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Provider: South London and Maudsley NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 23 October 2018

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

  • At this inspection we rated one service we inspected as inadequate and five services as good. When these ratings were combined with the other existing ratings from previous inspections, one of the trust services was rated inadequate, one was rated requires improvement, 11 were rated good, one was inspected but not rated and one had not been inspected.

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

  • The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to make the necessary changes to provide high quality care to their local communities.

  • The trust was participating very effectively in local care systems to drive progress to achieve integrated care. This was most developed in Lambeth but was also in progress in the other boroughs. The trust’s active participation in the South London Partnership was delivering new models of care for patients receiving national and specialist services. This meant that patients were receiving their care closer to home.

  • The trust’s strong academic and research links meant that many patients had access to innovative treatment. The trust had been at the forefront of developing new evidence based practice, including for people with eating disorders, in peri-natal care and in work with people with dementia, leading to improvements in treatment adopted both nationally and internationally.

  • The trust was making progress with their quality improvement programme and had set ambitious targets for the next three years. The early adopters of this work were understandably from higher performing teams. However, this needed to be embedded in more challenged teams as a way of facilitating improvements.

  • Staff engagement was (as shown in the staff survey) better than many other similar trusts. An ambitious programme of leadership walkabouts was promoting good communication. The trust promoted staff to speak up through the Freedom to Speak Up Guardian, although some teams were not yet aware of how to access this support and Freedom to Speak Up advocates did not receive specific training for their role. The trust was aware that there were groups, teams and individuals where deep-seated concerns still needed to be resolved.

  • The trust was working with the BME staff network to implement a range of measures to improve career progression and address discrimination for BME staff. It was recognised that this would take more time to fully implement and begin to have a positive effect on performance against the workforce race equality standard.

  • The trust had many excellent examples of working with people who use services and carers. This was supported by an active involvement register and a wide range of opportunities for volunteers. The trust was also looking to extend the number of peer workers. Staff were proactive in addressing the needs of people with protected characteristics. Staff enabled access to services for patients with physical disabilities, took account of individual’s cultural and religious needs and provided information in accessible formats. The trust worked in partnership with local BME communities to improve the design and delivery of services. Many staff were sensitive to the needs of LGBT+ people and the trust had developed a new policy to address needs of young people who were transgender.

  • The governors were performing their role well and holding non-executive directors to account. This had significantly improved since the last inspection and reflected the desire of the board to be open and transparent.

  • The trust had systems in place to identify risk and the board assurance framework had recognised the pressures on the acute care pathway. In addition, a system was in place to identify the performance of wards and teams using a range of indicators. However, there was a disconnect between these systems and the front-line services. This meant that where services needed to improve across the acute care pathway, targeted support had not been delivered.

  • The quality of the investigation reports following a serious incident were of a high standard and provided the necessary insight into where improvements were needed but further work was needed to ensure this learning was embedded across the trust.

  • The trust was actively engaged in pioneering and developing digital innovations. This included the piloting of electronic observations and a personal health record to digitally engage patients in their care.

  • The trust had made significant improvements to care environments since the comprehensive inspection in September 2015. This was particularly noticeable in the introduction of a single, centralised, purpose-built health-based place of safety at the Maudsley Hospital. The facility had a dedicated space for children and young people and provision for their parents to stay overnight. A psychiatric intensive care unit had won an award for the design of a new sensory room for patients and commissioned art work for the ward, which created a more therapeutic environment.

However:

  • At the time of the inspection, adult patients from the local communities being supported on the acute care pathway, either as an inpatient or by adult community mental health teams, could not be assured of receiving consistently high standards of care. These unwarranted variations in standards of care had a negative impact on the largest group of patients receiving care and treatment from the trust. We have taken enforcement action to ensure services improve.

  • The quality of leadership at a ward and team level varied and was a key factor in whether the service was operating well. The trust was aware of these variations and that some leaders needed more support to enable them to deliver a high-quality service. The trust had not ensured that the necessary support had been put into place. The trust anticipated that the recently introduced restructure of the operational directorates, resulting in smaller spans of control and increased levels of professional input, would deliver the support needed to make required improvements.

