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Provider: East London NHS Foundation Trust Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 26 June 2018

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

  • Since the last inspection in 2016, the trust has continued to make improvements. We inspected three services and carried out a well-led review. In all areas further progress had taken place and in forensic services the rating had improved from good to outstanding.
  • We rated safe and effective as good; caring, responsive and well-led as outstanding. Following this inspection, five of the trust’s fourteen core services were rated as outstanding and nine as good.
  • We rated well-led for the trust overall as outstanding.
  • The trust had addressed most of the areas where improvements were needed from the last inspection. In the inpatient and community services for people with a learning disability staff had received training in positive behaviour support, patients had individualised behaviour support plans and staff were supporting patients who had challenging behaviours appropriately. In the forensic service, the use of restrictive practices, including electronic monitoring for patients leaving the hospital was based on individual needs and not a blanket approach. Where work was still in progress, the trust had clear action plans and was monitoring progress closely.
  • The trust recognised that even though it had a rating of outstanding, that did not mean that all patients, carers or staff had an outstanding experience of care or of working for the trust. They had created a culture where people could share their experiences and concerns and where there was a genuine commitment to learning and making improvements. An example of this was found in the investigation of serious incidents and sharing of learning.
  • The trust has made further progress in the use of a quality improvement methodology. We saw that this methodology gave genuine opportunities for staff and patients in wards and teams to identify areas for improvement and make changes. The use of quality improvement was widespread throughout the trust. The methodology had been extended further to address strategic priorities such as improving care pathways and enhancing staff engagement.
  • The trust board was visionary and confident in performing its role. Board members reflected the diverse communities served by the trust. The chair and non-executive directors were committed to ensuring that patients received the best care possible and used their wide range of skills and experience to challenge the executive directors to deliver high quality services.
  • The trust has continued to grow, and shortly prior to the inspection had taken on the provision of community services in Bedfordshire. The trust worked collaboratively in innovative partnerships with other providers to deliver services in Tower Hamlets and Bedfordshire. The trust recognised the value of partnership working and when other providers could enhance the services delivered to patients.
  • The involvement of patients and carers remained central to the work of the trust. Patients were supported to express their wishes and to be active participants in meetings where their care was discussed. The involvement of patients and carers in the wider work of the trust had developed further since the last inspection. This included access to a range of opportunities to contribute to the trust strategy, support operational aspects of the work of the trust and monitor the services delivered by the trust.
  • The trust had strong governance systems supported by high quality performance information. This meant that at all levels of the organisation staff and members of the board had access to useful information that enabled them to gain assurance and make improvements where needed. This enabled the trust to achieve a balance between assurance and improvement work.

However:

  • We identified a number of areas where the trust can make further improvements.
Inspection areas

Safe

Good

Updated 26 June 2018

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

  • We rated the three services we inspected as good for safe.

  • Services were clean and systems were in place to ensure good standards of infection control.

  • Staff checked premises for risks and had effective plans to manage identified risks.

  • Services had safe staffing levels. Staff vacancy rates were low in the services we inspected. The trust did not use agency staff. Managers could easily arrange for bank staff to cover any vacancies and to provide additional input when this was required to keep patients and staff safe.

  • Staff worked with patients to assess their individual risks and to develop plans to manage risks. Staff were alert to changes of risk and made sure that management plans were updated as necessary.

  • The trust had used the learning from quality improvement projects on the risks of violence and aggression. The trust had innovative systems in place to manage risks to staff working on wards and in the community.

  • The trust ensured that ward staff were committed to only using restrictive interventions, such as restraint and seclusion, as a last resort. Staff received effective training on this and were skilled and experienced.

  • Staff reported incidents when appropriate. Reports of serious incidents were thorough. The trust ensured that staff learnt from incidents.

  • Staff identified and reported any safeguarding concerns.

However:

  • The trust provided a wide range of mandatory training. Although the overall completion of mandatory training was 85%, there were a few topics where the completion rates were below the trust target. Managers knew which staff needed to complete the training.

  • There were still a few cases where systems were not ensuring that medicines were always stored at an appropriate temperature.

Effective

Good

Updated 26 June 2018

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

  • We rated the three services we inspected as good for effective.

  • Care and treatment was tailored to each patient’s needs and followed national guidance. Staff provided medical and psychosocial interventions based on the evidence of effectiveness.

  • The physical healthcare needs of patients were assessed and managed. Staff ensured patients could access specialist health support when this was needed. Staff supported patients to improve their health and wellbeing through physical exercise and healthy eating.

  • Care plans were developed with the patient and reflected their views. Care plans were holistic and focused on the patient’s recovery.

  • Services had effective multi-disciplinary teams, comprised of skilled and experienced staff from the full range of mental health disciplines.

