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Provider: South London and Maudsley NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 30 July 2019

Our rating of the trust stayed the same. We rated it 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 continue making the necessary changes to provide high quality care to their local communities. Since the last inspection, the chair had retired unexpectedly and the deputy chair was acting during the interim while a new permanent chair was appointed. The non-executive directors felt that they were working closely and effectively with the executive directors and were well supported by the interim chair. The chief executive was retiring and a replacement appointed with a well-planned handover due to take place. The new chief executive was coming from a neighbouring trust and so was already familiar with the trust and local partnerships. A director of people and organisational development had been appointed working across two neighbouring trusts.

  • Since the last inspection, the directorate structures and borough-based working for local services had become more embedded. The directorate structures ensured clinical leaders had manageable spans of control. The numbers of matrons across the organisation had been increased to support teams to provide high quality care. This was leading to improved partnership working to address challenges in boroughs with partners to meet the needs of local people.

  • The board had improved oversight of operational issues. The governance processes had been strengthened with each directorate having a monthly quality and performance review. Links with wards and teams were also being strengthened. This was supported by a business information system which made information available in an accessible format at all levels of the organisation. This was enabling achievements and concerns to be escalated appropriately. The trust was identifying problem areas and work was, for the most part, underway to resolve matters.

  • The trust’s active participation in the South London Partnership was continuing to deliver new models of care for patients receiving national and specialist services. This meant that patients were receiving their care closer to home. The success of this work was leading to discussions with clinical commissioning groups about the transfer of budgets for local services.

  • Since the last inspection the trust had launched its strategy ‘Changing lives’. This recognised the needs of the population in the four London boroughs. The strategy also aligned to national priorities and the Five Year Forward View for Mental Health. The strategy stated how the trust will meet the aims of providing high quality services; working in partnership; being a great place to work; promoting innovation and providing value. The strategy had been presented using a range of formats including an excellent film following the lives of five patients and their clinicians talking about how the work of the trust had helped them to improve their lives.

  • The trust was making progress with their quality improvement programme and had set ambitious targets for the next three years. At this inspection, most of the wards and teams we visited spoke with enthusiasm about the quality improvement projects that were taking place. On inpatient wards we saw positive examples of reductions in violence and aggression linked to the ‘four steps to safety’ programme. Over 1000 staff had been trained in QI. Patients and carers were active participants in many of the projects. However, further work was needed to ensure that projects were available on the QI intranet so they could be shared between teams.

  • Staff engagement remained a high priority for the trust. An ambitious programme of leadership walkabouts was continuing to promote good communication. This meant that the leadership team had a good understanding of the challenges being faced by staff working in front-line services and were working to address them. This was particularly apparent in the service transformation work being carried out in adult community mental health services. The trust promoted staff to speak up through the Freedom to Speak Up Guardian and at this inspection there was an improved awareness of this role.

  • The trust, since the last inspection had continued to develop and deliver an equalities strategy. There had been a focus on BME staff experience led by the BME staff network. The trust had plans in place to improve the workforce race equality standards through offering leadership development for BME staff; having BME staff on recruitment panels for all band 7 posts and above; introducing a checklist to enable managers to reflect on whether alternative approaches could take place prior to a disciplinary process. Other networks were less well developed but were being supported to grow. This included an LGBTQ network and one for staff with lived experience.

However:

  • The inspection took place at a time when change was happening for the board and executive leadership team. Whilst it was positive to see the progress that had taken place, further work was needed to ensure effective leadership across wards and teams and for the improvements across the trust to be further embedded.

  • Although the trust had continued with their workforce strategy, staffing remained an issue. There were still a high number of nursing vacancies and staff turnover. Some staff and patients on acute wards told us that patient leave was often cancelled or postponed. Some wards did not have a permanent consultant psychiatrist, although locum arrangements were in place.

  • The trust had improved the experience of working age adults from the local communities who were on the acute care pathway, either as inpatients or under the care of the adult community mental health teams. However, there was more to do to deliver sustainable change. Patients were affected by the ongoing extreme pressures on the acute care pathway. Bed occupancy was above 100% on most wards, which meant staff may not have been able to manage the care of patients safely. There was not always a bed available for someone who needed one. The trust had 300 patients in out-of-area beds between February 2018 and December 2018. We found six incidents where patients in psychiatric intensive care units were ready for discharge to acute wards but were unable to transfer due to the lack of acute beds. This meant patients experienced care at a higher level of security than what was needed.