  • There had been breaches of fundamental standards of care on the acute inpatient wards, which had not been appropriately escalated to senior leaders in the trust. The flow of patients into and out of the acute care pathway was poor. Bed occupancy was above 100% on most of the acute wards. There was not always a bed available for someone who needed one. Some patients were sleeping on couches or in seclusion rooms rather than in a bed. This was unsafe and compromised the dignity of the patients. In the previous year there were over 30 incidents of this happening. Governance systems had not identified this unacceptable practice, or a few other serious shortfalls such as staff not always carrying out physical health checks on patients after they were administered intra-muscular rapid tranquilisation. This put patients at risk of avoidable harm.

  • The communication with wards and teams did not always happen effectively. Whilst the governance system included the expectation that each ward or team would have a quality governance meeting, these were not always happening regularly or including all staff. Information was not always shared consistently, which meant there were teams who did not have access to adequate learning from incidents, complaints or other methods of assurance such as clinical audits.

  • Staff did not always identify and report patient safety incidents, which prevented them from being investigated in promptly and prevented staff from learning from them. Environmental risk assessments were not always thorough and significant potential risks to patients had not been identified and therefore mitigated.

Inspection areas

Safe

Requires improvement

Updated 23 October 2018

Our rating of safe stayed the same. We rated it as requires improvement because:

  • At this inspection we rated safe as requires improvement in one of the six core services and good in the other five services. When these ratings were combined with the other existing ratings from previous inspections, four of the trust services were rated requires improvement and nine were rated good.

  • Staff did not always provide safe care and treatment to patients. Staff on the acute wards and psychiatric intensive care units did not always carry out and record physical health checks on patients following the administration of rapid tranquilisation. This was contrary to national guidelines and trust policy and put patients at risk of avoidable harm.

  • Although staff completed environmental and ligature risk assessments for all wards these sometimes failed to identify important risks. For example, some acute wards had failed to include the use of plastic bin bags in bathrooms, blind spots, and ligature points in their environmental risk assessments, which meant they were not adequately mitigated.

  • Following the use of restraint staff did not record in sufficient detail what had taken place, such as, the staff involved, the holds used or duration of the restraint. Of 32 records of patient restraint we reviewed on AL3, Ruskin/AL2 and John Dickson Wards, all acute wards, none of these recorded details of the holds used by staff or the staff involved.

  • Following our last inspection of acute wards and psychiatric intensive care units in February 2017, we told the trust to develop clear plans to reduce the number of restraints in the prone position. Although we found the trust did have an overarching plan in place, and in forensic wards significant progress had been made to reduce the number of restraints, on some acute wards, staff were unaware of key initiatives to reduce the level of restraint and prone restraint.

  • Staff did not always identify and report patient safety incidents. We found incidents on three acute wards that had not been reported but should have been. As a result, managers either failed to investigate them, or there were delays in investigation. Staff in the neuropsychiatric service recorded incidents but did not always categorise incidents appropriately to ensure that appropriate learning was shared with staff within the trust. Some acute wards teams had not met together for several months. Staff on those wards had not discussed and were not aware of incidents that had occurred in the service or trust as a whole or the learning identified from them.

  • Patients on one ward did not have direct access to drinking water and cups putting them at increased risk of dehydration.

  • Although the trust undertook regular recruitment campaigns to attract nurses with a range of skills there remained staff shortages in some wards and teams. In the acute wards and psychiatric intensive care units the overall vacancy rate had improved to 19% but there were seven vacancies on Tyson West 1, seven vacancies for nurses on Nelson Ward and five vacancies on Gresham 1. Staff turnover rates were above 25% on Rosa Parks Ward, ES1 and Nelson Ward. Staff and patients on these wards, told us that sometimes patients’ leave was postponed or cancelled when staff were not available but this was not recorded. There were a high number of vacancies on Norbury and Waddon wards in the forensic service. Sometimes shifts could not be filled and this had led to patient leave being cancelled on 22 occasions in a six-month period.

  • While most services prescribed, gave, recorded and stored medicines safely and there had been improvements in the way community staff transported medicines, staff did not always leave medicines in patients’ home in the correct packaging and labelling or assess and record the suitability of patients’ own medicines, before administration, in accordance with trust policy.

  • Equipment was not always replaced before it expired. While the trust provided suitable equipment for staff to use, in Lambeth Hospital, staff had not anticipated the expiry date of some items of emergency equipment. This led to a delay in receiving replacements for items that had passed their expiry date. In the clinic room on the neuropsychiatric ward we found wound dressings and blood testing equipment that were past their expiry dates.

However:

  • The trust had improved the environment for patients requiring a health-based place of safety since the inspection in 2015. The purpose-built, centralised service was visibly clean and well-maintained. The service was permanently staffed on a 24-hour, seven day a week basis and there was no need to obtain staff from other wards. Community teams operated from suitable premises that were safe.

