South West London and St George's Mental Health NHS Trust

Updated 16 January 2023

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

• We rated four of the five core and specialist services we inspected as good overall. Following the inspection 11 of the 12 core and specialist services in the trust were rated good overall.
• We rated well-led for the trust overall as good.
• There was good, effective leadership at all levels of the organisation. The trust senior leadership team was visible across the trust and modelled openness and transparency. Work had been carried out to co-produce a values and behaviours framework, which staff were positive about. The senior leadership team were compassionate and acted in accordance with the values. Since the last inspection the trust had completed work on a co-produced organisational strategy with defined strategic ambitions.
• There had been a number of recent appointments into permanent and temporary posts across the executive and non-executive teams. The team understood the plans for development both internally and externally and the size and complexity of the change agenda. Governance structures and processes had been strengthened throughout the organisation. The trust was well aware of the clinical areas they needed to improve, especially the quality and safety of care and leadership on the specialist eating disorder ward for children and young people.
• Since the last inspection in 2018 the trust had made improvements in a number of areas including in the physical health care of patients and the way patients were cared for after receiving rapid tranquilisation. Patients had good access to physical healthcare and were supported to live healthier lives.
• Services had enough staff with the right qualifications, skills, training and experience to keep patients safe and provide the care and treatment patients needed. Staff recruitment campaigns and efforts to retain staff were ongoing. The learning and development needs of staff were identified and prioritised through annual appraisals and regular clinical supervision. There were good opportunities for specialist training and professional development. Since the last inspection the trust had introduced a leadership development programme accessible to staff at all levels.
• Staff assessed and managed risks to patients well and achieved the right balance between maintaining safety and providing the least restrictive environment possible to facilitate patients’ recovery. Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. The trust was implementing a ‘safety in motion’ programme across inpatient wards, which had resulted in a significant reduction in the use of restraint and seclusion in the forensic wards.
• Managers investigated incidents and complaints and shared the lessons with staff to minimise the risk of them happening again. Since the last inspection the trust had involved patients and carers in improving the tone of complaint response letters, so that they were less corporate and conveyed empathy.
• Staff and service leaders understood their risks and were able to report them and escalate them when required. The board assurance framework was used actively by the board. The senior leadership recognised the need to do more to clearly link the framework to the strategic ambitions of the trust.
• Staff provided care that was personalised, holistic and recovery-oriented. Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. Staff were proactive in involving families and carers in patient care, when appropriate. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff from different disciplines worked well together to benefit patients. They provided a range of care and treatment interventions consistent with national guidance on best practice. Teams collaborated with each other and with external agencies. The trust worked well with partners, recognising the complexity of the local landscape and systems, developing work with the South London Partnership and volume of potential partners and meetings. The trust understood the need to continually risk assess areas of focus and priorities.
• The trust collected, analysed, managed and used information well to support all its activities. Managers had access to the information they needed to provide safe and effective care and used that information to good effect. The way information was presented to the board had been improved making it easier to confidently identify trends, expected variation and areas of declining performance.
• The trust engaged positively with service users and staff. The board and senior leadership team had involved service users, carers, staff and other stakeholders in the development of a trust strategy. The patient involvement team had increased the number of service users and carers on the involvement register. Service user and carer representatives were visible and valued contributors to board sub-committees and working groups.
• Work on equality and diversity had progressed since the last inspection. There had been an increase in the number of staff network groups. Plans to improve workforce race equality had been reviewed and re-energised.
• The trust had appropriate arrangements in place in relation to Mental Health Act administration and compliance. Staff understood their roles and responsibilities under the Act and discharged these well.
• The trust had made progress with it’s a quality improvement programme. Staff had been engaged in various ways to learn, improve and innovate and were given time to do this in their day to day roles. The trust was committed to improvement and innovation.