  • There were a few safety issues particularly on the acute inpatient wards that needed to be addressed to ensure the environments were safe and clean; that patients had their physical health monitored after the administration of rapid tranquilisation; that patient risk assessments were kept updated.

  • Whilst learning from incidents had improved within services and boroughs, there was still scope to further develop the shared learnin
Inspection areas

Safe

Requires improvement

Updated 30 July 2019

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

  • We rated safe as requires improvement in two of the four core services that we inspected on this occasion and good in the other two. When these ratings were combined with the other existing ratings from previous inspections, three of the trust services were rated requires improvement and 11 were rated good.
  • At the time of the last inspection of community based mental health services for adults of working age in July 2017, staff did not assess patients identified as needing a Mental Health Act assessment promptly. During this inspection, this remained an issue with delays in patients having Mental Health Act assessments in a timely manner. However, the trust was monitoring this closely and working with the local authorities and police to make improvements, with a clear message that assessments should never be cancelled due to difficulties in accessing a bed.
  • At the last inspection in July 2018, there were a high number of nursing vacancies and a high staff turnover on some acute and PICU wards. Patients’ leave was postponed or cancelled due to short staffing. At this inspection, although the trust had continued with their recruitment drive, staffing remained an issue. There were still a high number of nursing vacancies and staff turnover on some wards. Some staff and patients told us that patient leave was often cancelled or postponed. Some wards did not have a permanent consultant psychiatrist, although locum arrangements were in place. In perinatal community teams staffing vacancies and retention were having an impact on the consistency of support for patients, waiting times for non-urgent appointments and increased stress on the remaining staff.
  • Although improvements had been made to the environmental risk assessments as required at the last inspection in July 2018, not all environmental risk assessments on the acute and PICU wards had timescales for identified work that needed to take place or a clear person responsible. The use of plastic bin bags in communal areas across the acute wards was not consistent, or always recorded on environmental risk assessments.
  • Although most wards carried out physical health checks on patients after they received rapid tranquilisation as required at the last inspection in July 2018 in line with national guidelines and trust policy, we found three examples where records did not demonstrate staff completed physical health checks on patients following the administration of rapid tranquilisation. Staff did not always record on restraint records if patients received a debrief following a physical restraint.
  • Although the service generally controlled infection control risk well and equipment was clean. Some of the acute and PICU wards were not clean or well-maintained, especially in bathrooms and toilets. Where staff had identified maintenance and repair issues, the trust did not always address these in a timely manner.
  • Although staff in the community teams kept detailed records of patients’ care and treatment, as required at the previous inspection in July 2017, they had not always ensured that key risk assessment and risk management documents were up to date. These documents were not always accurate in relation to the patient’s current circumstances or risks.
  • On two PICU wards we found examples where, while patients had been kept immediately safe, it was not clear that the trust safeguarding policies had been followed, as decisions had been made not to raise safeguarding concerns when they should have been. The trust was working with the wards to ensure safeguarding issues were appropriately alerted in response to our concerns.
  • Incidents and learning from when things go wrong were not always effectively communicated across boroughs, particularly on the PICU wards.
  • Following our findings at the previous inspection of rehabilitation wards in September 2015, there had been a review of blanket restrictions on the wards, but staff on one ward were not clear about how these implementing this in practice. We also found that patients on rehabilitation wards who had been reluctant to leave the ward during fire drills, did not have a personal emergency evacuation plan in place to ensure that staff knew how to support them in the event of a fire.
  • The Trust medicine management audits for community mental health services had not picked up concerns we found relating to management of prescription stationery, antipsychotic medicines prescribed for patients on a community treatment order, and monitoring of medicines in stock at each service. On one rehabilitation ward we found that there was insufficient storage space in the clinic room for patients’ medicines.