  • Patients on inpatient wards had food and drink which met their needs. Patients could make themselves snacks and drinks.

  • Staff met their legal responsibilities in relation to the Mental Health Act 1983 and the Mental Capacity Act 2005.

However:

  • Although managers ensured that most staff received regular supervision, this was not the case in a small number of teams. However, the quality of supervision was good.

Caring

Outstanding

Updated 26 June 2018

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

  • We rated forensic services as outstanding for caring. We rated mental health wards for people with learning disabilities and community mental health services for people with learning disabilities and/or autism as good for caring.
  • Patients and carers consistently told us that they were treated with respect, kindness and dignity. Staff were always friendly, polite and respectful when speaking with patients. In forensic services, staff were very sensitive and carefully built relationships with patients. The trust respected the contribution patients made to the service and paid patients for the work they undertook.
  • Patients and carers told us they were fully involved in the process of planning their treatment and recovery. Staff always took steps to make sure that patients were supported to communicate their individual needs and preferences effectively and that their views were reflected in care plans. Families and carers were routinely involved in patients’ care and treatment. This included regular telephone contact and attending meetings.
  • In forensic services, patients and staff had co-produced hand books and welcome packs for new patients. Staff provided individually tailored support to ensure that patients felt at ease and could speak freely in meetings with staff about their care and treatment. Patients were always involved in staff interviews and the trust recruited peer support workers to work with patients.
  • Services fully involved patients in planning the development of the service. Patients were supported to meet together to discuss any issues they had with the quality of the service at ward level. In forensic services, patient representatives fed into clinical governance meetings and were partners with staff in making improvements across the service. Patient-led audits took place on the quality of the service. Patients were involved in the development of new policies. There were many examples of patients leading changes in terms of ward activities and meals provision.
  • The trust ensured patients were always involved in quality improvement initiatives. In forensic services, patients were fully involved from start to finish in projects to reduce levels of violence and aggression and the development and implementation of recent policies to reduce restrictive practices in the service.

Responsive

Outstanding

Updated 26 June 2018

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

  • We rated forensic services as outstanding for responsive. We rated mental health wards for people with learning disabilities and/or autism and community mental health services for people with learning disabilities as good for responsive.
  • Services met the needs of patients from diverse backgrounds. Staff could easily access interpreters and information for patients and carers was available in community languages.
  • In community services for people with learning disabilities and/or autism, staff often made home visits so that they could meet the needs of patients and carers. On the mental health ward for people with learning disabilities, the multi-disciplinary team included staff who also worked with patients in the community. Consequently, patients were supported by familiar staff when they transferred between services.
  • Patients in the forensic service could choose from a wide range of educational, vocational, and leisure activities. Patients had the opportunity to develop and practice life skills by attending literacy and computer classes. There were many opportunities for work experience, physical exercise and arts based leisure. New activities, such as a dance class, were arranged at the request of patients. Patients and staff co-produced and co-delivered a recovery college programme. This included workshops on hearing voices, medication, tribunals and legal rights.
  • The low secure forensic wards at Wolfson house had developed a ‘bridge project’ to support patients on discharge into the community and reduce the risk of social isolation. These wards had also introduced self-catering for the evening meal to ensure patients prepared for independence.
  • Patients and carers using all services told us they were aware of the trust’s formal complaints procedure. Feedback from informal and formal complaints was used to learn lessons and make any necessary improvements.