However:

• In the specialist eating disorder ward for young people staff did not always assess and manage environmental risks effectively and staff took an overly restrictive approach to the care of young people without clear rationale or individual risk assessment. Staff did not understand how the Mental Capacity Act 2005 applied to young people aged 16 and 17 or the principles of Gillick competence as they applied to those aged under 16. The leadership of the ward needed strengthening to bring about improvements in care.
• The trust operated in a complex and changing environment and was engaged in the delivery of a multi-million-pound estate modernisation programme and the transformation of local community mental health services. The board needed to continue to review the board assurance framework regularly and re-examine the alignment of the framework in line with the evolving strategy and strategic aims of the organisation. The size and complexity of the ongoing change agenda and recent and immanent changes at board level, meant that the trust needed to continue to monitor and evaluate the capacity and capability of the senior leadership to ensure the continued delivery of high-quality services.
• Although the trust had made considerable progress in addressing equality and diversity issues in a range of areas further work was needed ensure equality and diversity was integrated into all areas of work throughout the organisation.
• The trust had a relatively low number of clinical psychologists providing therapeutic input across services. The provision benchmarked poorly against other similar trusts. Similarly, there were small numbers of social workers available across the trust to complement the work of multidisciplinary teams. This had a negative impact in terms of patient access to appropriate services.

Updated 6 December 2014

We found evidence that the teams worked with people to keep them safe. Risk assessments were completed at the first visit along with care plans. We saw people were supported with comprehensive risk management plans.

Staffing levels varied significantly in the teams. Merton team was fully staffed and included social workers (AMHPs). All staff we spoke with on this team said they felt the team was well staffed, whilst Kingston and Wandsworth had vacancies and the staff teams did not have social workers attached. Staff we spoke with felt that these teams were understaffed even when they had their full complement of workers.

People's records we viewed clearly demonstrated collaborative working with MDT’s such as district nurses, CMHT’s and hospital wards.

We saw that paper care plans were completed during the initial assessment visits with people who used the service. They were then scanned into the trust data base system. Most care plans we checked were signed by people and/or their relatives.

The manager told us staff had access to specialist training. Some staff told us they completed CBT training and a recovery worker said they had applied to be seconded to train as a nurse.

We saw that information about the trust complaints system was contained in the welcome packs that people were given.

Updated 6 December 2014

Staff told us that they were confident tin raising concerns about practice of other staff and were confident that actions would be taken by the managers of the community teams. This meant that processes were in place to safeguard people who used the service from harm and abuse. Staff demonstrated a good understanding of what they required to do to make improvements to the treatment and care provided to people who used the service.

Staff told us that they were able to access training specific to people with learning disabilities, ensuring they met people's needs. There were vacancies in MSCMHLDT for a clinical psychologist and one community learning disabilities nurse and at WCMHLDT two trainee psychologists and one community learning disabilities nurse. The team managers told us that this had been difficult, but "everybody pulls together and we manage."

The trust uses a computerised system with all care plans, risk assessments and notes for people who used the service kept electronically. We viewed six randomly selected care plans which were found to be comprehensive and demonstrated how staff supported people who used the service and showed that people who used the service or their carers were involved in the formulating of care plans and the review processes. Regular health checks were carried out where required ensuring people's wellbeing and physical health was monitored. Overall the records we viewed were of a good standard, regularly updated, comprehensive and well maintained.

Staff told us that they worked together as a team with other professionals, which ensured people's mental health and physical health needs were met holistically. People who used the service told us that they were always involved in their care and were able to discuss any issues with members of the teams. Staff told us us that they were able to access other professionals available from community teams managed by local authorities, however they told us that at times this was very challenging.

MSCMHLDT and WCMHLDT was fully accessible for people who have mobility problems and information was available in a format accessible to people who were not able to read.

We did not monitor responsibilities under the Mental Health Act 1983 at MSCMHLDT and WCMHLDT; however we examined the providers responsibilities under the Mental Health Act 1983 at other locations and we have reported this within the overall provider report.

Updated 15 June 2022

We carried out this short notice announced focused inspection in line with our inspection methodology. This inspection included a follow up on our last inspection to see if improvements had been made at the service.

Avalon Ward is an 18-bed national, specialist service providing care and treatment for male and female patients over the age of 18, experiencing severe eating disorders. On the day of the inspection the ward had a reduced bed capacity of 15 with all beds occupied.

Wisteria Ward is a 12-bed ward for male and female young people between the ages of 11 and 18 with severe eating disorders and weight loss related to mental health problems. It is a national service and accepts referrals from across the country. At the time of the inspection the ward was located in temporary accommodation with a reduced bed capacity of seven beds which were all occupied.