However:

  • Staff assessed and managed risks to patients and themselves. Risks to patients were discussed in multidisciplinary meetings, individual reviews, and handovers meetings. Staff responded promptly to sudden deterioration in a patient’s health. In community teams, when necessary, staff worked with patients and their families and carers to develop crisis plans. Staff monitored patients on waiting lists to detect and respond to increases in the level of risk. Staff followed good personal safety protocols. At our last inspection in July 2018, on one acute ward staff failed to record observations of a patient who required intermittent monitoring. At this inspection, this was no longer an issue. Staff recorded observations of patients as prescribed by the multidisciplinary team.
  • The trust had worked hard to implement plans to reduce the number of patients being restrained. Since our last inspection in July 2018, the proportion of restraints that involved patients being restrained in the prone position had decreased from 54% to 39%. Staff were aware of the provider’s restrictive interventions reduction programme and some wards had participated in Safe wards (a quality improvement initiative). The quality of the recording of patient restraint had improved across the wards.
  • Most clinical premises where patients received care were safe, well equipped, furnished and maintained, and fit for purpose. Staff used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health. At our last inspection of acute and PICU wards in July 2018, we found that patients on one ward did not have direct access to drinking water, and the service had not anticipated the expiry date of some items of emergency equipment. At this inspection, these issues had been addressed. Emergency equipment was well-maintained and were within its expiry date.
  • At the last inspection of rehabilitation wards in September 2015, we identified risks with ligature points and fire safety arrangements. Improvements had been made to ensure the physical environment was safely managed. Staff ensured that improvements were made in how mixed-sex wards were controlled.
  • At the 2015 inspection we also found that staff on the rehabilitation wards had not felt supported by management when staffing vacancies were high. At the current inspection we found that the service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm. In the community mental health teams, the number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed.
  • At the last inspection of acute and PICU wards in July 2018, staff did not always identify and report patient safety incidents. At this inspection, there had been an improvement. Staff were pro-active in reporting incidents of restraint and rapid tranquilisation. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. However, the learning from incidents was still being embedded on the rehabilitation wards and some PICU wards, and some staff found it hard to articulate the changes that had taken place in response to this learning.

Effective

Good

Updated 30 July 2019

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

  • At this inspection we rated effective as good in two of the four core services and requires improvement in two core services. When these ratings were combined with the other existing ratings from previous inspections, 10 of the trust services were rated good, two were rated outstanding and two were rated requires improvement.
  • At the last inspection of community services in July 2017, we found that patients did not always have person-centred care plans. At the current inspection we found that staff in all services assessed the physical and mental health of all patients promptly. Most care plans were personalised, holistic and recovery-orientated. We saw good examples of community and inpatient care plans that were holistic and addressed the patient’s mental health, physical health, and relationships including their sexual orientation, and accessing the community. Staff involved patient’s family members or carers when possible. There were separate care plans in place for babies in the mother and baby unit.
  • Staff supported patients to live healthier lives including smoking cessation. Most patients on the wards could access a gym and could access a healthy living group.
  • Staff from different disciplines worked together as a team to benefit patients. Staff held regular and effective multidisciplinary team meetings, where patients’ care and treatment were comprehensively discussed. Staff supported each other to make sure patients had no gaps in their care. Managers supported staff with appraisals, supervision and opportunities to update and further develop their skills. The teams had effective working relationships with other relevant teams within and outside of the trust.
  • Staff provided a range of treatment and care for the patients based on national guidance and best practice. They used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit, benchmarking and quality improvement initiatives.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice.
  • Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

However:

  • On the rehabilitation wards, patients’ care plans did not reflect work to provide rehabilitation with a view to discharge, until near to the time when patients were being discharged. This meant that most patients did not have achievable goals designed to support their recovery. Although staff provided some interventions to support patients on these wards to develop everyday living skills, this was limited. Only one rehabilitation ward was supporting some patients to take their medicines independently, and support with self-catering was not sufficiently developed to promote patients to be fully independent in this area.
  • In several community mental health teams, we found examples where community team staff had not updated the care plan document since the patient had been transferred to the team from an inpatient ward, so their current relevant needs had not been assessed.
  • Whilst staff understood their roles and responsibilities under the Mental Health Act 1983 and Code of Practice these were not always discharged well. There were delays in requesting a second opinion appointed doctor and staff had not ensured that some patients had legally consented to medicines prescribed to them, on some acute and PICU, and rehabilitation wards. On the rehabilitation wards staff did not always know when they should explain a patients’ rights to them or record this. In the community teams, record keeping in relation to patients who were subject to a Mental Health Act community treatment order required improvement.
  • At the last inspection of acute and PICU wards in July 2018, some wards did not always carry out physical observations of patients with specific health needs. At this inspection, progress had been made, but there was still room for improvement in completing records of blood glucose monitoring and fluid charts for patients and supporting patients who had a high body mass index.
  • At the last two inspections in January 2017 and July 2018, on the acute and PICU wards we found that staff supervision rates were low. At this inspection, although supervision had improved on most wards, it was still particularly low on some wards. It had also been low on the mother and baby unit in recent months. Staff reported that this was due to staffing shortages.
  • At the last inspection of acute and PICU wards in July 2018, we found that although staff had access to training in caring for patients with learning disabilities, this training did not specifically include autism. There were a number of patients with autism admitted to the wards, and staff said they did not have access to autism training. At this inspection, most staff had not received autism training, but since our inspection, the trust had established an autism training programme for all acute and PICU wards. We also found that the rehabilitation wards could offer a service to patients with autism, but staff had not received training to meet their specific needs.
  • Psychology support varied across the team. One rehabilitation ward did not have a psychologist in place to support patients for eight months. On most acute wards psychology input was low with one psychologist working across several wards. Although there had been an increase in psychology input to some community teams since our last inspection, some patients in early intervention teams could still wait over a year for individual therapy. In perinatal teams waits for psychological therapies did not always meet the recommended timeframes. Group work was being offered to support patients in the interim period.

Caring

Good

Updated 30 July 2019

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

  • At this inspection we rated caring as good in all four core services. When these ratings were combined with the other existing ratings from previous inspections, 12 of the trust services were rated good, and two were rated outstanding.
  • Staff treated patients, families and carers with compassion and kindness. They demonstrated a good understanding of patients’ and carers’ needs and interacted with them in a respectful and receptive way. Staff communicated well with patients so that they understood their care and treatment.
  • Staff involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. Patients’ views were incorporated, even when they differed from the clinical teams. They ensured that patients had easy access to independent advocates, and wards held regular community meetings at which patients were encouraged to give feedback. The perinatal community teams had recently set up a service user forum across all four boroughs. Patients across the services provided feedback and input on services, training and policies and helped with recruitment.
  • Staff informed and involved families and carers appropriately. Staff invited families and carers to attend patient multidisciplinary team meetings and gained their feedback on the service they received via surveys. Acute wards at the Bethlem hospital held regular carer’s forums. Staff at Westways (one of the rehabilitation units) were establishing a family/carer user group to better understand their views. The trust facilitated service user and carer advisory groups as a way of involving patients and carers in the development of the services.
  • At the last inspection in July 2018, patients on two wards said that some staff did not seem to care about them, were disrespectful towards them or too busy to help them promptly. At this inspection, this was no longer an issue and were very complimentary about the way they were treated by staff.
  • At the last inspection in July 2018, we found that confidential information was visible to people standing outside the nurses’ office on two wards. At this inspection, this was no longer an issue.

However:

  • The trust did not have a standardised method for staff to record that the patient had been given a copy of their care plan unless they were under the Care Programme Approach review.

Responsive

Good

Updated 30 July 2019

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

  • At this inspection we rated responsive as requires improvement in two of the four core services and good in the other two services. When these ratings were combined with the other existing ratings from previous inspections, two of the trust services were rated requires improvement and 12 were rated good.
  • At the last inspection in July 2018, 20% of patient discharges from the acute wards were delayed, and staff had not always been proactive in addressing barriers to patients being discharged. At the current inspection, there had been an improvement. Three percent of patient discharges were delayed, and staff were demonstrably proactive in addressing barriers to patients being discharged.
  • The community services were easy to access, with referral criteria that did not exclude patients who would have benefitted from care. Staff assessed and treated patients who required urgent care promptly and patients who did not require urgent care did not wait too long to start treatment. Staff followed up patients who missed appointments.
  • Staff took account of patients’ individual needs including those with a protected characteristic. Services provided interpreters for patients whenever this was needed, to support patients at ward rounds and in other aspects of their care. Staff helped patients with communication, advocacy and cultural and spiritual support.
  • The design, layout, and furnishings of the units supported patients’ treatment, privacy and dignity. Each patient had their own bedroom and could keep their personal belongings safe. The community services, and most wards were accessible to patients with physical disabilities and mobility issues.
  • Staff ensured patients had a choice of food to meet the dietary requirements of different religious, cultural and personal needs. Patients on most wards were satisfied with the quality and choice of food provided.
  • The ward teams had effective working relationships with staff from services that would provide aftercare following the patient’s discharge and engaged with them at admission and when patients were ready for discharge. Some patients were accessing community-based activities that promoted their rehabilitation.
  • The services treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff, although on Rosa Parks Ward complainants were not always kept up to date about the status of their complaint.