Well-led

Outstanding

Updated 26 June 2018

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

  • Whilst the trust was rated outstanding at the last inspection, it had not stood still and had continued to challenge itself to make further improvements in a wide range of areas including quality improvement and patient participation.
  • The trust had retained an overwhelmingly positive culture. Staff were largely very happy and said how much they enjoyed working for the trust. They valued the open culture and felt that when concerns were raised they were taken seriously and where possible addressed. They also felt supported by the trust’s ‘no blame culture’ and willingness to learn when things went wrong. This was reflected in the results of the staff survey where the trust overall staff engagement score was 3.90. It was better than the national average of 3.79 for trusts of a similar type. The trust recognised that not all teams were as positive as others, and was using the quality improvement methodology to enable those teams to make changes where needed. They were also working to support staff in Luton, Bedfordshire, Richmond and Barnet to feel engaged.
  • The trust was providing more services than at the last inspection and was now delivering community health services in Tower Hamlets and Bedfordshire as part of innovative partnerships. The trust had kept the capacity and capability of senior leaders under review. Leadership had been strengthened to support the services in Luton and Bedfordshire through ongoing engagement with external stakeholders. There was an awareness of where leaders were stretched or might need additional support with delivering aspects of their role.
  • The trust had a dynamic and forward-thinking board. The chair enabled board members to use their skills and experience to provide appropriate levels of challenge when making difficult decisions. All board members were very passionate about their responsibility to ensure the delivery of high quality care.
  • Quality improvement remained central to the work of the trust. The numbers of staff training and using the methodology had continued to grow. Staff could describe the wide range of projects they were working on. Quality improvement methodologies were also being developed to support some of the trust’s strategic priorities such as improving care pathways and access to services.
  • The trust was very proud of the diversity of the communities it served and the staff working in the trust. The board was diverse and the latest staff survey showed small improvements in the scores relating to the workforce race equality standard. Four staff networks were in place for people with protected characteristics and network leads had some protected time to develop these further. The trust recognised that there was work to be done to further develop their commitment to equality, diversity and human rights.
  • People participation was at the centre of the trusts work. Within each directorate, further work had taken place since the previous inspection. Patients and carers had access to a range of opportunities to contribute to the trust strategy, support operational aspects of the work of the trust and monitor the services delivered by the trust. However, further progress was needed to increase the number of peer support workers across the trust.
  • Governors were supported with their role and since the last inspection had improved the systems in place to hold non-executive directors to account. They felt engaged and valued by the trust.
  • The trust had continued to further improve the systems and processes in place to support the governance of the trust including financial governance. This included the further development of the performance report which had become an integrated quality and performance report. This report clearly identified the main issues and the actions being taken by the trust. The board assurance framework had also been improved. This now provided greater clarity about the risks, on the action being taken and the governance processes for ensuring improvements took place. Ward and team managers had access to useful and accurate information to support them manage the services.
  • The trust was continuing to develop its use of technology to promote mobile working for community staff. Communication was enhanced for teams through the use of video conferencing. Staff engagement was supported by access to an easy to use intranet and creative use of social media. Some teething problems in the use of new technology still needed to be ironed out.
Checks on specific services

Child and adolescent mental health wards

Outstanding

Updated 1 September 2016

We rated East London NHS Foundation trust’s child and adolescent mental health wards as outstanding because:

  • Young people received care and support according to their individual and diverse needs. Staff went the extra mile and formed strong relationships with young people and families, who all told us that they were treated with respect, kindness and compassion which promoted their wellbeing. Young people, families and staff worked in true partnership when planning care and setting individual goals.

  • Staff recognised the totality of the needs of each young person and their family. This included their mental and physical health care needs, relationships, education, social, cultural and religious needs. They met each of these with sensitivity.

  • The service was well staffed and staff turnover was low. Vacant shifts were filled by existing staff members or a small group of regular bank staff who were supervised and trained at the Coborn Centre, which ensured continuity of the delivery of care.

  • Staff worked hard to keep young people safe and to support them to improve their health, develop skills and progress towards discharge.

  • Staff were encouraged to be innovative and improve the service. Recent quality improvement work to reduce incidents of violence and aggression had started to lead to a reduction in use of restraint, though this work was ongoing.

  • Young people were actively involved in the running of the service. This included joining staff at the end of a shift to reflect on how this had gone. They could also contribute ideas through a regular group to improve the service and these were being implemented. Young people also helped with staff recruitment.

  • There were many facilities available including use of fitness equipment, a sensory room, art room and other multi purpose rooms. The building was modern and there were various outside spaces which all young people could access. Families could stay in a family suite on the unit if needed.

  • Care records were of a high quality and included input from young people and families. Staff generally had a good understanding of risk and risk assessments were frequently updated.

  • Effective governance processes were in place. Staff also understood safeguarding procedures and reporting of incidents was embedded practice. Incident thresholds were consistent across the service and all staff knew how to report them electronically. We were given examples of learning from incidents that had led to changes to improve the service.

However:

  • All of the young people we spoke with felt that the food was of poor quality and there was lack of choice.

  • Staff did not record the fact that they had read patients their rights in a timely manner after admission or detention under the Mental Health Act nor that risk assessments had been updated before section 17 leave was granted. They also failed to record the duration of incidents of restraint except for those in the prone position.

Community mental health services with learning disabilities or autism

Good

Updated 26 June 2018

A summary of this service appears in the Overall Summary.

Wards for people with a learning disability or autism

Good

Updated 26 June 2018

A summary of this service appears in the Overall Summary.

Forensic inpatient or secure wards

Outstanding

Updated 26 June 2018

A summary of this service appears in the Overall Summary.

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

Updated 7 February 2018

This was a focused inspection and we did not rate the service.

  • The trust had investigated four unexpected deaths and one near-miss incident that occurred in the service in the period from December 2016 to July 2017. The trust had used the learning from these incidents to make significant improvements to the service. The trust had also made progress in addressing the recommendations from the previous inspection in June 2016.