The trust advised us that both wards would be back at full capacity by July 2022.

In addition, the trust has an eating disorders day unit operating Monday to Friday during office hours which accommodates up to ten male and female patients over the age of 18 years. The service is for patients with a diagnosed eating disorder and who require a more intensive treatment programme of care and treatment than could be offered by the community mental health teams. We did not inspect this service.

South West London and St George’s Mental Health NHS Trust specialist eating disorders services were last inspected in September and October 2019, when the overall rating for service was Requires Improvement. Safe, effective, responsive and well led were rated as Requires Improvement and caring was rated as Good. We also identified breaches of Regulation 11: need for consent, Regulation 12: safe care and treatment, Regulation 13: Safeguarding from abuse and improper treatment, Regulation 14: meeting nutritional and hydration needs and Regulation 17: good governance.

Avalon Ward was inspected but not rated in August 2020 in response to information of concern we received. At this inspection we identified a breach of Regulation 14: meeting nutritional and hydration needs.

Our rating of services improved. We rated them as good because:

• Staff had training in key skills, including therapeutic eating, and understood how to protect patients from abuse.
• Both wards were visibly clean and well maintained. Staff managed infection risk well.
• The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff assessed risks to patients and acted on them. They provided effective care and treatment, appropriate support around nutrition and hydration and offered emotional support when patients needed it.
• The service had systems and processes in place to safely administer and record medicines use. Medicines for use in emergencies were easily accessible to staff.
• Staff worked well together for the benefit of patients, supported them to make decisions about their care and provided information to enable them to live healthier lives. They were focused on the needs of patients receiving care.
• Staff treated patients with compassion and respected their privacy and dignity. Staff provided emotional support to patients, families and carers.
• The services provided effective evidence based treatments for adults and young people with eating disorders based on national guidance and best practice.
• Leaders ran both wards well using reliable information systems. Staff felt respected, supported and valued. The staff had improved their engagement with patients, families and carers. All staff were committed to continually improving the service provided.

However:

• The building Wisteria Ward was located in was not suitable for good patient care and treatment. It was small and spaces had to be shared amongst staff and patients which at times impacted negatively on the patient’s experience. The ward is due to move to improved accommodation in July 2022 and the trust invested £1.92m in the refurbishment.
• There were high vacancy rates for registered nurses and health care assistants on both wards. Wisteria Ward had not had a clinical psychologist in post since December 2021. The trust was actively recruiting into vacant posts and reviewed job descriptions to make them more attractive.
• Not all staff who needed to had completed basic life support training. Compliance was at 73% across the entire eating disorder service line. The trust had an action plan to address this shortfall including additional training sessions planned.
• Adult patients and young people and their carers / parents on both wards told us they were unsure how to make a complaint.
• Although improved overall since the last inspection visit, there were a few gaps in recording patients’ physical observations in records we reviewed on Avalon Ward. Some staff on Wisteria Ward were not recording observation scores promptly and were holding this information in their heads until they could access a computer. There was a potential risk of inaccurate recording.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well led.

Before the inspection visit, we reviewed information that we held about this service.

The team that inspected the service consisted of two inspectors, one inspection manager, a medicines inspector, one specialist advisor, with experience working in eating disorders service and an expert by experience, someone who has experience of care and treatment in an eating disorders service.

During the inspection visit, the inspection team:

• Observed how staff were caring for patients
• Attended multidisciplinary meetings on both wards
• Spoke with the managers of both wards
• Spoke with 24 staff members including consultant psychiatrists, junior doctors, clinical psychologists, advanced nurse practitioners, registered nurses and health care assistants.
• Spoke with four patients and eight carers, parents or relatives
• Looked at the quality of the environment on each ward.
• Reviewed nine patients care and treatment records
• Reviewed documents related to the running of the service

What people who use the service say

We spoke to four patients. We received a mixture of both positive and negative comments. All patients said they felt safe on the ward and the majority said they received good care and treatment from staff.

Patients told us that most staff were supportive and caring around mealtimes and although there were still occasional issues with catering, including incorrect portion sizes, this happened infrequently.

Carers of patients and young people told us their relative felt safe on the ward, that staff were polite and courteous and that both wards provided a positive environment.

However, patients on Wisteria Ward told us there was a lack of therapy available to them. Patients on both wards told us some non-permanent staff did not speak to them in a caring way.