  • We found improvements in the quality of risk assessments and risk management plans in several services. Staff used a new template, which prompted them to complete these records in detail. Staff completed and updated risk assessments for each patient when necessary and used these to understand and manage risks individually. In the forensic wards staff completed clinical risk management assessments (HCR-20) for all patients within three months of admission and reviewed the HCR-20 every six months in accordance with national guidance. The home treatment teams stored risk assessments consistently, which made them easily accessible, an improvement since September 2015. In the home treatment teams, for adults and for older people, staff discussed, categorised and managed patient risk using a zoning system in daily meetings to keep patients and others safe. Patients had crisis plans so they knew who to contact if their health had deteriorated.

  • Staff understood how to protect patients from abuse and the services worked well with other agencies to keep patients safe. Staff had training in how to recognise and report abuse. Staff knew what incidents to report and how to do so and escalated incidents in line with trust policy.

  • The trust had clear lone working protocols, which helped protect staff working on their own in the community. Staff understood and followed the protocols and knew how to summon assistance in an emergency.
  • Community teams (in older people’s services and the home treatment teams) had enough staff with the right qualifications, skills, training and experience to provide safe care and treatment. A dedicated team staffed the health-based place of safety day and night. Community-based staff had manageable caseloads. New posts had been created at Croydon memory service to shorten waiting times for the service. Teams responded promptly to urgent referrals and provided timely assessments of patients. The community mental health teams for older people were able to allocate patients to a care coordinator immediately, when needed.

  • The services planned for emergencies, reviewed procedures, and undertook regular fire drills. Staff understood their roles if an emergency should happen.

Effective

Good

Updated 23 October 2018

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

  • At this inspection we rated effective as requires improvement in one of the six core services and good in the other five services. When these ratings were combined with the other existing ratings from the previous inspections, two services were rated as requires improvement for effective, nine as good and two as outstanding.

  • The services provided care and treatment based on national guidance and evidence of its effectiveness. Staff used a range of evidence-based, validated tools to complete comprehensive assessments for patients in the memory clinics. Some tools were available in other languages and more culturally appropriate versions to enable effective assessments for all patients. Staff provided a range of evidence-based care and treatment interventions and were knowledgeable in respect of relevant national guidelines. Staff participated in clinical audit to provide assurance of the quality of care and treatment delivered to patients and drive improvement. Outcomes for patients were measured using appropriate tools to monitor the effectiveness of the interventions implemented.

  • Staff worked together as a team to benefit patients. Nurses, doctors and other healthcare professionals supported each other in the provision of care and treatment. A full range of professional disciplines worked within the teams. When necessary staff made referrals to specialist health staff outside the team or trust. Most staff were experienced in their roles and many had undertaken specialist training.

  • We found there had been improvement in the quality of patient care plans since our previous inspections in 2015 and 2017. Care plans in most services were personalised, holistic and recovery oriented. Patients’ recovery goals were determined by their needs.

  • Staff supported patients to live healthier lives. The trust provided very good support for patients who wanted to stop smoking and encouraged patients to exercise. Staff completed a comprehensive physical health assessment on each patient shortly after admission and used a recognised tool to monitor patients’ physical health. The home treatment teams ran a weekly physical health clinic to support patients with their physical health needs.

  • Staff used technology to support patients effectively. Staff in Lambeth, Lewisham and Southwark had good access to information held about patients by other health providers, which enabled prompt and effective care and treatment. Staff were able to use a secure portal to review patients’ physical health investigation results directly. On ES2, an acute ward, staff had completed a quality improvement project where patients’ physical observations were monitored electronically. This had positive outcomes in terms of improving patient care and the accuracy of monitoring.

  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They had received appropriate training and knew how to support patients, including those who lacked the capacity, to make decisions about their care.

However:

  • In some wards and teams, managers did not hold regular supervision meetings with staff to monitor the effectiveness of their work and provide timely support. At the previous inspection of acute wards for working age adults and psychiatric intensive care units in January 2017, we found that staff supervision rates were low. At this inspection, we found that supervision rates continued to be low in the acute wards. Fifty-two per cent of staff had received the required supervision from March 2017 to February 2018. Although this improved between April to June 2018 to 75%, nearly one quarter of the acute wards had completed less than 65% of planned staff supervision in that period. Similarly, less than half of the registered and non-registered nursing staff in the Lishman Unit (specialist neuropsychiatric service) had received regular clinical supervision. In the eating disorders inpatient service completion of monthly staff supervision had fallen to 70% in May and 65% in June 2018. 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 sure about the frequency of supervision taking place.

