East London NHS Foundation Trust

We rated the East London NHS Foundation Trust wards for people with learning disabilities or autism as good because:

• The intensive support team that staffed the ward, provided a unique service model to support patients in the community before and after admission to the Coppice, and worked on preventing crises and hospital admissions.

• Staff worked constructively with patients and their representatives to involve them in planning their care and treatment.

• Staff interacted with patients in ways which enhanced their dignity, independence and confidence.

• Staff described a positive working environment and constructive working relationships with multi-disciplinary team (MDT) colleagues.

  The environment had been risk assessed to ensure patients’ safety and there were plans in place for redecoration.

• Staff worked effectively with commissioners in relation to the admission and discharge of patients.

However:

• Patients using the service did not have care plans that incorporated positive behaviour support approach. Training was planned for staff on this approach but had not been fully implemented.

• Plans were in place to provide more multi-disciplinary input to the service, especially psychology, but at the time of the inspection this was not fully implemented.

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.

We have given an overall rating to East London NHS Foundation Trust of outstanding because:

• We have rated four of the fourteen core services that we inspected as outstanding and ten as good.

• The trust is well led with a visionary board and senior leadership team who have created an open culture that welcomes innovation. There are hard working and enthusiastic staff throughout the organisation who enjoy their work and are committed to improving services. Sitting alongside this are clear systems of assurance that enable the trust to get things right.

• The trust has invested over the previous two years in a wide scale quality improvement programme. This has been embraced by staff working in the trust. The methodology has successfully encouraged innovation and improvement which we were able to see throughout the inspection. There was a genuine passion to ensure that the services provided are the best possible.

• Staff worked with patients and their carers to ensure they were partners in their care. Patients were supported to express their wishes. They were active participants in all the meetings where their care was discussed. But more than this, patients were actively involved in the running of the trust. Opportunities were in place throughout the organisation to promote this participation. Examples included patients helping to recruit and train staff. Also patients developed and helped with audits and other quality checks.

• The trust was mindful of the need to provide the safest care possible. This included making the buildings where care was delivered as safe as possible, providing enough appropriately trained staff, ensuring equipment is in good condition and ensuring all staff considered potential risks for people receiving care.

• Staff were genuinely engaged in the work of the trust. Many staff had worked at the trust for a number of years and said they would not want to work anywhere else. They knew the senior staff in the organisation, feel it was non-hierachical and said they could raise concerns or ideas in the knowledge that they would be taken seriously.

• Staff had access to a wide range of opportunities for learning and development, especially leadership training, which had helped many staff to make progress with their career whilst also improving the care they delivered to people using the services. Staff from East London had helped manage the changes in Luton and Bedfordshire which had provided them with opportunities to develop their leadership skills.

• The trust staff understood the importance of supporting patients with their physical as well as their mental health. In Newham this was made easier as the trust provided mental health and community services. There was positive work taking place to facilitate close working with GPs. Innovative work was taking place to promote good physical healthcare for patients, for example arranging health screenings for female patients.

• The trust staff worked well with commissioners and other statutory and third sector providers to make sure the best services were provided and to support patients to access all the services they need.

• The trust recognised and celebrated the diversity of the patients and staff and worked to meet the needs of people using the services. There were a lot of exciting initiatives to meet the needs of people using the trust’s services. The trust also had an active department of spiritual, religious and cultural care.

  However:

• Although we have rated the trust outstanding overall, our inspection has identified a number of areas in core services rated good or outstanding where further improvement can be made. We expect the trust to continue its journey of continuous improvement and  we will work with the trust to agree an action plan based on the findings of our inspection.            

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.

Community mental health services for people with learning disabilities were good because:-

• The trust provided a range of community based services to meet the needs of people with learning disabilities with complex needs in Luton and Bedfordshire.

• Patients and carers told us that staff were kind, caring and helpful. Staff had a good awareness of the individual needs of people who used services. There were comprehensive, individualised care plans and thorough risk assessments in place which involved patients and reflected their communication needs.

• Staff had a good understanding of how to report incidents and were able to give examples of incidents in the service and reflect learning from incidents and complaints. Staff also had a good understanding of safeguarding and when they needed to raise an alert. Staff undertook a range of clinical and non-clinical audits within the teams and used the results of these to improve the service.

• Staff had access to a range of training and opportunities to progress their careers. They did however need to receive training on positive behaviour support which was essential for supporting people who had complex behaviours. Some members of the team would also benefit from training on the Mental Capacity Act which the trust had plans to provide to all staff.

• The service did not have a single manager to coordinate the work of the different teams, psychology and therapies. The trust was aware of this issue and was working to recruit a strategic lead for the learning disability services. Staff were positive about the local leadership within their teams.

However:

• Some multi-disciplinary staff felt less well supported by the trust.

• There was limited psychology and therapy input into the teams but work was underway to review these services and improve access.

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.

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. 

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.

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.

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.

We rated the forensic services directorate overall as good because:

• Staff were caring, respectful and committed to patient welfare. At Wolfson House, each ward had a written philosophy on display which stated staff would support patients to be involved in their care. This philosophy was reflected in patient records and in how staff conducted meetings.