However:

  • Although there had been improvement since our last inspection in July 2017, the Croydon assessment and liaison team was unable to meet their target for assessing non-urgent referrals within 28 days and the team had a long waiting list of over 550 triaged non-urgent at the time of inspection
  • The service needed to further improve its bed management of the acute wards and PICUs. Bed occupancy was above 100% on most wards, which meant staff may not have been able to manage the care of patients safely. There was not always a bed available for someone who needed one. The trust had 300 patients in out-of-area beds between February 2018 and December 2018. We found six incidents where patients in psychiatric intensive care units were ready for discharge to acute wards but were unable to transfer due to lack of acute beds. This meant patients experienced care at a higher level of security than what was needed.
  • At the last inspection in July 2018, there was not always a bed available for patients returning from leave. At this inspection, although the number of incidents had decreased significantly, and senior managers had good oversight, there were still four occasions where a bed was not available when patients returned from leave.
  • The length of stay on the rehabilitation wards was very variable. Whilst the aim was for the length of stay to be under a year, several patients had been on the wards for a number of years. However, there were plans being developed with the South London Partnership to reconfigure the rehabilitation model and address this.
  • There were shortfalls in the environment on some wards and in some community teams. The facilities on LEO Unit (acute ward) did not always promote patients’ privacy and dignity. Some bedroom doors did not give patients the option to close vision into their bedrooms, therefore staff and patients passing by could see into their bedrooms. On the mother and baby unit there was a lack of ensuite facilities, an insufficiently sized nursery, lack of safe garden space, and not enough space for patients to meet with visitors. The trust had a long-term estate strategy, 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.
  • Some patients on the rehabilitation wards were not satisfied with the quality of food or the choices available to them, although work was underway to improve food provision.

Well-led

Good

Updated 30 July 2019

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

  • At this inspection we rated well-led as requires improvement in one of the four core services and good in the other three services. When these ratings were combined with the other existing ratings from previous inspections, one of the trust services was rated requires improvement, 11 were rated good, and three were rated outstanding.
  • At the last inspection we found that, 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. There had been breaches of fundamental standards of care and on the acute wards with some patients sleeping on couches. At this inspection we found that the trust board and senior leaders had implemented changes that were improving care. Considerable work had already taken place but there was more to do to deliver sustainable change.
  • The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to continue making the necessary changes to provide high quality care to their local communities. Since the last inspection the chair had unexpectedly retired and the deputy chair was acting during the interim while a new permanent chair was appointed. The non-executive directors felt that they were working closely and effectively with the executive directors and were well supported by the interim chair. The chief executive was retiring and a replacement appointed with a well-planned handover due to take place. The new chief executive was coming from a neighbouring trust and so was already familiar with the trust and local partnerships. A director of people and organisational development had been appointed working across two neighbouring trusts.
  • Since the last inspection the directorate structures and borough-based working for local services had become more embedded. The directorate structures ensured clinical leaders had manageable spans of control. The numbers of matrons across the organisation had been increased to support teams to provide high quality care. This was leading to improved partnership working to address challenges in boroughs with partners to meet the needs of local people.
  • The board had improved oversight of operational issues. The governance processes had been strengthened with each directorate having a monthly quality and performance review. Links with wards and teams were also being strengthened. This was supported by a business information system which made information available in an accessible format at all levels of the organisation. This was enabling achievements and concerns to be escalated appropriately. The trust was identifying problem areas and work was, for the most part, underway to resolve matters.
  • The trust’s active participation in the South London Partnership was continuing to deliver new models of care for patients receiving national and specialist services. This meant that patients were receiving their care closer to home. The success of this work was leading to discussions with clinical commissioning groups about the transfer of budgets for local services.
  • Since the last inspection the trust had launched its strategy ‘Changing lives’. This recognised the needs of the population in the four London boroughs. The strategy also aligned to national priorities and the Five Year Forward View for Mental Health. The strategy stated how the trust will meet the aims of providing quality services; working in partnership; being a great place to work; promoting innovation and providing value. The strategy had been presented using a range of formats including an excellent film following the lives of five patients and their clinicians talking about how the work of the trust had helped them to improve their lives.
  • The trust was making progress with their quality improvement programme and had set ambitious targets for the next three years. At this inspection most of the wards and teams we visited spoke with enthusiasm about the quality improvement projects that were taking place. On inpatient wards we saw positive examples of reductions in violence and aggression linked to the ‘four steps to safety’ programme. Over 1000 staff had been trained in QI. Patients and carers were active participants in many of the projects. However, further work was needed to ensure that projects were available on the QI intranet so they could be shared between teams.
  • Staff engagement remained a high priority for the trust. An ambitious programme of leadership walkabouts was continuing to promote good communication. This meant that the leadership team had a good understanding of the challenges being faced by staff working in front-line services and were working to address them. This was particularly apparent in the service transformation work being carried out in adult community mental health services. The trust promoted staff to speak up through the Freedom to Speak Up Guardian and at this inspection there was an improved awareness of this role.
  • The trust, since the last inspection had continued to develop and deliver an equalities strategy. There had been a particular focus on BME staff experience led by the BME staff network. The trust had plans in place to improve the workforce race equality standards through offering leadership development for BME staff; having BME staff on recruitment panels for all band 7 posts and above; introducing a checklist to enable managers to reflect on whether alternative approaches could take place prior to a disciplinary process. Other networks were less well developed but were bring supported to grow. This included an LGBTQ network and one for staff with lived experience.