  • Although care plans covered all aspects of patients’ needs including social, physical and mental health needs and were usually shared with patients, they were not easily accessible to patients with dementia to enable their understanding.

  • Although staff in the eating disorders service had received some specific training related to their role the service did not have a formal eating disorders competency framework for staff. There was risk that staff did not have all the specialist skills they needed to care for a patient with an eating disorder.

Caring

Good

Updated 23 October 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.

  • Most staff treated patients and carers with kindness and compassion. Patients reported that staff treated them well and described staff as friendly, caring and supportive. Staff treated people with dignity and respect and gave them the opportunity to make choices and have control of decision-making. Staff communicated well with patients so that they understood their care and treatment and found effective ways to convey information to patients with communication difficulties.

  • Staff had good understanding of patients’ individual needs, including their personal, social and religious needs. Staff developed care plans in collaboration with patients to support them with these needs.

  • Staff involved patients and those close to them in decisions about their care, treatment and the service. Patients in most services reported that staff had offered them a copy of their care plan and that they felt involved in their care and treatment.

  • Staff encouraged patients to give feedback about the service to identify areas for improvement. Most wards held regular community meetings so that patients could raise any concerns they had. Staff acted on the issues raised. Each forensic ward had a patient representative, who attended regular meetings with senior managers, to help bring about improvements across the service. Staff in the health-based place of safety had produced a specific survey for patients to feedback about their time in the service.

  • Staff involved carers appropriately and provided them with support when needed. Staff in the eating disorders service delivered a two-day carers’ workshop and families and carers were invited to attend meals with patients and engage in family therapy. Some services had an identified carers involvement lead. Four acute wards held monthly carers’ forums. The trust facilitated service user and carer advisory groups as a way of involving them in the development of the services.

  • Services provided access to independent advocacy support for patients. Details of how to contact the advocate were displayed where people could see them.

However:

  • Although patients and carers were encouraged to provide feedback about the service in a patient experience survey, there were no alternative feedback methods designed to be accessible for patients living with dementia.

  • While most staff cared for patients with kindness and compassion, feedback from patients on two wards was less positive. On one acute ward patients reported that some staff did not seem to care about them or were too busy to help them. Some patients on one PICU reported poor treatment by staff during episodes of restraint and seclusion.

  • In two wards, confidential patient information written on a white board in the ward office was visible to other patients and visitors outside the office.

Responsive

Good

Updated 23 October 2018

Our rating of responsive went down. We rated it as good because:

  • At this inspection we rated responsive as good in five of the six core services that we inspected and one as inadequate. When these ratings were combined with the other existing ratings from the previous inspections, one was inadequate, one was requires improvement and 11 services were rated as good.
  • The trust had made improvements to service environments since the inspection in 2015. The trust had introduced a single centralised health-based place of safety, purpose built to a high specification. The health-based place of safety had dedicated facilities for children and young people that included the provision for parents to stay overnight. ES1, a psychiatric intensive care unit, had a new sensory room that had received a national award for its design. Patients could use the space to calm themselves. The trust had worked in partnership with a charity to commission art work for the ward, which created helped create a therapeutic, and much improved environment and experience for patients. Community services provided pleasant waiting areas and had the necessary space to carry out consultations and group activities. The trust had improved seating in the outpatient department waiting area at premises in Lambeth.

  • Forensic wards had made improvements to the quality of meals provided to patients. The catering provider met regularly with patients and staff to discuss menus. Some wards were beginning to introduce self-catering, which enabled patients to choose their own food and facilitated greater independence.

  • Services took account of patients’ individual needs. Staff were proactive in addressing the needs of people with protected characteristics. Staff enabled access for people with physical disabilities, took account of patients’ cultural and religious needs and provided information in an accessible format. Lambeth and Southwark memory service were working to increase accessibility to the service for black and minority ethnic people, in line with the trust’s equality priorities for 2017-2020. Staff were inclusive of and welcoming to LGBT+ patients. They were sensitive to the way they phrased questions about significant relationships and linked LGBT+ people with community groups and resources.

  • The forensic service had worked with colleagues in the South London Partnership to bring back 37 forensic patients from around the country so that they could be closer to their communities and families.