• There were many opportunities for patients to earn money through contracts of employment on site, as well as through work placements in the community. This was part of an employment pathway which include training and a competitive recruitment process.

• There was an integrated substance use support service for patients (SUSS). Patients and staff were very happy with this service. the clinical team felt their work was integrated within the overall care plan of patients who used this service.

• The quality improvement project on violence reduction at the John Howard Centre was effective. The use of restraint, rapid tranquilisation and the seclusion room was reduced through the introduction of a sensory room, increased range and frequency of occupational therapy activities and a strong emphasis on positive behavioural support techniques.

• There was a strong occupational therapy team on both sites who were well trained. The therapy team followed a clear model of care with structured assessment tools to plan care and monitor outcomes for patients.

• The learning disability wards made good use of care and treatment reviews to keep the care of patients discharge focused. The learning disability wards used the positive behaviour support model and had staff who specialised in learning disabilities and forensic mental health.

• Staff, clinicians and senior management demonstrated the trust values in what they said and how they acted. Staff responded to questions on every subject by reflecting the needs and wellbeing of the patients. Everyone we talked to was open, transparent and engaged with the welfare of the patients.

• There were strong managers supporting the ward team and patients. There was effective use of managerial and clinical supervision. This was reflected in the perception of the staff of strong leadership and effective management.

However:

• At the John Howard Centre the risk assessments used to determine which patient needed to have an electronic device during escorted leave needed further work as they did not correspond with patients’ care plans or reflect their individual views. Electronic devices at the John Howard Centre were introduced in response to the concerns of the local community, police, and media about the absconsion and potential risk of patients.

• At Wolfson House the service had moved from paper to electronic records a few months before the inspection, and staff were not uploading and storing risk assessments in one consistent place across patient records. This meant it could be hard for staff to find them.

• On Clerkenwell ward at the John Howard Centre, the emergency alarm system was not suitable for patients with learning disabilities. The ward was noisy with regular alarms and flashing lights, which triggered patients’ symptoms.

• Low secure patients were being cared for on a site where they were subject to the same access security as the other patients who were on medium secure wards. Work with commissioners needs to take place to move these ward to a more appropriate setting.

• At Wolfson House, we were not assured that all staff consistently identified safeguarding issues when reporting an incident.

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.

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.

We rated acute wards for adults of working age and psychiatric intensive care units as outstanding because:

• Patients and family members told us that they received good quality and compassionate care on the wards we visited and this was reflected in observations we carried out on the wards. The care reflected the vision and values of the trust.
• Despite considerable pressure, patients had access to beds when they needed them. Robust and proactive bed management and regular meetings with internal and external partners meant that access to appropriate beds was usually possible. These were mostly near to where people lived.
• There were clear and robust governance processes in place. Staff on the wards had accurate and current information about incidents, complaints and feedback and information was shared between the wards, directorates and board. Staff were learning from this information and making improvements.
• Staff told us that they were proud to work for the trust and that they felt supported and had opportunities for further self-development. We spoke with staff at all levels through the wards and departments we visited and the overwhelming positive feedback about the trust as an employer we received was exceptional. Staff felt that they were listened to, whether raising concerns or giving suggestions about improvements that could be made in the services.
• Staffing was sufficient to meet the needs of patients on the wards. There was little use of agency workers and, when agency workers were employed, they were employed on contracts to ensure continuity of care. There was a low level of sickness and staff felt well supported in terms of managing their health and their work life balance.
• Patients were involved in many creative ways in their care. We saw evidence of this in care planning and meetings which were in place to ensure that the patient voice was heard. An example of this were patient led audits which had led to improvements in food and how ward rounds were conducted.
• The importance of carers was recognised and they were also offered a range of opportunities to be involved in the care that was delivered.
• Patients were offered a range of therapeutic activities and access to facilities that were varied and met their needs. This included gyms, multi-sensory rooms and other facilities such as music rooms.
• The staff were all very aware of the diverse needs of the patients and were able to meet each person’s individual needs.
• The quality improvement programmes running on the wards in London and starting in Luton and Bedfordshire had led to quantifiable improvements in the patient experience and had improved patient and staff engagement with the service. Examples of this included reductions in violence and aggression through the introduction of more activities and allowing patients to keep their own mobile phones. Other ongoing work included supporting patients to eat healthily, supporting female patients to have their health checks and looking at the impact of music on levels of violence and aggression.

However:

• In some areas, knowledge about the Mental Capacity Act (MCA) was not sufficiently robust to ensure that, when necessary, information about decision specific assessments such as the type of treatment that a patient was consenting to was recorded. The trust was implementing a mandatory training programme on the MCA.
• Some wards in Luton and Bedfordshire were large and above the recommended number of beds on an acute ward of 16. The Luton wards were too warm.
• There were some areas where there was limited psychology input which meant that recommended psychological therapies were not always available to all patients on the wards. The psychology services in Luton and Bedfordshire were going through a period of change to improve access to the service.
• There was scope for some improved recording of patient information, for example risk assessments and restraint, although the care practice was safe.

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.