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Provider: Camden and Islington NHS Foundation Trust Good

Older full service inspection reports for Camden and Islington NHS Foundation Trust (published 22 August 2014).

Inspection Summary


Overall summary & rating

Good

Updated 6 March 2018

Our rating of the trust improved. We rated it as good because:

  • We rated safe as requires improvement; caring, responsive and well-led as good; and effective as outstanding. Following this inspection, two of the trust’s eight services are rated as outstanding and six as good.
  • We rated well-led for the trust overall as good.
  • By applying the strict aggregation principles, the caring, responsive and well-led questions would also be rated as outstanding. However, we decided to deviate from the aggregation rules because the outstanding ratings applied to two core services and one of these, the substance misuse services, were only a small proportion of the trust’s overall services.
  • There had been a number of changes in non-executive and executive directors. They had ensured that most of the improvements identified at the previous inspection had been addressed. The trust was well-led and the senior team had an appropriate range of skills, knowledge and experience.
  • The trust had clarity about its strategic priorities and the culture it wanted to embody. An excellent clinical strategy provided clear future direction for the services delivered by the trust. This strategy drew on details of the local population and the prevalence of mental health needs. The clinical strategy had been produced with input of patients, carers, staff and governors. The clinical strategy linked with the estates redevelopment programme at St Pancras.
  • The trust promoted the use of research to improve the care and treatment of patients. There were examples of research being used to improve the care of people using the services delivered by the trust. For example, the carers of patients using the memory clinics were being offered access to a programme of psychological therapies which improved their ability to cope with the challenges of supporting a relative with dementia.
  • There were many examples of innovative models of care that were well regarded such as the practice based mental health teams in Islington. These teams had staff working in the GP premises to deliver joined up care within a primary care setting. The trust had plans to roll this model out in Camden as well. Another example was the rehabilitation services in Islington where patients with enduring mental health conditions were being supported to live more independently supported by consistent care professionals. In this example, services had been developed in partnership with the third sector.
  • The trust had made good progress in ensuring that patients also had their physical health care needs met. For adults being supported by the community recovery and rehabilitation teams, weekly physical health clinics were being developed. These had a particular focus on supporting patients who were hard to engage or not registered with a GP to ensure their physical health needs were addressed. The integrated learning disability teams supported patients to access appropriate healthcare input and worked collaboratively with GPs and the acute hospitals.
  • There were many examples of person-centred care, where staff had been thoughtful about working with patients and carers to meet their individual needs.

However:

  • The trust still faced many challenges with the recruitment and retention of staff. Whilst the recruitment of qualified nurses is a national and regional challenge, the trust had an unusually high level of vacancies for unqualified care staff. There was also an impact from this on the care being provided to patients on the acute admission wards in terms of their access to escorted leave and the time available for structured individual sessions with their named nurse.
  • At the time of the inspection, 63% of staff had completed their mandatory training. There were some significant shortfalls in staff needing to complete life support and break away training. This shortfall was as a result of the trust opening up the training to more staff and additional sessions were being provided, but this work needed to be completed.
  • Further work was needed in terms of maintaining the safety of patients when physical interventions are used. On the acute wards records of restraint did not always include details of the type of restraint used, the names of the staff involved and the length of time that staff restrained the patient. Also the acute wards did not take sufficient steps to ensure the safety of patients who had received rapid tranquilisation. Staff did not always explain to patients the importance of monitoring their respiration, heart rate or blood pressure. When patients declined checks of their vital signs after the injection, staff did not make any further attempts to carry out these observations.
  • There were significant pressures in accessing an acute bed. This was impacting on the amount of time patients were waiting at home, in acute hospital emergency departments and in health based places of safety for a bed. At the time of the inspection, 15 patients were placed in beds in the independent sector. The trust hoped that their recently opened female psychiatric intensive care unit and the further development of their community services would lead to an improvement in these demands. The trust was working well to support the timely discharge of patients.