  • The services treated concerns and complaints seriously, investigated them and shared lessons learned with staff. Patients and carers knew how to complain, and give feedback about the service.

However:

  • Although most people could access the service they needed to, the flow of patients into and out of the acute care pathway was poor. Bed occupancy was above 100% on most of the acute wards. There was not always a bed available for someone who needed one. The trust had placed almost 300 patients in out-of-area beds in the year from February 2017 to January 2018 because of a lack of available beds within the acute wards and PICU. At the time of the inspection, 29 patients were placed out of the area due to a lack of beds being available.

  • There was not always a bed available for patients returning from leave. In the last 12 months, four patients returning from leave or recalled to hospital and 27 patients returning from being absent without leave slept on sofas, in seclusion rooms and in other areas of the wards until a bed could be found. There was not always a bed available promptly for patients who needed a transfer to a psychiatric intensive care ward. This led to patients being secluded in unsuitable environments, such as bedrooms, whilst waiting for a transfer.

  • Although the trust had recently taken steps to address the issue of delayed patient discharges with local health and system partners, 20% of patient discharges from acute wards were delayed. Staff on the acute wards were not proactive in planning for patients’ discharge or addressing barriers to discharge.

  • In the health-based place of safety, although staff had significantly reduced patient length of stay since 2017, 23% of patients admitted to the health-based place of safety breached the 24-hour target length of stay for assessment in May 2018. The trust monitored breaches closely to ensure further improvements were made.

  • Following the inspection of community-based mental health services for working age adults in July 2017, we rated this core service requires improvement overall, requires improvement for safe, effective and responsive and good for caring and well-led. We asked the trust to make improvements to quality of patient risk assessments and care plans; the length of time patients waited for a Mental Health Act assessment; and the long waiting times for patients referred to the Croydon assessment and liaison team. We have not yet returned to re-inspect this core service to see whether improvements have been made.

Well-led

Good

Updated 23 October 2018

Our comprehensive inspections of NHS trusts have shown a strong link between the quality of overall management of a trust and the quality of its services. For that reason, we look at the quality of leadership at every level. We also look at how well a trust manages the governance of its services – in other words, how well leaders continually improve the quality of services and safeguard high standards of care by creating an environment for excellence in clinical care to flourish.

We rated the trust as good because:

  • The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to make the necessary changes to provide high quality care to their local communities.

  • The trust was participating very effectively in local care systems to drive progress to achieve integrated care. This was most developed in Lambeth but was also in progress in the other boroughs. The trust’s active participation in the South London Partnership was delivering new models of care for patients receiving national and specialist services. This meant that patients were receiving their care closer to home.

  • The trust’s strong academic and research links meant that many patients had access to innovative treatment. The trust had been at the forefront of developing new evidence based practice, such as the use of talking therapies for patients with psychosis, leading to improvements in treatment nationally and internationally.

  • The trust was making progress with their quality improvement programme and had set ambitious targets for the next three years. The early adopters of this work were understandably from higher performing teams. However, this needed to be embedded in more challenged teams as a way of facilitating improvements.

  • Staff engagement was (as shown in the staff survey) better than many other similar trusts. An ambitious programme of leadership walkabouts was promoting good communication. The trust promoted staff to speak up through the Freedom to Speak Up Guardian, although some teams were not yet aware of how to access this support. The trust was aware that there were teams and individuals where deep-seated concerns still needed to be resolved.

  • The trust was working with the BME network to implement a range of measures to improve career progression and address discrimination for BME staff. It was recognised that this would take more time to fully implement.

  • The trust had many excellent examples of working with people who use services and carers. This was supported by an active involvement register and also a wide range of opportunities for volunteers. The trust was also looking to extend the number of peer workers.

  • The governors were performing their role well and holding non-executive directors to account. This had significantly improved since the last inspection and reflected the desire of the board to be open and transparent.

  • The trust had systems in place to identify risk and the board assurance framework had recognised the pressures on the acute care pathway. In addition, a system was in place to identify the performance of wards and teams using a range of indicators. However, there was a disconnect between these systems and the front-line services. This meant that where services needed to improve across the acute care pathway, targeted support had not been delivered.

  • The quality of the investigation reports following a serious incident were of a high standard and provided the necessary insight into where improvements were needed. Further work was, however, needed to ensure this learning was embedded with teams across the trust.