Seven out of eight carers we spoke to told us communication with both wards was poor and inconsistent.

Updated 12 June 2018

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

• Staff kept appropriate records of patients’ care and treatment. Risk assessments were completed on admission and reviewed regularly and care plans were up to date. At the last inspection in March 2016, on Aquarius Ward, a new template for care planning had been introduced, but was not fully embedded. During this inspection, we found the team had fully embedded the new care plan template.

• Staff used de-escalation techniques before restraint was used. Staff ensured physical health observations were carried out following rapid tranquilisation, in line with national guidance. There was excellent recording of this by staff on Aquarius Ward.

• Staff participated in regular clinical audits, which helped ensure the quality of the services delivered on the wards. Staff received regular supervision and appraisals. At the last inspection in March 2016, on Aquarius Ward, records of supervision sessions were not kept securely or consistently. During this inspection, we saw evidence that supervision records were stored securely and consistently on the trust’s electronic database.

• Feedback from patients and carers was generally positive. Young people and carers felt involved in their care and treatment.

• Staff and patients had access to the full range of rooms and equipment to support treatment and care, including an outdoor area and an onsite school. The trust had onsite accommodation, near to but separate from the ward, where parents and carers could stay when visiting their child, as some lived far away from the units.

• Ward managers created a culture in which staff felt supported. Staff told us they felt respected, supported and valued by their team. Staff were committed to delivering quality improvements in the wards.

• At the last inspection in March 2016, staff did not recognise that using the low stimulus room and preventing young people from leaving was seclusion. The necessary safeguards were not in place for young people. During this inspection, we found this was no longer the case. Staff followed trust policy and ensured the necessary safeguards and reviews of seclusion were completed in these circumstances.

• At the last inspection in March 2016, the ward manager on Aquarius Ward was unable to provide accurate figures for compliance with mandatory training. During this inspection, we found this was no longer the case. The ward’s mandatory training compliance rate was 87%.

However:

• The wards did not provide an advocacy service to informal patients. This meant that the young people who were not detained under the Mental Health Act did not have access to an independent voice to represent their views and wishes on the wards.

• Some patients said the food was of a poor quality and was not appetising. For example, patients on Corner House said meals were often overcooked or undercooked, and the portions were small.

• Ward staff did not keep a log of local, informal complaints, which could have made it more difficult to identify trends, and was a missed opportunity for learning.

• Staff on Corner House felt that communication with the onsite school staff could be improved to the benefit of the children and young people.

Updated 12 June 2018

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

• Young people and families said that the services had been helpful to them and this was reflected in feedback surveys that services collected each month. They said that staff provided them with information about what to expect when first using the service and were kind and patient.

• Services had a range of experienced and qualified staff who were able to deliver interventions in line with national guidance. Staff were trained in safeguarding and followed appropriate steps to keep young people safe. Services had embedded a protocol for assessing and managing people of different risks, including supporting those on the waiting list.

• Teams worked well with other services both within the trust and externally to provide a consistent and seamless service to children, young people and their families. Teams had taken a proactive approach to providing information to young people. For example, staff identified that several young people had presented at emergency departments having misused a particular substance during a short period of time. The service worked with external organisations, to notify them and also to put together information packs for young people about the dangers of the substance.

• Since the last inspection in March 2016, the trust had successfully addressed five areas of improvement. These included, the management of low risk patients, working with commissioners to highlight the need for additional resources to address long waiting times, particularly for psychological therapies and the completion of staff safeguarding training.

• Staff enquired about, considered and acted on the diverse needs of young people and their families. One team had an LGBT champion and signposted LGBT+ young people to local LGBT+ groups and useful websites. Staff worked closely with a specialist local authority team to support young people from the local South Korean community referred to CAMHS. Premises were accessible to people with physical disabilities.

• Governance systems supported service managers to access the information they needed to run services effectively and identify areas of development. All services had good systems to report and learn from incidents. Staff met regularly and learning from incidents and complaints was evident.

• Staff were very positive about their teams, said that they felt supported by colleagues and managers and that everyone was dedicated to supporting young people who accessed their services.