  • The size of Ash ward had been reduced from 27 beds to 19 beds which allowed staff to have better oversight of patients. However, some wards continued to have bed numbers in excess of Royal College of Psychiatrist guidance.

  • Ward procedures had changed across the service with more focus on the security and safety of the wards. Some procedures, for example measures to restrict contraband items and the use of ‘front sheets’ to clearly identify the purpose of increased observations, needed further embedding.

  • The trust was working in partnership with the police to reduce patient access to illegal substances on the wards. Staff had received training on suicide prevention and the management of physical health conditions. A physical health nurse was available to support staff teams to provide appropriate care and treatment for the physical health needs of patients.

  • Staff thoroughly assessed risks to patients and provided care which addressed their needs. There had been improvements in staff updating risk assessments following incidents since our last inspection. Patients reported that staff involved them in planning their care and treatment. Since our previous inspection, the trust had improved patients access to psychological assessment and therapy.

  • The recruitment and retention of nursing staff continued to be problematic for the trust. A number of initiatives were underway to recruit staff. In the interim, the trust had employed locum agency nurses to ensure that patients were cared for by a consistent staff team. Staff reported their morale was good and felt that the service was improving.

  • Overall, medicines were managed safely. At the previous inspection we found that clinic rooms were sometimes hot, which could affect the efficacy and safety of medicines. During this inspection we saw that whilst there had been improvements, the clinic room on Townsend Court had been hotter than the recommended temperature on some occasions and staff had not rectified this.

However, we found the following issues that required further improvement:

  • Staff did not always make the appropriate checks on the physical health of patients after rapid tranquilisation. This may have put the health of patients at risk.

  • Staff were not consistently reporting incidents such as breaches of security. This meant that there may have been lost opportunities to learn from incidents to make improvements to the safety of service.

  • Staff did not keep adequate records on cleaning and maintaining equipment.

  • Staff take up of basic life support and immediate life support training was below 75%. Measures were in place on each ward to mitigate this on each shift.

Mental health crisis services and health-based places of safety

Good

Updated 1 September 2016

We rated the crisis services and health based places of safety as good because:

  • There were good levels of staffing in all the services. There were procedures in place for managers to follow when demand for the service increased. Many staff had worked in the teams for a number of years and knew some of the patients well. The teams made very limited use of temporary staff which promoted good consistency of care.
  • Staff managed cases through daily handover meetings. Everyone in the team participated in these meetings at which patients were reviewed, risks were assessed and patient visits were co-ordinated. There was a clear system for rating the risk patients presented and this was reviewed every day.

  • We observed interactions between staff and patients that were consistently caring, respectful, responsive and included both practical and emotional support. Staff demonstrated a very detailed understanding of individual patient’s needs. There was a collaborative approach to care planning with patients. Care plans focused on patients self-defined needs and objectives. There was a strong focus on recovery in all the care plans.

  • Psychological therapies were available and psychological approaches formed part of the daily professional practice of nurses. Staff reviewed patients’ physical healthcare, including support with blood monitoring for patients with diabetes.

  • Morale, team working and mutual support were strong in all of the teams. Staff spoke very positively about their work and the support they received from colleagues. Staff were supervised regularly and appraisals were carried out annually. There was clear evidence of supervision taking place each month and appraisals took place once a year. Records of appraisals included many positive comments about the employee’s progress and development. There were opportunities for leadership development and career progression.

  • Staff safety was carefully considered. There were good protocols in place for lone working. A new alarm system had been introduced that incorporated an emergency call button to the police and global positioning system (GPS) tracking.

  • The target time for teams to respond to referrals was 24 hours in 80% of referrals. All teams exceeded this target. In some areas, the person being referred was contacted by telephone within four hours. The team responded promptly and adequately when patients contacted the service. There was a dedicated phone line for current patients.

  • Staff took active steps to engage people who may have felt reluctant to use the service. There was a focus on understanding the individual needs, preferences, and context of people’s lives. Staff offered practical support if this was the patient’s priority. Staff were proactive in contacting patients when they did not attend appointments or when they were not in when staff visited. There was a clear procedure for further visits, contacting family or friends with the patient’s consent, contacting the GP and asking the police to conduct a welfare visit.

  • The teams met the individual needs of patients. For example, the use of interpreters was an integral part of service delivery. In one team there were two bi-lingual support workers who spoke the primary community language.

  • Two teams had been accredited by the Royal College of Psychiatrists through the home treatment accreditation scheme since 2012.

However:

  • Patients using the service were sometimes being brought by the police to the health based place of safety from their home, rather than from a public place which was contrary to section 136.
  • Patient records were poorly kept in the health based places of safety which made it hard to know how quickly they were assessed and whether their rights had been explained to them.
  • Home treatment teams were not meeting to share good practice.