  • The trust was actively engaged in pioneering and developing digital innovations. This included the piloting of electronic clinical observations and a personal health record to engage patients digitally in their care.

However:

  • At the time of the inspection, patients from the local communities of working age adults being supported on the acute care pathway, either as an inpatient or by adult community mental health teams, could not be assured of receiving consistently high standards of care. These unwarranted variations in standards of care impacted on the largest group of patients receiving care and treatment from the trust.

  • The quality of leadership at a ward and team level was variable and was a key factor in whether the service was operating well. The trust was aware of these variations and that some leaders needed more support to enable them to deliver a high-quality service. The trust had not ensured that packages of support had been put into place. The trust anticipated that the recently introduced restructure of the operational directorates, resulting in smaller spans of control and increased levels of professional input, would deliver the support needed to make these improvements.

  • There had been a breach of fundamental standards of care on the acute inpatient wards, which had not been appropriately escalated to senior leaders in the trust. Some patients were sleeping on couches or in seclusion rooms rather than in a bed. This was unsafe and compromised the dignity of the patients. In the previous year there were over 30 incidents of this happening. Governance systems had not identified this unacceptable practice, or a few other serious shortfalls such as physical health checks not taking place after all cases of patients being administered intra-muscular rapid tranquilisation.

  • The communication with wards and teams did not always happen effectively. Whilst the governance system included the expectation that each ward or team would have a quality governance meeting, these were not always happening regularly or including all staff. Information was not always shared consistently, which meant there were teams who did not have access to adequate learning from incidents, complaints or other methods of assurance such as clinical audits.

Checks on specific services

Specialist community mental health services for children and young people

Good

Updated 8 January 2016

We gave an overall rating for the specialist community mental health services for children and young people of good because:

  • Young people and their families were treated as partners in their care and staff treated young people and their families with kindness, dignity and respect.

  • Managers supported staff to deliver effective care and treatment. Staff adopted a multi-disciplinary and collaborative approach to care and treatment.

  • There was clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was apparent across the services.

  • Most young people, children and families could access services promptly. There were robust systems in place to manage referrals and waiting lists. However in some areas waiting lists for assessment and treatment were not meeting national targets.

  • There was strong leadership at both local team and service level which promoted a positive culture. There was a commitment to continual improvement across the services.

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.

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.

Neuropsychiatry services

Good

Updated 23 October 2018

We rated this service 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.

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.

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

Inadequate

Updated 23 October 2018

  • The trust had failed to make improvements in relation to some matters we said the trust must address at the last inspection in January and February 2017. The trust had systems in place to identify wards who may need additional support, but had not ensured this support was in place to enable wards to make the necessary improvements in the quality of care and treatment.

  • The trust had not ensured that all environmental risks relating to ligature anchor points, blind spots and the use of plastic bin liners were included in environmental risk assessments and that staff were aware of these risks and how to mitigate them.

  • The trust had not embedded plans to reduce patient restraint and prone restraint, in particular. Staff in many of the wards were not using the ‘four steps to safety’ approach, which had been adopted as a quality improvement initiative to reduce violence and aggression and associated restrictive practices, including restraint.

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

  • The service had a high number of delayed patient discharges. On some wards, staff failed to effectively plan for patients’ discharges and failed to work pro-actively to ensure that patients could be discharged as soon as they were ready. In the past 12 months, the trust had not been able to provide a bed for four patients returning from authorised leave and 27 patients returning from unauthorised leave. Thirty one patients altogether had had to sleep on sofas or in other temporary facilities.

  • Staff did not always appropriately record patient safety incidents. Many staff were not aware of serious incidents that had taken place on other wards or across the trust or learning from these incidents. Team meetings where incidents and complaints were discussed had not taken place consistently across all the wards.

  • The service did not provide adequate support to staff to ensure they had the necessary skills to support patients effectively. Although staff had access to training in caring for people with learning disabilities this did not include patients with autism, although staff told us that patients with autism were admitted to the wards. Managers had not held supervision meetings with staff as frequently as they should to provide support and monitor the effectiveness of their work.

  • Some wards had high levels of staff vacancies, a high turnover of managers or interim managers. This had an impact on the stability of teams, consistency of care provided and patient experience.

  • Staff did not always provide adequate support to patients with specific physical health needs. We found examples of staff not taking regular blood tests when these were required and staff failing to act on concerns that a patient was not drinking enough. Patients on Johnson PICU did not have unrestricted access to drinking water, creating a risk of dehydration, particularly in hot weather. Some emergency equipment was out of date and although this was recognised by staff, they had not identified it in time to replace the equipment before the expiry date.