• The trust had set up a CAMHS emergency care team in response to the level of acuity and pattern of young people presenting to emergency departments in a crisis. Staff were able to offer assessments and appropriate onward referrals to suitable services promptly.

However:

• Although the recording of patient information by staff had improved since the last inspection in 2016, staff did not always save and record information about patient care in a consistent way in electronic records.

• Staff had begun implementing the use of crisis information sheets and ‘what if’ plans in order to provide young people and families with information about what to do in a crisis or when their health deteriorated. These were not yet fully developed or embedded in practice.

• The electronic records system and IT infrastructure did not support staff to carry out their roles as effectively as possible. Staff reported that access to emails and the patient records system was often interrupted and the records system itself did not allow for information to be stored and re-accessed in a clear way.

• Staff did not always record the wishes and views of young people in care records, so could not demonstrate that young people and families were involved in care as much as they could be.

• Kingston CAMHS did not have robust systems for recording who was on the premises at any particular time, which had fire safety implications.

Updated 16 June 2016

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

People who used services and carers told us that staff were kind, caring and helpful. Staff had a very good awareness of the individual needs of people who used services and this was reflected in comprehensive, detailed and individualised care plans and thorough risk assessments which involved people who use services and reflected the communication needs of people who used the services.

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 undertook a wide range of clinical and non-clinical audits within the teams and worked to improve outcomes through these.

There were no waiting lists for the service. People referred to the service were seen in a timely manner and had access to out of hours emergency support if necessary.

Staff were very positive about the local leadership both from their line managers and from the consultants within the team and this was the basis of positive team work in a multidisciplinary setting.

However, the team manager post for Wandsworth community mental health learning disability team was vacant and had been vacant for 15 months at the time of our inspection. This post was being covered by the manager of the Merton and Sutton team. Efforts had continuously been made to recruit into this post but it did leave both teams without a full time manager on site.

Updated 2 December 2016

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

• Following our inspection in March 2016, we rated the services as good for effective, caring and well led.

• During this most recent inspection, we found that the services had addressed the issues that had caused us to rate safe and responsive as requires improvement following the March 2016 inspection.

• The community based mental health services older people were now meeting Regulations 12 and 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

Updated 20 December 2019

• The service provided safe care. Clinical premises where patients were seen were safe and clean and the physical environment of the health-based place of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams was not too high to prevent staff from giving each patient the time they needed. Staff ensured patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff working for the mental health crisis teams developed recovery-oriented care plans informed by a comprehensive assessment. They provided treatments that were informed by best-practice guidance and suitable to the needs of the patients. Local audits of the quality of patient care and treatment records were completed and the trust had plans to strengthen these in the future.
• The trust was working to expand the range of specialists working within the crisis teams to meet the needs of the patients. Managers ensured that staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. Progress was being made to involve patients, families and carers in care decisions.
• The mental health crisis service and the health-based place of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were seen immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
• The service was well-led and the governance processes ensured that service procedures ran smoothly.

However:

• Staff did not always clearly record, which team or practitioner had oversight and managed patients’ long term physical health conditions, where relevant.
• Staff at Wandsworth home treatment team did not always keep patients updated about changes to their appointments.
• The trust acknowledged that it needed to continue with its work to consider the multi-disciplinary make-up of the home treatment teams and to develop a consistent auditing process for patient care and treatment records.
• The trust had only recently started to reliably record how many times patients waited longer than 24 hours in the health-based place of safety and whether an extension to their length of stay had been authorised. The trust was working to improve the overall quality of data going forward and was monitoring this closely.

Updated 20 December 2019

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors to provide safe care to patients. Staff assessed and managed risk well. They minimised the use of restrictive practices and followed trust safeguarding policies and procedures.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who had a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• At Burntwood Villas staff did not always dispose of expired medicines in a timely way and did not always label patients’ medicines clearly.
• Blood glucose monitoring equipment on two wards was not calibrated in line with the manufacturer’s instructions.
• Although the trust had guidance in place, ward staff we spoke with were not clear about what to do if a patient refused to leave in the event of a fire
• On Ruby and Halswell wards it was not always clear that issues brought up by patients in the community meetings were quickly addressed by staff.