  • Whilst risk was managed well, the risk assessment records were not always stored consistently.

  • One home treatment team was not learning from serious incidents.

Community health services for adults

Good

Updated 1 September 2016

Overall we rated this service as good because:

  • Patients and carers fed back that staff were very professional, caring and supportive.

  • Access to the services were well managed through a central point of access who were able to direct patients to the most appropriate team.

  • There was evidence of appropriate treatment across community health services for adults that were delivered in line with national guidance and best practice.Staff had access to evidence-based advice, information and guidance. Staff with specialist skills and knowledge were used by community teams to provide advice or direct support in planning or implementing care. Teams worked together in a coordinated way and made appropriate referrals on to specialised services to ensure that patients’ needs were met. Quality improvement work had been used to reduce the number of patients acquiring a grade 2, 3 and 4 pressure ulcer whilst using the service.

  • Staff could access interpreters and translation services, with patient literature available in languages used by people in the local community and in accessible formats. Staff had a good understanding of the different cultural needs and backgrounds of patients.

  • Most staff in adult community services were positive about their local and trust leadership. All staff were proud to work for the trust and positive about their work. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of service provision.

However:

  • There was an inconsistency in the completion of healthcare records. Assessments, physical health observations, care plans and risk assessments were not always completed and readily available to staff working in the services. This meant that nursing staff may not always have a clear understanding of the risks or a patient’s health status when giving treatment.

  • Some staff were not aware of the term ‘duty of candour’ although they were able to describe how they applied this in practice.

  • Whilst the trust had systems in place for identifying and reporting safeguarding risks, to safeguard people from abuse, staff were not always able to decide the threshold for making an alert.

  • The services were making very limited use of outcome measures as a way of evaluating the progress being made by patients.

  • Staff understood the importance of obtaining the patients’ consent to treatment. Bespoke training had been provided and staff had access to trust MCA advisors. However, some staff lacked confidence in using the Mental Capacity Act.

  • Patients were offered a morning or afternoon appointment slot by the district nurses but would have preferred more information about the time of their appointment.

  • Some patients were waiting a long time to receive a service from the wheelchair team, although this had been identified on the directorate risk register and actions to improve the service were in place.

Specialist community mental health services for children and young people

Outstanding

Updated 1 September 2016

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

  • Staff treated young people and their families as partners in their care. They understood the importance of being kind and respectful. There was genuine empathy and understanding of individual needs and wishes, which was reflected in the work undertaken with young people and their families.

  • Managers supported staff to deliver effective care and treatment. Staff adopted a multi-disciplinary and collaborative approach to care and treatment. There was strong leadership at both local team and service levels, which promoted a positive culture. There was a commitment to continual improvement across the services. Managers recognised the importance of consulting with staff in the development of services.

  • There were clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was evident in all services. Teams considered the review of incidents to be an opportunity for learning. There was good evidence of learning and improvements following incidents both within ELFT and in other trusts. CAMHS teams used learning from national inquiries to make improvements. For example, Lord Laming’s report on the Victoria Climbie. There were regular learning events in teams.

  • Most young people, children and families could access services promptly. Where there were improvements to be made, CAMHS teams had used the quality improvement methodology and had adopted a systematic approach to bring about these improvements. There were robust systems in place in all teams to manage referrals and waiting lists. Staff worked to ensure that young people attended their appointments. The numbers of patients who did not attend were closely monitored.
  • Staff were proactive in identifying trends amongst the young people they worked with and were working collaboration with other agencies to ensure that emerging needs were met. CAMHS staff were forward thinking in their approach and looked at how to improve accessibility for young people who might find it hard to engage. For example they were looking at developing a smartphone application . Staff were doing this in their own time.
  • CAMHS teams were aware of the diverse needs of people using the services. Individual teams had undertaken work to ensure that diverse needs were met. For example, Tower Hamlets CAMHS had looked at the needs of the Bangladeshi community and their access to community services. They produced a report that identified that the young people were under-represented within the client group. City and Hackney CAMHS had identified that African Caribbean boys were at risk of becoming involved in gang related activity and were working with statutory partners and the voluntary sector to target these young people. Groupwork programmes were run in other languages, for example, Bengali.
  • The importance of service user participation was a strong feature of the work undertaken by CAMHS. The participation worker in Luton and Bedfordshire had worked with a young person to write a training package about discrimination and confidentiality. There were specific pilots in other CAMHS teams for phobic children.
  • Teams were conscious of the trends amongst the young people they worked with and endeavoured to respond to these in a timely manner. For example in Bedfordshire, a particular school had reported an increase in the number of young people who had self-harmed. The team had provided training to the school. The team was also running a pilot programme with a school to look at the issues relating to online bullying and with another school regarding child sexual exploitation as there had been an increase in these cases in the county. The team were also working with the National Society for the Prevention of Cruelty to Children to support these young people. There was strong working relationship between Bedfordshire CAMHS and the family nurse partnership (FNP). FNP provide a programme for vulnerable young first time mothers. The partnership between the team and FNP meant that staff were able to offer support to teenage mothers who may be experiencing postpartum depression or other mental health problem.

