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Provider: South London and Maudsley NHS Foundation Trust Good

Reports


Inspection carried out on 2 July to 16 August 2018

During a routine inspection

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.


CQC inspections of services

Service reports published 23 October 2018
Inspection carried out on 2 July to 16 August 2018 During an inspection of Specialist eating disorder services Download report PDF | 636.74 KB (opens in a new tab)Download report PDF | 1.6 MB (opens in a new tab)
Inspection carried out on 2 July to 16 August 2018 During an inspection of Community-based mental health services for older people Download report PDF | 636.74 KB (opens in a new tab)Download report PDF | 1.6 MB (opens in a new tab)
Inspection carried out on 2 July to 16 August 2018 During an inspection of Neuropsychiatry services Download report PDF | 636.74 KB (opens in a new tab)Download report PDF | 1.6 MB (opens in a new tab)
Inspection carried out on 2 July to 16 August 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 636.74 KB (opens in a new tab)Download report PDF | 1.6 MB (opens in a new tab)
Inspection carried out on 2 July to 16 August 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 636.74 KB (opens in a new tab)Download report PDF | 1.6 MB (opens in a new tab)
Inspection carried out on 2 July to 16 August 2018 During an inspection of Forensic inpatient/secure wards Download report PDF | 636.74 KB (opens in a new tab)Download report PDF | 1.6 MB (opens in a new tab)
See more service reports published 23 October 2018
Service reports published 19 April 2018
Inspection carried out on 1 February 2018 During an inspection of Specialist eating disorder services Download report PDF | 302.25 KB (opens in a new tab)
Service reports published 31 October 2017
Inspection carried out on 17-20 July 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF | 485.05 KB (opens in a new tab)
Service reports published 7 June 2017
Inspection carried out on 13-15 March 2017 During an inspection of Wards for older people with mental health problems Download report PDF | 376.34 KB (opens in a new tab)
Service reports published 5 May 2017
Inspection carried out on 30 January 2017 - 2 February 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 589.33 KB (opens in a new tab)
Service reports published 19 August 2016
Inspection carried out on 18 - 19 May 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 281.87 KB (opens in a new tab)
Service reports published 12 January 2016
Inspection carried out on 23 September 2015 During an inspection of Other specialist services Download report PDF | 201.57 KB (opens in a new tab)
Service reports published 8 January 2016
Inspection carried out on 23-25 September 2015 During an inspection of Community mental health services with learning disabilities or autism Download report PDF | 314.95 KB (opens in a new tab)
Inspection carried out on 21-25 September 2015 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 323.1 KB (opens in a new tab)
Inspection carried out on 22 and 25 September 2015 During an inspection of Wards for people with a learning disability or autism Download report PDF | 291.73 KB (opens in a new tab)
Inspection carried out on 21 – 25 September 2015 During an inspection of Forensic inpatient/secure wards Download report PDF | 301.59 KB (opens in a new tab)
Inspection carried out on 22-24 September 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF | 360.34 KB (opens in a new tab)
Inspection carried out on 21st - 25th September 2015 During an inspection of Community-based mental health services for older people Download report PDF | 302.4 KB (opens in a new tab)
Inspection carried out on 21-25 September 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 351.99 KB (opens in a new tab)
Inspection carried out on 22 – 25 September 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 454.53 KB (opens in a new tab)
Inspection carried out on 9 and 22-24 September 2015 During an inspection of Child and adolescent mental health wards Download report PDF | 329.69 KB (opens in a new tab)
Inspection carried out on 16 September - 25 September 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 318.58 KB (opens in a new tab)
Inspection carried out on 21-25 September 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF | 286.51 KB (opens in a new tab)
See more service reports published 8 January 2016
Inspection carried out on 21-25 September 2015

During a routine inspection

We have given an overall rating to South London and Maudsley NHS Foundation Trust of good.

 

We have rated two of the eleven core services that we inspected as outstanding, six as good and three as requires improvement.  

 

 

The trust has much to be proud of and also some significant areas that need to improve. The trust was well led with a dynamic senior leadership team and board. There were also many committed and enthusiastic senior staff throughout the organisation working hard to manage and improve services. The trust recognised that they needed to focus on getting the basics right and the results of the inspection would confirm that this was correct.

 

The main areas which were positive were as follows:

 

  • Most of the staff we met were very caring, professional and worked tirelessly to support the patients using the services provided by the trust.

  • The trust was supporting patients with their physical health. People had their health assessed in a comprehensive manner and were being supported to have any health care needs addressed.

  • Staff had access to a wide range of opportunities for learning and development, which was helping many staff to make progress with their career whilst also improving the care they delivered to people using the services.

  • The trust was very aware of best practice and was using guidance and research to inform their work. This meant patients were receiving high quality care. For example patients had access to a range of psychological therapies alongside their medical treatment.

  • The trust provided many opportunities for patients to be involved in the running and decision making about services. This input was leading to changes across the services.

 

There were three services that required improvement and on the acute wards for adults of working age the safety was rated as inadequate. The main areas for improvement were as follows:

 

  • The trust had a substantial problem with staff recruitment and retention. There were too few staff to consistently guarantee quality of care especially on the acute wards for working age adults. There were staffing problems in some other areas but these are not as severe.

  • The trust needed to make improvements across most of its services in the documentation of risk for individual patients. This is to ensure the information was readily available, accurate and being followed.

  • The trust must improve its practices in relation to restrictive interventions such as the use of restraint and seclusion.  They have started to tackle this problem but there is much more to be done.  The trust must ensure that staff use restraint only as a last resort, that they minimise the use of restraint in the prone position, that they accurately document and record the use of restrictive interventions.

  • The trust must also make sure that where it has medical equipment, especially for emergency resuscitation that all the necessary equipment is available, maintained and has parts that are in date.

  • The trust had a number of environments that were not safe or where the risks were not being robustly mitigated to keep patients safe.

 

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

 

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.