Updated 16 January 2023

Burntwood Villas is a locked step-down mental health rehabilitation unit for up to 12 patients with one 8 bedded unit and one satellite self-contained 4 bedroomed open-door villas (Redwood Villas). Burntwood Villas accommodates up to 8 male and female patients and Redwood as a semi-independent property houses up to 4 male patients. Staff are present at Burntwood Villas at all times. Redwood Villas is not staffed, but staff from Burntwood Villas visit once per shift to check on the welfare of patients. Phoenix Ward is an 18 bedded mixed sex rehabilitation ward, each bedroom with ensuite facilities.

This was a short announced comprehensive inspection that included a follow up of previous regulatory breaches and requirement notices imposed after a focused inspection of Burntwood Villas in 2021. The inspection of Burntwood Villas in April 2021 identified breaches of regulations 12 and 17 and 18 and resulted in an overall rating of requires improvement for the long stay/rehabilitation core service.

Overall Summary

• We rated the long stay or rehabilitation mental health wards for working age adults as Good for Safe, Effective, Caring, Responsive and Well-led and Good overall.
• We found that significant improvements had been made at Burntwood Villas since the focused inspection in April 2021. There were improvements in all areas of concerns highlighted in the previous inspection report.
• The acuity of patients admitted to Burntwood Villas had reduced and the service was admitting patients in accordance with its inclusion and exclusion criteria. The service provided a rehabilitation model, that staff understood, in line with the operational policy. Staff planned and managed discharge well and had alternative pathways for people whose needs it could not meet.
• The ward environments were clean and well furnished. Staff and patients had access to nurse call alarms and the service had taken steps to ensure that the service was compliant with fire safety measures. Staff knew the procedures to follow in an emergency and followed appropriate infection control measures.
• The service had enough staff, who knew the patients and received appropriate training to keep them safe from avoidable harm. Staff assessed and managed risk and followed good practice with respect to safeguarding.
• Staff developed care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the clients and in line with national guidance about best practice. They ensured that clients had access to physical healthcare and supported clients to live healthier lives.
• Managers investigated incidents and shared lessons learned with the whole team. The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medicines on each patient’s mental and physical health.
• Staff treated patients with compassion and kindness and understood the individual needs of patients, including those with protected characteristics. Staff involved patients in care planning. Staff used kind words and tone when speaking with patients.
• Staff worked well together as a multidisciplinary team and with those outside the ward. The leadership team had a good understanding of what a high-quality rehabilitation service should encompass. The ward teams included or had access to a range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received regular supervision, annual appraisals and training.
• The service was well-led. Leaders had the skills, knowledge and experience to perform their roles, were visible in the service and approachable for patients and staff. The service treated concerns and complaints seriously, investigated them and learned lessons from the results.

However:

• The medicines trolley and fridge on Phoenix Ward were visibly dusty and there was an absence of cleaning records for this equipment since 2020.
• Staff did not always repeat vital signs monitoring of patients who had elevated national early warning scores in line with trust policy, although these were followed up and repeated the next day.
• Although staff were aware of and able to articulate risks to individual patients, two patient risk assessments had not been updated recently and did not completely reflect current risks.
• While staff on Burntwood Villas carried out fire drills every six months, staff had not carried out a fire drill on Phoenix Ward since October 2021, almost 12 months before the inspection. Managers told us that a drill was planned.