However:

  • Administrative staff in Luton and Bedfordshire CAMHS experienced low morale. They were going through changes in how their work was delivered.

  • Not all staff had completed safeguarding children levels 2 and 3training although safeguarding practice was good and further training was planned.

Wards for older people with mental health problems

Outstanding

Updated 1 September 2016

We rated wards for older people with mental health problems provided by East London Foundation Trust as outstanding because:

  • Patients received care, treatment and support that met their individual and diverse needs. We received very positive feedback from patients and carers that they were treated with dignity, respect, kindness and compassion. was a caring and person-centred culture throughout the service. Staff were fully committed to working in partnership with patients and carers. Staff engaged with patients in a positive way which promoted their well-being.

  • Patients were cared for in a clean, safe and well-maintained environment. Appropriate furnishings and equipment were available to support the patient group. Environments had been adapted to meet the specific needs of patients, for example appropriate colour schemes, matt flooring, signage and the use of wall art for patients with dementia.

  • There was a recognition of the importance of making sure people were offered food and drinks which met their health needs, was appropriate for their cultural and religious needs and where they received the right support to enjoy their meals.

  • Robust risk management arrangements were in place. Risks were assessed and reviewed regularly to ensure people’s individual needs were being met safely. Monitoring and reviewing risks enabled staff to understand risks and give a clear, accurate and current picture of safety. Patients where able and their carers were involved in managing risks and risk assessments were person-centred and proportionate.

  • A multi-factorial falls prevention assessment tool had been developed by staff working in the service and was used across the wards and had reduced the number of patient falls. Harm caused by physical violence on a number of wards had been reduced through the quality improvement violence reduction programme.

  • Staff knew how to protect patients from harm and were knowledgeable about how to recognise signs of potential abuse and the reporting procedures that were in place. Staff understood their roles and responsibilities to raise concerns and report incidents and near misses.

  • Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. Managers responded to any staff shortages quickly.

  • There was a holistic approach to assessing, planning and delivering care and treatment to patients throughout the service. There was comprehensive monitoring of patients’ physical health needs, advice and guidance was sought from other healthcare professionals as required. Staff worked collaboratively with other professionals in the trust to ensure best outcomes for patients.

  • Patients received care and support from staff that had the required skills, knowledge and training to meet their needs effectively. Staff support was provided through a programme of supervision and appraisal. Specialist training,including how to support people with dementia had been provided. Staff also had access to leadership training and felt they were able to progress their careers.

  • Teams included a range of staff specialities and staff were skilled and experienced working with the patient group.

  • Staff across the service applied the Mental Health Act and Mental Capacity Act legislation appropriately to meet the specific needs of individual patients. A significant number of patients had authorised Deprivation of Liberty Safeguards in place. This helped to ensure they were cared safely but also in the least restrictive way.

  • Patients, carers and family members were involved in the decisions about the care and treatment planned. Carers and relatives were included in meetings, kept well informed and had access to carers groups and training.

  • Services were planned and delivered to take into consideration patient’s individual needs and circumstances in partnership with other teams in the trust, social services and third sector providers. These complex working relationships were effective and supported patients with their ongoing care.

  • A complaints procedure was in place. Staff addressed patients’ concerns and complaints in a timely manner and used learning from them to improve the service.

  • The service had a positive, open and inclusive culture which centred on improving the quality of care patients received through empowerment and involvement. Throughout our inspection we saw that staff embedded the values of the trust in all aspects of their work and spoke about the patients being at the heart of the service.

  • Staff enjoyed working at the service and were committed to providing good quality care and support to patients.

  • There was a strong commitment to quality improvement and innovation from all staff at all levels. Staff took ownership for the QI programme and spoke proudly of the improvements made.

  • Services were developed in line with evidence based practice.
  • The service had been shortlisted for several awards including the National Patient Safety award for missed doses in medication. Staff on Sally Sherman ward were nominated for and won the Nursing Times Award 2015 for the care of older people.

Community health inpatient services

Good

Updated 1 September 2016

Overall we rated this service as good because:

  • Staff promoted the privacy and dignity of patients. We also observed staff to be caring in their interactions with patients. All the patients we spoke with told us that staff were kind and treated them with respect. We did not come across any examples where this was not the case. Patients and relatives felt involved and included.

