessment at Westways and Tony Hillis and patients’ views were incorporated, even when they differed from the clinical teams. All units actively sought patient feedback on the quality of care provided. Staff supported patients to make a formal complaint if they needed to.
  • Staff involved families and carers and invited them to attend patient review meetings. Staff at Westways were establishing a family/carer user group to better understand their views.
  • Staff helped patients with communication advocacy and spiritual support.
  • Staff engaged actively in quality improvement activities and national accreditation schemes.

Wards for older people with mental health problems

Good

Updated 7 June 2017

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

  • The wards had addressed the issues that had caused us to rate effective, caring, and responsive as requires improvement following the September 2015 inspection. Although they had addressed issues from the previous inspection under safe, it remained as requires improvement as we identified some new concerns.

  • At the inspection in September 2015, we found unpleasant odours by toilet areas at Greenvale and Chelsham House. At the current inspection there was an improvement in the standard of cleanliness, with no lasting odours.

  • At the previous inspection in September 2015, we found that risk assessments were not completed in sufficient detail so that they could be used by care professionals supporting patients. At the current inspection there was an improvement in the level of detail recorded in risk assessments.

  • At the previous inspection in September 2015, in Greenvale the wheelchairs were not all fitted with footrests and that staff did not always move patients safely. At the current inspection all wheelchairs were intact and well maintained and appropriate hoisting equipment was available for staff.

  • At the previous inspection in September 2015, medicines on Greenvale and Ann Moss specialist care unit were sometimes unavailable to use when needed. At the current inspection there was improved medicines management at these units, including dedicated trust pharmacy provision.

  • At the previous inspection in September 2015, we found that staff supporting patients with dementia did not have current training in dementia care. At the current inspection, dementia training was being provided both by distance learning and at ward level. Staff displayed a good understanding of meeting the needs of patients with dementia. The trust had also taken steps to recruit to vacancies across the wards, and improved staff cover of shifts.

  • At the previous inspection in September 2015, we found that patients and their relatives were not always involved in assessments. At the current inspection there was an improvement in the recording of patients’ and carers’ involvement in care planning and assessments. Staff were using a new care planning system. Psychologists produced formulations with patients, their relatives and members of the multi-disciplinary ward teams, to develop a better understanding of the best way to support individual patients.

  • At the previous inspection in September 2015, we found that staff required support to improve their communication and interactions especially at mealtimes. At the current inspection we observed that the vast majority of staff supported patients in a caring way, including at mealtimes. The meal experience had improved, and some patients were involved in setting tables.

  • At the previous inspection in September 2015, we found that care was not always delivered in a manner that considered privacy and dignity, including same gender care and failing to close observation windows on bedroom doors when they were not needed. At the current inspection, care was provided within gender specific areas. Staff closed observation windows when not in use, and further protected patient privacy by closing curtains fitted around them.

  • At the previous inspection in September 2015, we recommended an improvement in the accuracy of recording of food and fluid charts for patients assessed to be at risk of dehydration and malnutrition. During the current inspection, there was improved recording to ensure patients’ food and fluid intake was monitored accurately.

  • At the previous inspection in September 2015, we recommended that, when staff explain to patients their rights under section 132 of the Mental Health Act, this is recorded, and that staff give patients a copy of their section 17 leave form. At the current inspection staff kept records of when detained patients’ rights were read to them and these were audited. We also found that staff offered patients copies of their leave forms.

  • Staff were implementing a number of quality improvement initiatives. These included Four Steps to Safety, a system for safer care with an aim to reduce violence and aggression. On Hayworth ward, the occupational therapy team had developed a ‘this is me’ booklet that they prepared with patients to go with them when they left the ward. The booklet contained information about the person’s life and areas of interest and included photographs. Other quality improvement projects included implementing electronic observations for health monitoring, reductions in enhanced observations, research into the cognitive effects of physical health medicines, and twinning wards with general hospital wards for older people.

  • The trust provided a service user and carer advisory group, which involved patients and carers with experience of the trust’s older adults’ services. The group provided opportunities to review current practice, recruitment, staff training and support each other. The trust’s psychologists also offered support to patients’ relatives as part of their role on each ward.

However:

  • There were gaps in mandatory training for staff in mandatory areas including intermediate life support, basic life support, and fire safety.

  • In two cases staff had not recorded patients’ vital signs after they had administered rapid tranquilisation to the patients.

  • Staff had no records of blind spots on each ward, to ensure that they paid particular attention to these risk areas.

  • There were gaps in staff supervision on some of the wards.

  • We observed two occasions when staff carried out clinical observations in a communal area, without giving patients the option of doing this in a private area such as the ward clinic room or their bedroom.

  • Ward managers were not aware of the issues recorded on the service’s risk register, and there was room for further development in links between senior management and ward level.

Perinatal services

Good

Updated 30 July 2019

We rated this service as good because:

  • The service provided safe care. Staff assessed and managed risk well and followed good practice with respect to safeguarding and management of medicines. Managers investigated incidents appropriately, shared lessons learned with the wider service, and gave patients honest information and suitable support.
  • Staff developed holistic, recovery-oriented care and treatment informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation. Staff directed patients to other services when appropriate and, if required, supported them to access services, such as local children’s centres.
  • 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 and respected their privacy and dignity. They understood the complex individual needs of patients preparing for motherhood, and as new mothers, and supported them to manage their mental health, and develop parenting skills. They actively involved patients and families and carers in care decisions.
  • The service was easy to access. Staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff followed up patients who missed appointments.
  • The service was well-led, and governance processes ensured that procedures relating to the work of the service ran smoothly. Staff were encouraged to be involved in research and innovative practices.

However:

  • Staffing vacancies and poor staff retention were having an impact on the consistency of support for patients and led to increased stress on the remaining staff. However, recruitment was taking place specifically for the service and they were also using regular temporary staff where possible. One community perinatal team had waiting times for non-urgent appointments to see a doctor of over four weeks although urgent appointments were available.
  • Although it did not compromise safety because staff mitigated the risks, the physical environment of the mother and baby unit was not ideally suited to support high quality care. There was a lack of ensuite facilities, the nursery was too small, the garden space was not safe for use by all patients, and there was not enough space for patients to meet with visitors. The trust had a long-term estate plan but these shortfalls could not be addressed quickly. In the Southwark, Lambeth and Lewisham perinatal community teams, there were insufficient rooms available to meet with patients. Whilst appointments had not been cancelled, staff had to plan carefully to ensure everyone was seen.
  • There were long waits for psychological therapies in the community perinatal teams, which did not always meet the recommended timeframes of assessing patients within two weeks and providing treatment within four weeks. In two boroughs patients were waiting up to 16 weeks. More clinical psychologists were being recruited and assistant psychologists were offering more group work in the interim period.
  • Whilst average numbers of staff receiving regular supervision across the services was over 80% there were a few areas where this had gone lower. For example, in March 2019 this had fallen to 67% in the MBU. However, all staff felt well supported by their managers and had regular access to reflective practice. The MBU manager was aware of levels of supervision and was working to ensure they were consistently within the trust target.

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

Good

Updated 20 August 2021

Community-based mental health services for adults of working age

Requires improvement

Updated 20 August 2021