Updated 20 December 2019

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

• We rated this service as good for safe, effective, caring, responsive and well-led.
• Leaders at all levels were compassionate, inclusive and effective. They demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Leaders demonstrated good leadership and motivated their teams to ensure high quality care was delivered in all areas. Excellent, collaborative, multidisciplinary team working ensured patients’ holistic needs were met.
• Leaders had the skills, knowledge and experience to perform their roles to a high level, were visible in the service and approachable for patients and staff. The service treated concerns and complaints seriously, investigated them and learned lessons from the results. 
• Staff provided excellent support to families and carers, considered their needs and were proactive in involving them in their relative’s care. The social worker held a social care surgery every week, supporting carers in the consideration of future placements.
• Staff ensured that physical health monitoring of patients’ vital signs was undertaken and recorded to a high standard, including after every use of rapid tranquilisation. There was excellent medical provision on the wards, with good access to doctors at all times. Doctors worked very well with specialists from other health care organisations to provide the best possible care to patients. Staff carried out detailed assessments of the physical and mental health of all patients on admission.
• Staff engaged actively in local and national quality improvement activities. Staff were involved in a quality improvement initiative to reduce falls on the wards.
• Since the previous inspection in March 2016, the number of staff working on each ward had been increased during busy times, and the use of agency staff members had reduced. There were also improvements in the quality of recording of risk assessments for patients, and records of cleaning clinical equipment. Staff had received more training in moving and handling patients with mobility needs, including the use of hoists. There had been an improvement in staff morale, and interactions with patients on Crocus Ward, so that these were less task focussed. The décor, furnishings and layout on Crocus Ward had been upgraded to provide a more comfortable and dementia friendly environment. Occupational therapy support on both wards had increased, ensuring that patients had access to a range of appropriate activities to meet their needs
• Wards were safe, clean, well-equipped, and well maintained, with sufficient trained and skilled staff to support patients safely. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, and de-escalating, challenging behaviour. Staff understood how to protect patients from abuse and/or exploitation and the service worked well with other agencies to do so.
• The wards had a good track record on safety. Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support. 
• Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. They held weekly physical health clinics, made timely referrals to specialist healthcare teams, and supported patients to live healthier lives. Staff used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit, benchmarking and quality improvement initiatives. 
• Staff had regular individual supervision sessions and annual appraisals and described good opportunities for professional development within the trust.
• Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Staff involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. 
• Staff ensured that patients had easy access to independent advocates, and provided weekly ‘Know your rights,’ and ‘Know your medicines,’ sessions for individual patients.
• Staff managed beds well, ensuring that a bed was available when needed and that patients were not moved between wards unless this was for their benefit. Staff worked creatively to prevent delayed discharges and avoided evening admissions.

However:

• Although care plans, particularly on Crocus Ward, were patient centred and holistic, on Jasmines Ward care plans did not always include the detailed plans of care that were recorded in the progress notes. In a small number of cases patient records did not always include the management of incontinence and how this would be addressed.
• Care plans were not user-friendly and accessible to patients, particularly those with cognitive impairment.
• Further staff training was needed in how to check and maintain the correct pressure for individual patients using a pressure relieving mattresses, to ensure that this was effective.
• Staff across different core services did not have easy access to Mental Health Act documentation confirming the legal authority to administer medicines to detained patients at the point of administration. The trust had plans to change the electronic prescribing system to address this. Staff did not always have clear instructions on how to safely administer medicines authorised to be administered covertly.

Updated 20 October 2021

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the services.

The wards we visited were:

• Ward 3 at Springfield University Hospital: a 20 bed mixed gender ward for male and female patients of working age.
• Jupiter Ward at Springfield University Hospital: a 21 bed mixed gender ward for male and female patients of working age.
• Lilacs Ward at Tolworth Hospital: an 18 bed mixed gender ward for male and female patients of working age.
• Lavender Ward at Queen Marys Hospital: a 22 bed mixed gender ward for male and female patients of working age.

The last inspection of this service took place in October 2019. We rated the service as good overall.

We changed the rating of one key question, Safe, following this inspection. The ratings for Effective, Caring, Responsive and Well-led remained rated as good.

Overall Summary

The core service remained Good overall although we limited the rating for safe to Requires Improvement as we identified breaches of regulation. This was a lowering of the rating since the last inspection.

We found:

• All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose.
• Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
• The service had enough nursing and medical staff, who knew the patients and received appropriate training to keep patients safe from avoidable harm. Staff received regular supervision and most had received an annual appraisal in the last year.
• Staff listened to patients’ complaints and tried to address them. Complaints were shared with the staff teams. Leaflets and posters were displayed on the wards letting people know how to complain, although some patients told us they did not know how to complain.
• We observed staff engaging with patients in a kind and caring way during the inspection. Staff involved patients in their care and asked them to give feedback about their experience.
• Staff felt respected, supported and valued and described an open, compassionate and responsive culture. Staff worked well together and were supportive of each other.

