South London and Maudsley NHS Foundation Trust

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

There was a breach of regulation 17(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although there were processes in place, oversight by managers of staffing numbers on the ward at weekends, was not sufficient prior to the inspection, to ensure the safety of patients and staff. There was insufficient monitoring of compliance with the trust policy on patients absent without leave, including recording around decisions made when a patient subject to restrictions did not return from leave on time. This was a breach of regulation 17(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the provider indicated that the clinical application of this policy had been reiterated to the clinical team.

The ward manager was committed to improving safety and providing high quality care. Managers were accessible to patients and staff. Staff came from diverse backgrounds. The governance system ensured that senior managers and clinical leaders had sight of most areas of practice requiring improvement. There was a clear framework to structure ward business meetings. This framework included a range of quality indicators and discussions regarding learning from incidents and complaints. Managers had good access to information about the performance of their ward. There were monthly team meetings where staff had the opportunity to raise any concerns. Patients and carers had the opportunity to give feedback on the service.

The ward was part of the forensic service’s strategy to continually improve the quality of care and treatment provided to patients, including quality improvement projects in physical health support.

As part of the trust modernisation programme to improve mental health services and facilities, Lambeth Hospital was expected to close in 2025 and the Ward in the Community was scheduled to relocate to the Bethlem Royal Hospital. Some staff expressed concerns about the forthcoming move, and how this would affect them, indicating the need for an equality impact assessment for staff affected by the move.

Managers met regularly to discuss patient care and treatment as well as discharge arrangements and held a local risk register for the ward. Staff knew how to use the whistle blowing process and how to contact the freedom to speak up guardian. Leaders were visible in the service and approachable for patients and staff, and leadership development opportunities were available.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

Staff told us they felt comfortable to raise concerns with their manager and that they would be listened to and that any concerns they raised would be addressed. Staff spoke positively about opportunities for professional development. There were development opportunities available for both qualified and unqualified staff. The ward accepted student placements and encouraged students to join the trust once they had completed their course.

Staff appraisals included conversations about career progression where relevant and how they could support staff development.

Staff were aware that they could access support for their own physical and emotional health needs through the trust’s occupational health service. Staff were also able to access support and advice through the employee assistance line.

Leaders had the skills, knowledge and experience to perform their roles and had a good understanding of the ward. The ward manager understood how their ward was performing in terms of quality outcomes for patients as well as the condition of the environment.

Although leaders understood what the local risks were and had quality assurance measures in place, at the time of the inspection, oversight was not sufficient to ensure safe and effective staffing at weekends. Leaders were clear that their priority was to ensure a high-quality service to support patients to become well and learn to live independently.

Leaders were visible in the service and approachable for patients and staff. Leadership development opportunities were available, including opportunities for staff below ward manager level. There were managerial courses for deputy managers as well as for band 5 nurses to progress to be band 6 nurses. The trust also ran a preceptorship programme. Bands 2, 3 and 4 support workers had opportunities to study and obtain the care certificate. The trust also ran an associate practitioner programme for support workers, which could allow them to qualify as nurses.

Leaders were preparing for the ward to move location to a new ward environment, although this had been repeatedly delayed. They also noted changing pressures on forensic and general adult pathways over time, which had led to a review and redesign of the model of care for the ward to ensure that the service met patients’ needs. A working group was meeting regularly to review the wards rehabilitation model and related operational policy. This review included working with patients, carers, staff and other stakeholders with the aim of developing a holistic rehabilitation model to improve patient outcomes and reflect current needs and priorities.

Staff did not report any cases of bullying or harassment on the ward and told us that they felt supported by their colleagues. Staff knew how to use the whistle blowing process and how to contact the freedom to speak up guardian. A copy of this was available on the trust intranet and the contact details were displayed on the ward.

Staff did not express any concerns about workforce equality, diversity and inclusion. They noted that a celebration for Black History Month had recently been held on the ward. Following a recent incident on the ward, staff said they were careful to ensure that sufficient male staff were always on duty.

Some staff expressed concerns about the forthcoming move of the ward to the Bethlem hospital, and how this would affect them, indicating the need for an equality impact assessment for staff affected by the move.

The staff survey from 2023 indicated most positive feedback of 7.6 regarding the service being compassionate and inclusive, 7.4 regarding staff engagement and 7.3 for teamwork. The least positive feedback was for staff morale at 6.1.

Although there were processes in place, oversight by managers of staffing numbers on the ward at weekends, was not sufficient prior to the inspection, to ensure the safety of patients and staff. There was also insufficient oversight of recording around decisions made when a patient subject to restrictions did not return from leave on time. There was insufficient monitoring of compliance with the trust policy on patients absent without leave, including recording around decisions made when a patient subject to restrictions did not return from leave on time. This was a breach of regulation 17(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the provider indicated that the clinical application of this policy had been reiterated to the clinical team.

As part of the trust modernisation programme to improve mental health services and facilities, Lambeth Hospital was expected to close in 2025 and the Ward in the Community was scheduled to relocate to the Bethlem Royal Hospital. Managers indicated that the number of patients on the ward would remain at 13 (at least initially) when the move took place to the Bethlem, to make the transition more manageable.

There was a clear framework for the discussion of important information such as learning from incidents, complaints, audits and alerts and staff met regularly at business team meeting to discuss this. The ward matron was the champion for complaints and whistleblowing concerns. Only 3 complaints had been received since 2021. Performance and quality inpatient meetings were held monthly to look at the ward’s performance with an action plan put in place to address any areas for improvement noted.

Staff had implemented recommendations from reviews of deaths, incidents, complaints and safeguarding alerts at the service level. There was immediate learning each time a serious incident occurred. Staff participated in practice assurance visits to other wards to check fundamental standards of care as well as local audits.

Managers met regularly to discuss patient care and treatment as well as discharge arrangements and held a local risk register for the ward. Staff at ward level escalated concerns to the manager who assessed the risk and added risks to the register if they met agreed criteria.

The service had plans for emergencies. This included contingency arrangements for adverse events. The continuity plans included basic instructions for staff to follow in the event of a major incident, or disruption to the ward due to loss of utilities and inadequate staff cover.

Staff kept patients up-to date by displaying information on notice boards as well as discussion of any relevant matters during community meetings and one-to-one sessions. There were monthly team meetings where staff had the opportunity to raise any concerns.

Patients and carers had the opportunity to give feedback on the service. There was a patient representative on the ward who the trust regularly engaged with to seek feedback as well as ideas for changes to the services, and patients were asked to participate in questionnaires.

Staff used feedback from patients and carers to bring about improvements on the ward.

Quality improvement projects that the ward were involved in, alongside the other forensic wards, including work on physical health improvement and substance misuse support, which was a particular issue within the local neighbourhood. They continued to look at reducing restrictive practices. The ward also continued to embed SafeWards - a model of care that aims to minimize conflict and reduce the need for coercive interventions by addressing factors that can lead to triggers for conflict.