Inspection areas

Safe

Requires improvement

Updated 6 March 2018

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

  • We found two of the services we inspected were rated as requires improvement for safe: Acute wards for adults of a working age and psychiatric intensive care and Mental health crisis services and health-based places of safety.
  • Further work was needed in terms of maintaining the safety of patients when physical interventions are used. On the acute wards records of restraint did not always include details of the type of restraint used, the names of the staff involved and the length of time that staff restrained the patient. Also the acute wards did not take sufficient steps to ensure the safety of patients who had received rapid tranquilisation. Staff did not always explain to patients the importance of monitoring their respiration, heart rate or blood pressure. When patients declined checks of their vital signs after the injection, staff did not make any further attempts to carry out these observations.
  • Some teams did not have sufficient staff at all times to allow them to deliver a full range of care. For the adults of a working age and psychiatric intensive care units there was a vacancy rate of over 20% on all wards. Between September and November 2017, 235 shifts were unfilled. In mental health crisis services and health based places of safety, the Islington crisis resolution and home treatment team (CRHT) had high caseloads, which resulted in high individual workloads for staff. There was high turnover of staff across the CRHTs.
  • Not all staff had completed all their mandatory training. The trust had very low levels of completion in some courses, such as for breakaway and intermediate life support. This was because the trust had extended the number of staff who needed to complete this training and plans were progressing to ensure this training was completed.

However:

  • The trust provided care in environments that were mostly clean, tidy and comfortable. Staff completed assessments of environmental risks and put in place plans to manage these.
  • The trust planned care to ensure there were sufficient numbers of staff to meet the needs of patients most of the time.
  • Staff assessed risks for most patients and worked with them to manage these risks. Staff completed risk assessments for patients. They monitored patients and updated these as risks changed.
  • The trust had robust systems in place to manage risks to staff working on wards and in the community.
  • Most staff knew how to make referrals to child and adult safeguarding and followed safe processes to manage medicines.
  • Staff knew how to report incidents and did so. When incidents happened, the trust investigated them, identified what staff needed to learn from the incidents and supported staff to make changes.

Effective

Outstanding

Updated 6 March 2018

Our rating of effective improved. We rated it as outstanding because:

  • We found three of the eight services we inspected outstanding for effective: the community-based mental health services for adults of working age, community-based mental health services for older people and the community mental health services for people with a learning disability or autism.
  • In these services, there was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Staff worked with patients to develop care plans that met their needs.
  • Staff followed guidance in delivering care. People’s care and treatment was based on the best available evidence.
  • The trust had developed many innovative models of care that were well regarded, such as the practice based mental health teams in Islington. These teams had staff working in the GP premises to deliver joined up care within a primary care setting. The model was being rolled out in Camden. The rehabilitation services in Islington had worked in partnership with the third sector to develop services that supported patients with enduring mental health conditions to live more independently, whilst still being supported by care professionals.
  • The trust had made good progress in ensuring that patients also had their physical health care needs met. For adults being supported by the community recovery and rehabilitation teams, weekly physical health clinics were being developed. These had a particular focus on supporting patients who were hard to engage or not registered with a GP to ensure their physical health needs were addressed.
  • The trust had robust policies and procedures in place to monitor adherence to the Mental Health Act. Staff demonstrated good practice in applying the Mental Capacity Act

However:

  • The rehabilitation mental health wards for working age adults did not provide services of a consistently high standard. The services in Camden did not demonstrate that active rehabilitation opportunities were offered at all stages of the patients care and treatment. Patients, particularly in the inpatient wards, were not given sufficient opportunities to ensure that they developed skills relating to activities of daily living. There had not been sufficient occupational therapy provision to support this.

Caring

Good

Updated 6 March 2018

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

  • We rated six services as good and two services as outstanding for caring.
  • Most staff supported patients with kindness, compassion and respect. They maintained patients’ privacy and dignity. We observed staff to be respectful, kind and compassionate and most patients we spoke with were positive about staff.
  • Staff involved patients, and where appropriate, their families and carers in decisions about their care. They supported carers to access support services.
  • Staff supported patients to access independent advocacy services.