However:

  • The trust had made improvements in many areas identified at the previous inspection. These areas included providing information about fire safety procedures and evacuation, carrying out fire drills, improved pest control, and a reduction in patients going absent without authorised leave.

  • The trust had improved safeguarding procedures since the previous inspection in 2017. 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 knew how to apply it in their everyday work.

  • The trust provided statutory and mandatory training in key skills to all staff and made sure everyone completed it. There had been an increase in the number of staff who had completed training in the Mental Capacity Act. Most staff had completed the trust’s new annual performance appraisal or were booked to do so. Staff at the Ladywell Unit had received specialist training in cognitive behavioural therapy to enable to them to provide better support for people with emotionally unstable personality disorders.

  • Although patients on two wards reported poor attitudes amongst some staff, most staff were kind and compassionate. We observed positive, caring and supportive interactions between staff and patients throughout the inspection.

  • Many staff had received training in quality improvement and some wards were implementing creative and innovative approaches to care delivery. Innovations included using video conferencing to encourage community staff to become more engaged in multidisciplinary team meetings, the introduction of care planning surgeries, weekly health and well-being clinics and the introduction of electronic observation recording. The new sensory room, with light projection and soft furnishing, and art work on ES1 had won an award in 2018.

  • Staff actively encouraged patients and carers to be involved in care planning and sought their views on a range of aspects of their care and treatment. Staff acted on feedback from patients and carers to make improvements to the service. Some wards had identified staff who took a lead on carers’ involvement. Four wards held monthly carers’ forums. The trust facilitated service user and carer advisory groups as a way of involving them in the development of the service.

Forensic inpatient/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.

Community-based mental health services for adults of working age

Requires improvement

Updated 31 October 2017

Following this inspection, we rated community-based mental health services for adults of working age provided by South London and Maudsley NHS Foundation Trust as requires improvement because:

  • In the previous six months, there were 11 incidents when patients identified as in need of a Mental Health Act assessment, were not assessed promptly. This was due to a lack of hospital beds, complicated further by issues beyond the trust's control including the availability of AMHPs and the police. This placed patients and others at potential risk, and a significant responsibility on care coordinators in managing their needs in the community.

  • In September 2015, the trust did not have a consistent approach to ensuring that risk screens and assessments had the detail necessary for all care professionals. At the current inspection 26% of the 131 patients’ risk assessments we looked at did not have a current risk assessment and management plan in place. This was a particular concern in the early intervention team in Lambeth, where six of seven records we looked at did not have current risk assessments and risk management plans. Staff did not always review patients’ risk assessments after changes to their circumstances such as discharge from hospital, transfer from another team, or following risk events, which placed patients at potential risk of harm.

  • There were no care plans available in 31% of 16 patient records we reviewed in the early intervention teams. In some teams, care plans were not always completed in full to ensure that patients received appropriate support. In September 2015, we recommended that the trust ensure that patients were routinely involved with developing their care plans, and offered copies of the plans, and that this be recorded. This was still not happening in most community teams we inspected at the current inspection.

  • Patients referred to the Croydon assessment and liaison (A&L) team were not being seen within trust target timescales. This left some of them waiting up to 18 weeks for an assessment, thereby increasing chances of deterioration and putting them at greater risk of avoidable harm.

  • In some teams, patients were waiting for approximately one year for individual psychological therapies.

  • There were low rates of completion of training in annual basic life support, infection control and fire safety in several teams.

  • Staff did not always record that they had explained to patients on community treatment orders, their rights, in accordance with the Mental Health Act (MHA) Code of Practice. There were also some inaccuracies in capacity to consent records kept with patients’ medication administration records.

  • Staff in some early intervention teams had caseload sizes in excess of the nationally recommended maximum number. This created pressure on the teams and potentially affected the quality of care that patients received.

  • The trust was working to improve relationships between the community teams, wards, and home treatment teams. However, community team staff did not always keep in regular contact with patients admitted to wards and ward staff.

  • There were barriers to effective patient movement along the care pathway. Patient transfers between teams were sometimes delayed because specialist teams lacked appropriate or sufficient staff, or staff were unclear about the referral criteria and thresholds of different teams. Staff experienced difficulties accessing funding for specialist placements for patients and sometimes had to make repeated applications.