However:

  • The inspection took place at a time when change was happening for the board and executive leadership team. Whilst it was positive to see the progress that had taken place, further work was needed to ensure effective leadership across wards and teams and for the improvements across the trust to be further embedded. The trust recognised that continuing to improve the care of patients receiving acute care and treatment remained an ongoing priority.
  • Services did not use a recognised model of rehabilitation care on each rehabilitation unit and did not have a clear overarching rehabilitation strategy. Most staff did not understand the model of care provided. Some interventions to support the development of independent living skills and support their rehabilitation and recovery were quite limited.
  • At the last inspection in July 2018, eight of the acute and PICU wards did not have a permanent ward manager, which led to a lack of stability. At this inspection, there had been an improvement, and the trust had worked hard to recruit into these posts. However, there were five wards that did not have a permanent ward manager. The interim ward managers told us they were being supported by senior managers. Whilst progress had been made the five ward managers and three consultant psychiatrist posts needed to be filled to strengthen the leadership across the acute wards.
Checks on specific services

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.

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

Requires improvement

Updated 30 July 2019

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

  • Although the trust had made improvements since our last inspection in July 2018, there were still areas that required improvement.
  • The trust had continued with their recruitment drive. However, staffing remained an issue. Some wards had high number of nursing vacancies and some wards had consultant psychiatrist and ward manager vacancies. Some wards had high staff turnover rates. This impacted on the stability of teams and the consistency of patient care and experience.
  • The service needed to improve bed management on the acute wards and PICUs. Bed occupancy was above 100% on most wards. In the last 12 months, the trust had 300 patients in out-of-area beds. There were six incidents where patients in PICUs were ready for discharge to acute wards but were unable to transfer due to lack of acute beds. This meant patients experienced care at a higher level of security than what was needed.
  • At the last inspection in July 2018, there was not always a bed available for patients returning from leave. At this inspection, although the number of incidents had decreased significantly, and senior managers had good oversight, there were still four occasions where a bed was not available when patients returned from leave.
  • Although improvements had been made to the environmental risk assessments, the trust had not ensured all environmental risk assessments had timescales for identified work that needed to take place. The trust did not have clear information about who was going to take responsibility for these actions. The use of plastic bin bags, which can present a safety risk for some patients, in communal areas across the acute wards was not consistent. Plastic bags in communal areas were not always identified on the wards’ environmental risk assessment.
  • Although most wards carried out physical health checks on patients after they received rapid tranquilisation, in line with national guidelines and trust policy, we found three examples where this was not always the case.
  • Some of the wards were not clean or well-maintained, especially in bathrooms and toilets.
  • The service did not always provide support to staff to ensure they had the necessary skills to support patients. Not all staff had access to autism training despite caring for some patients with autism on the wards. The trust had recently established an autism training programme for acute/PICU wards, but staff from some wards had not yet been provided with the training. Supervision had improved since our last inspection, however, it remained low on some wards.
  • Managers did not always ensure that lessons learned from the investigation of incidents and adverse events that happened on the PICUs was communicated across boroughs.
  • Some wards did not always follow the trust safeguarding policy. We found examples on ES1 and Eden Ward, where safeguarding alerts had not been escalated.
  • On some wards, staff did not always request an opinion from a second opinion appointed doctor in a timely manner. Not all patients’ physical health treatment was included on their certificate of consent to treatment, therefore it was not clear from the records what legal authority was relied upon to permit this treatment.
  • Although improvements had been made in supporting patients with specific physical health needs, we still found examples where recording of blood glucose monitoring and fluid charts were incomplete.