Responsive

Good

Updated 6 March 2018

Our rating of responsive improved. We rated it as good because:

  • We rated six services as good and two services as outstanding for responsive.
  • The services had clear criteria for who they would offer a service to. Patients could access services when they needed to and few services had long waiting lists. Staff had systems in place to manage patient admissions to beds and they planned for patients’ discharge.
  • Most patients received care in facilities that promoted comfort, dignity and privacy.
  • Staff supported patients to maintain relationships.
  • Staff worked with patients to plan care that met their specific needs. They took account of the needs of different groups and made adjustments to support these patients. Staff supported patients with the cultural and religious needs.
  • Staff we spoke with knew how to support patients to make a complaint. The service provided information on how to make a complaint. Staff investigated complaints and, where appropriate, acted to make improvements following them.

However:

  • There were significant pressures in accessing an acute bed. This was impacting on the amount of time patients were waiting at home, in acute hospital emergency departments and in health based places of safety for a bed. At the time of the inspection, 15 patients were placed in beds in the independent sector. The trust hoped that their recently opened female psychiatric intensive care unit and the further development of their community services would lead to an improvement in these demands. The trust was working well to support the timely discharge of patients.

Well-led

Good

Updated 6 March 2018

Our rating of well-led improved. We rated it as good because:

  • Across the services, staff expressed confidence in the leadership skills of their team and divisional managers who were visible and accessible to staff.
  • Staff felt strongly aligned to the visions and values of the trust and how this was put into practice within their services.
  • Governance processes were in place such as a range of audits and the collection of data to provide assurance on the progress of services. Staff were able to add risks to the divisional risk registers so they could be escalated and addressed when needed.
  • There was a clear framework of what to discuss at divisional and team meetings. This ensured learning from incidents and complaints and the sharing of good practice.
  • In some services there was good use of research to improve the quality of the service delivered to patients.

However:

  • In a few services the engagement with staff, patients and carers could be improved around changes that were taking place. For example in the rehabilitation services where changes were proposed particularly in the Camden services. Also on Pearl ward for older people where the needs of the patients admitted to the ward had changed.
  • Whilst most staff said they received regular management and clinical supervision, systems were not in place to ensure supervision was appropriately recorded.
Checks on specific services

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

Good

Updated 6 March 2018

A summary of this service appears in the Overall summary.

Community mental health services for people with learning disabilities or autism

Good

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.

Community-based mental health services for adults of working age

Good

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.

Community-based mental health services for older people

Outstanding

Updated 6 March 2018

A summary of this service appears in the Overall summary.

Liaison psychiatry services

Updated 12 January 2018

We did not rate this service as this was a focussed inspection.

We found the following issues that the service provider needs to improve:

  • Although Camden and Islington hadengaged with the three acute trusts, the Whittington the Royal Free and UCLH, to develop a joint action plan following a serious incident involving the death of a patient, there were some areas where the actions were not fully embedded. Camden and Islington had not effectively assured themselves that necessary actions were being carried out.At the Whittington Hospital ED, the assigned acute staff did not attend to their observation duties consistently. These are responsibilities to observe patients with mental health problems who have been assessed by the liaison team as having a risk of self-harm. At the Royal Free and UCLH, security staff, rather than clinical and adequately trained staff, observed patients whilst mental health nurses were requested.

  • Camden and Islington needed to continue their work with the Whittington, to ensure the assessment rooms in the ED offered appropriate levels of privacy and provided an environment where patients could wait in comfort. There were plans to make improvements by December 2017.

  • Camden and Islington was not making improvements in response to some feedback from inspections and peer review visits. For example the provision of information about services and legal rights under the Mental Health Act 1983 and Mental Capacity act 2005 and the completion of comprehensive patient records.

However, we also found the following areas of good practice:

  • Liaison staff assessed most patients promptly within their target of one hour after they arrived at the ED.
  • At all three acute trusts, liaison staff delivered regular training sessions to acute staff working in ED to develop their knowledge of mental health patients.

Long stay/rehabilitation mental health wards for working age adults

Good

Updated 6 March 2018

Mental health crisis services and health-based places of safety

Good

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.

Substance misuse services

Outstanding

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.

Wards for older people with mental health problems

Good

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.