  • Services were safe. There was a good culture for the timely reporting of incidents including all serious incidents and the trust were able to identify themes and trends across community inpatient services. Safeguarding processes enabled the identification of possible abuse and encouraged reporting. Processes for the safe administration of medication were in place. Patient records were up to date, written legibly, dated and signed. Wards were clean and staff were trained in infection prevention and control. The wards were fully staffed and there were enough staff to meet the needs of the patients. .

  • The wards delivered care in line with current national guidelines. Patients received timely pain relief. Staff understood the importance of nutrition and hydration. Patients received adequate assistance to eat and drink. Staff were also able to access key skills training appropriate to their role.

  • Patient admissions and discharges were appropriately planned and managed to ensure effective care and transition with the acute hospital and community services. Staff understood their roles in regards to patient consent and capacity. There was good multi-disciplinary working and inter-agency working.

  • The wards were meeting the needs of vulnerable people. For example, a range of ‘easy read’ and braille information was available to patients. Community therapy assessments had taken place and the multidisciplinary team was involved in preparations for discharge. Patients reported that their care and treatment needs were being met. It was reported that call bells were responded to appropriately and night staff were also responsive.

  • Staff reported to us that they had confidence in their leadership, who they found responsive, and that members of the executive team were visible. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of service provision.

However:

The treatment rooms where medication was stored were too hot. Trust managers were aware of this and taking steps to ensure the rooms were an appropriate temperature. 

Community-based mental health services for adults of working age

Good

Updated 1 September 2016

We rated community-based mental health services for adults of working age as good because:

  • The services were well led. Staff, patients and carers all felt appropriately engaged. In Luton and Bedfordshire a large and challenging programme of change was being well managed.

  • Staff morale was positive and staff told us that they were involved in developing the service to improve outcomes for patients. Staff also had opportunities for career progression.
  • Staff were clear about their team role and how they managed the patient journey from acceptance by the CMHT to discharge to primary care.
  • Patients told us they were treated with respect and involved in developing their support.

  • There were good links with primary care and key partners such as the police and housing organisations in each locality.
  • Staff supported patients with their physical health and innovative practice such as health pods in team bases were supporting this work.
  • CMHT staff were skilled and experienced and could develop recovery orientated care plans which drew on local resources to ensure patients received effective support.
  • Staff caseloads were manageable and staff said leadership and support in the trust was good.
  • Staff were flexible and responsive to support patients to engage with their services. They were prepared to see people at appropriate times and locations to help them attend appointments.
  • Teams had access to clear information, showing trends and identifying when improvements needed to take place. Teams also made good to use of learning from patient feedback, complaints and incidents to reflect on and improve services.

However:

  • In Newham North recovery team, staff record keeping in relation to medicines required improvement.
  • The CMHT premises for some CMHTs in Bedfordshire were not suitable for patients and staff.
  • In Luton, the CMHTs needed to ensure that record keeping on the outcome of referrals was improved.

  • In Luton, services for people with very complex needs required development.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 1 September 2016

We rated long stay/rehabilitation mental health wards for working age adults as good because:

  • Staff on both wards promoted the privacy and dignity of patients. Staff were kind and caring in their interactions with patients and relatives. All the patients we spoke with were positive about staff and said they treated them with respect. Both wards had a staff member who was the designated carer lead. Patients and relatives felt involved and included in decisions about care and treatment.

  • The wards were safe. Staff reported incidents appropriately and in a timely manner. Staff understood and implemented trust safeguarding procedures. This allowed the identification of possible abuse and protection of patients. Medicines were stored safely and staff administered medicines as prescribed. Wards were clean and staff carried out regular infection control audits.

  • Patients had good access to physical healthcare including access to specialists when needed. Staff used the national early warning score and escalated concerns to medical staff when required. Patients were supported to self-medicate at 105 London Road. Both wards had effective relationships with community care-coordinators and local voluntary sector organisations who provided support to patients on the wards and in the community. Care plans were holistic and person centred.

  • Both wards were spacious with a full range of rooms to support treatment and care. Information on how to complain was displayed in communal areas on both wards. Patients had access to appropriate spiritual support. 105 London Road also had a spiritual kindle for patients to read scriptures on. Staff could access interpreters and knew how to download patient information in different languages.

  • Staff reported to us that they had confidence in their leadership, who they found responsive, and that members of the executive team were visible. Senior managers visited the wards and attended ward team meetings. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of service provision.

However:

  • At 105 London Road, the Section 17 leave documentation did not always make completely clear the extent or boundary of where detained patients could go when they left the ward. Staff told us that leave defined as within the ward boundary also included the local shop which was more than five minutes walk away and outside the boundary of the premises. Also, staff at 105 London Road had not completed a risk assessment of all detained patients immediately before they took section 17 leave.