However:

  • The trust had made improvements in many areas identified at the previous inspection. These areas included ensuring all patient restraints were recorded in sufficient detail, improved recording of patient observations and incident reporting, appropriate checking of emergency equipment, ensuring that patient information was not visible to other patients on Nelson Ward, and ensuring that staff on Croydon PICU and Aubrey Lewis 2 demonstrated kindness and compassion in their interactions towards patients.
  • Most staff told us that the trust’s move to a borough-based structure had improved their way of working. Staff said senior managers were much more visible and approachable on the wards. Senior managers said they had better oversight of the wards, and communication had improved from ward to board. Staff told us that the culture had also improved since the last inspection, in particular the trust promoted a more positive and open culture.
  • At the last inspection in July 2018, whilst governance systems and processes could identify the wards at risk of not delivering high quality care and treatment, appropriate support had not been put in place. At this inspection, improvements had been made. We found the trust had implemented support plans for wards that needed to improve. Managers had a greater oversight of the wards, which led to less variation in the quality and safety of care and treatment being delivered between wards.
  • The trust had worked hard to implement plans to reduce the number of patients being restrained. Since our last inspection in July 2018, the proportion of restraints that involved patients being restrained in the prone position had decreased. Staff were aware of the provider’s restrictive interventions reduction programme.
  • At our previous inspection in August 2018, staff restricted patients on Johnson Ward’s access to drinking water. At this inspection, we found that this was not the case on any of the wards we visited.
  • The trust had made improvements to delayed patient discharges since our last inspection in July 2018. There had been a 17% decrease in the number of delayed discharges and staff were proactive in addressing barriers to patients being discharged.
  • Most care plans were personalised, holistic and recovery orientated. We saw good examples of care plans that included needs such as mental health, physical health, LGBT+ and accessing the community.
  • Staff treated patients, families and carers with compassion and kindness. Staff demonstrated a good understanding of patients’ and carers’ needs and interacted with them in a respectful and responsive way.

Community-based mental health services for adults of working age

Requires improvement

Updated 30 July 2019

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

  • Although staff kept detailed records of patients’ care and treatment, they had not always ensured that key risk assessment and risk management documents were up to date. These documents were not always accurate in relation to the patient’s current circumstances or risks.
  • At the last inspection in July 2017, patients identified as in need of a Mental Health Act assessment were not assessed promptly. During this inspection, this remained an issue. There were still delays with patients getting Mental Health Act assessments done in a timely manner. However, the trust was monitoring this closely and working with the local authorities and police to make ongoing improvements. They had also given a clear message that assessments should never be cancelled due to difficulties in accessing a bed.
  • Although there had been improvement since our last inspection, the Croydon assessment and liaison team was unable to meet their target for assessing non-urgent referrals within 28 days and the team had a long waiting list of over 550 non-urgent cases.However, the teams did have systems in place to monitor patients on the waiting list.
  • The trust did not have effective medicine management audits, monitoring of prescribing and prescription stationery management.

However:

  • The service provided safe care. The premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. 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 the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
  • The service was easy to access. Staff assessed and treated patients who required urgent care promptly and most patients who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care. Governance processes ensured that that procedures relating to the work of the service ran smoothly.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.