  • Although governance systems were in place, they were not always effective in bringing about timely improvements to systems to monitor risk assessments and care plans, identify when these were out of date, and address long waiting times. 

However:

  • We rated Well-led as good, despite the core service having three domains that were rated as requires improvement. This was because service managers were aware of the issues we found relating to risk assessments and care plans, and working to address them. They had also taken proactive steps to address long waiting times in the Croydon A&L team, and regarding delays in Mental Health Act assessments.

  • In September 2015, the trust did not have safe systems for transporting medicines, medical waste and sharps, and not all equipment used in teams was safe and in working order. During the current inspection, we found that regular checks were in place to ensure that equipment was serviced, and new bags and arrangements were provided to transport medicines, waste and sharps safely. In September 2015, we recommended that the trust ensure that all staff follow the lone working policy to ensure their safety. Staff were following the policy during our current inspection.

  • In September 2015 we recommended that the trust should ensure full staffing of the south Southwark A&L team, and that vacancies across the recovery teams should be filled. At the current visit we found that the trust had put in place a recruitment and retention strategy, and there was a marked improvement in the numbers of permanent staff recruited to these teams, although this continued to be a challenge. In September 2015, we also recommended that the trust monitor the number of changes patients were having of care coordinators in the recovery teams to keep this to a minimum. At the current inspection, we found that the trust collected information on the changes to patients’ care coordinators, indicating an improvement in this area. However, this was still a challenge in some teams due to vacancies and long-term sickness of staff.

  • In September 2015 we recommended that the trust should ensure all staff know how to signpost patients to local advocacy services when needed. At the current inspection we found that staff made information available to patients on local advocacy groups.

  • The trust offered patients the opportunity to participate in innovative treatments. For example, patients who met the research criteria could participate in trials of a new digital therapy. The therapy aimed to assist patients to understand and control their thoughts.

  • Staff used case discussion and formulation meetings to improve the quality of care and treatment for patients. Staff fed-back to their teams about successful interventions with patients. Patients described staff as accessible, caring and respectful. They told us staff listened to them and gave them time to discuss issues of concern. The trust collected data on patients’ experiences of services and staff used feedback to improve each service.

  • There were clear governance structures in place for each clinical academic group overseeing community services, and a wide range of quality improvement projects in place encouraging staff to be actively involved in improving services.

  • Patients were able to access a number of groups held within the community including a 'Hearing Voices Group’ that was co-facilitated by patients.

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.

Other specialist services

Updated 12 January 2016

Since the last inspection of the ward in March 2015 a number of developments had taken place to improve the safety for patients on Fitzmary 2. A refurbishment programme was underway that was replacing some fittings which could be used as ligature anchor points. Also the environment was improving with bathroom facilities being refurbished. Comprehensive risk assessments were being completed when patients were admitted to the ward. Staff had a good understanding of safeguarding procedures and who to contact when they needed to make an alert.

However, there were still some areas where improvements should continue to take place. This included ensuring observations took place as needed and were recorded, keeping risk assessments up to date and ensuring temporary staff working on the ward had a local induction.

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.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 8 January 2016

We rated South London and Maudsley NHS Foundation Trust’s rehabilitation mental health wards for working age adults as good.

Most patients were positive about the support they received from staff and felt safe on the ward. On Westways ward we observed good interaction between staff and patients where an open dialogue was encouraged. Carers told us it was easy to contact family members on the ward and generally felt happy about the care and treatment. Most staff were responsive, discreet, respectful and provided appropriate emotional support. Patients had access to a wide range of therapeutic activities.

Safe staffing levels were usually in place and patients did not have escorted leave or activities cancelled. Staff mostly felt well led by managers. Staff were well supported with regular supervision and access to a range of learning and development opportunities. Multi-disciplinary teams worked together well across the services.

Staff across the services were aware and had learned lessons from serious untoward incidents. Staff were aware of types of safeguarding concerns and the reporting procedures.

The four rehabilitation wards that were inspected were very different. Westways provided a really good service that met the patients individual needs. The other wards had a range of different issues where improvement was needed. Across most of the units staff were unable to clearly articulate the model of care being delivered and how the service achieved the outcomes for patients using the services. At Heather Close and the Tony Hillis unit blanket restrictions were in place that did not reflect the individual needs of people using the service. Whilst work was taking place to reduce high risk ligature points, the existing risks were not being mitigated and ligature cutters were not readily available in the event they may need to be used. At Heather Close fire safety precautions were not being fully implemented.

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.

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.