  • It was difficult for patients to access psychological therapies as there was no psychologist in the multidisciplinary teams. There was a risk that this would limit patients’ access to NICE recommended therapies such as cognitive behaviour therapies and family interventions.

  • Some individual patient care plans did not record clearly defined and measurable recovery goals for all the needs identified. This made it difficult for staff to evaluate the progress patients were making in some areas.

Community-based mental health services for older people

Good

Updated 1 September 2016

We rated community-based mental health services for older people as good because:

  • Staff were providing a safe service. Staff were aware of the risks for individual patients, medication was managed well and staff had a good understanding of safeguarding. Staff were mostly able to see patients in a timely manner and prioritised people who needed urgent support.

  • Staff were consistently caring and showed warmth, kindness and respect to patients and their carers. They provided practical and emotional support. There was good evidence of patient and carer involvement in all aspects of their own care including the development of their care plans. Staff went the extra mile to care for patients in a holistic and person centred way. They were very mindful of peoples needs based on their religion, culture, disabilities and relationships. Training courses and accessible information was provided for patients and carers. The needs of carers were assessed and support groups were provided.

  • Practice reflected current guidance and there was good access to a wide range of interventions. There was good use of outcome measures to monitor if services were effective. Audits that were specific to the service were carried out to provide assurance of robust care with improvements made where needed.

  • Staff morale was very good. They were well supported with access to training, supervision and other opportunities to reflect and learn. Innovations to support staff such as the use of mindfulness were in place. There were opportunities for leadership training and career progression.

  • The teams worked well with GPs, the local authorities and other local services and groups. This enabled patients and their carers to experience a more joined up service.

  • Patients, carers, staff and external stakeholders were encouraged to give feedback through a range of mechanisms and these were used to make improvements.

  • The quality improvement programme in the trust encouraged innovation and examples of this was seen across the services.

However:

  • Whilst achieving targets for assessments and diagnosis for memory clinics were being robustly tackled with action plans in place, there was still work to do to consistently provide a responsive service especially across the Bedfordshire teams.

Community health services for children, young people and families

Good

Updated 1 September 2016

Overall rating for this core service Good because:

  • The children and young people services (CYP) had good processes for reporting and learning from incidents. There were robust child safeguarding systems.
  • Staffing levels were good, with good recruitment and retention of staff. Caseloads were well managed.
  • There were effective systems to protect staff and manage risk appropriately. There was good compliance with hygiene and infection control processes.
  • CYP practitioners provided competent, thorough and evidence based care and treatment in line with national guidance. CYP services used nationally recognised outcome measures to monitor performance.
  • There was effective internal and external multidisciplinary team working.
  • Staff sought patients’ consent to treatment and recorded this appropriately.
  • Staff were supportive and caring of clients and families they worked with, and provided patient-centred support in both clinics and in homes. Clients were very happy with the care and treatment provided.
  • Staff planned and delivered services in line with local needs. Service users could access a range of CYP services in a number of locations. There was good understanding of the different cultural needs and backgrounds of clients. There was good access to translation services. There was good provision of services and support for vulnerable client groups.
  • Staff told us that service leaders were very supportive, accessible and approachable. Staff reflected the trust values and vision. The CYP service worked in partnership with clients and the local community to improve services and health outcomes. There was an appropriate strategy in place for the CYP service.
  • There were really robust governance structures and systems in place for the review of performance and risk management information. The information supported the management of the services and was accurate and in an accessible format. Service changes and improvements took place as a result of these governance processes.
  • Staff really valued working for the trust and there were different ways in which the trust engaged with staff including their participation in focus groups.
  • The trust sought feedback from people using the service and engaged them in work to improve services. Changes were made as a result of this input.
  • The service was constantly innovative and actively participated in quality improvement projects. For example the team supporting patients with sickle cell had initiated and hosted an annual conference for several years to share good practice.

However:

  • The health centres where the CYP services held clinics were not always safe or child friendly. These environments were in the process of being upgraded.
  • Staff did not always recognise the terminology of ‘duty of candour’ although they understood and implemented an open, honest approach which acknowledged with patients when things went wrong.
  • There were insufficient arrangements for client transition from paediatrics to adult services because of uncommissioned gaps for 16-17 year olds in therapy service provision. This was an issue the trust had raised with commissioners.
  • There were some instances of ineffective communication by practitioners; particularly in situations where both practitioner and client did not speak English as a first language.
  • At the time of the inspection some service redesign was taking place as a result of decisions made externally to the trust and a few staff felt that the engagement and consultation linked to this could be improved.