However:

• Although most patient care records showed that staff were aware of and put in plans to mitigate and address patient risks, on Lavender ward one patient’s care plan lacked sufficient detail in respect to their physical health care. Subsequently the patient developed a suspected urinary tract infection. After patients had been seen by a specialist, staff did not always follow up on recommendations the specialist made in relation to the patient’s physical health.
• On several occasions records showed that staff completed intermittent observations at regular, predictable intervals. By conducting observations at exactly the same time within a specific time period there was a risk that patients could predict what time staff would be observing them and plan to harm themselves in between times. The trust engagement and observations policy did not set out clear and achievable expectations regarding four times an hour observations.
• Staff did not always report and grade incidents clearly and in line with trust policy.
• Newly introduced electronic physical health monitoring and engagement and observation forms were not completed accurately and consistently by staff. Some staff told us they would like more training.
• Staff did not always complete and record Mental Capacity Act assessments when appropriate.
• Relatives and carers told us it was difficult to contact the wards as their phone calls often went unanswered. The female lounge on Ward 3 was full of furniture and the belongings of former patients making it impossible to use.

How we carried out the inspection

During the inspection visit, the inspection team:

• spoke with four ward managers and one service matron
• spoke with 11 members of staff including occupational therapists, junior doctors and registered and non-registered nurses
• spoke with 19 patients
• spoke with six patient relatives
• observed three staff handovers, and a multi-disciplinary meeting
• reviewed 12 patient care records
• completed tours of the ward areas
• reviewed clinic rooms on each of the wards

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Most patients that we spoke to said that the majority of staff were caring and treated them with respect and kindness. One patient told us that staff seem to really care about patients and felt they could talk to staff. However, patients said that some staff could be abrupt, and staff didn’t speak to them in a caring manner. We received a mixed response from patients when asked about if they felt involved in their care and treatment. Some patients felt involved and were aware of their care plan however other patients told us they were not involved and were not aware of their care plan. Nearly all patients that we spoke to felt safe on the ward.

Updated 12 June 2018

• The clinical team were knowledgeable and skilled. They had a wealth of experience. The team was led by managers who were committed to ensuring that high quality care was delivered. The clinical team worked closely with their partner providers to ensure that patients received the care and treatment they required.
• The service recognised the importance of ensuring that patients were supported to remain in good health. The clinical team had a nurse that specialised in physical health. The service had good links with the local acute hospital’s accident and emergency department. The service ran physical health clinics and the clinical team ensured that they referred patients to these clinics. Patients received a comprehensive physical health assessment.
• The clinical team monitored patients who were prescribed high dose methadone. The guidance suggests that all patients who are prescribed 100mg or above should have regular cardiac monitoring. The clinical team monitored all patients who were prescribed 70mg or above. Where cardiac abnormalities were detected staff escalated this to colleagues in the acute hospital.
• Patients were provided with crisis cards, which outlined what they should do if they became concerned that they may relapse.
• Patients stated that the staff were kind and compassionate. The clinical team had a good understanding of the needs of their patient group.
• The service had undertaken a needs analysis of the patient group. As a result, the service had made links with the local lesbian, gay, bisexual and transgender (LGBT+) forum. This was to ensure that LGBT+ patients were offered the support when needed.

However:

• Staff stored clinical information, particularly in relation to patients’ physical health, in different places on the electronic patient record, which meant that it could be difficult for staff to find it when they needed to. This was brought to the attention of the trust who took immediate steps to provide staff with guidance regarding the recording of information on the electronic patient record.
• It was not clear how recently staff had cleaned the physical health monitoring equipment as this was not recorded. Staff had not labelled the yellow sharps disposal bins correctly. There was a risk that equipment might not have been clean and safe to use.
• The trust had not reviewed prescribing protocols since the publication of new UK clinical guidance in July 2017. There was no assurance that the prescribing protocols were still in line with best practice.
• The clinical team did not have mechanisms to monitor informal or local complaints. This was a missed opportunity for learning.
• The soundproofing in the therapy rooms was poor. Conversations could be heard outside. This had been brought to the attention of the lead provider who was addressing this issue.

Updated 12 June 2018

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

• During this inspection, we found that services had addressed the issues that caused us to rate it as requires improvement following the March 2016 inspection.

• The services had embedded systems to support staff to remain safe whilst carrying out their work. Staff assessed risks for patients and worked with them to manage these risks. Staff knew when to report incidents and when to make vulnerable adult and children safeguarding referrals. Medicines management within the teams had improved since our last inspection, in March 2016. Staff safely transported, stored and administered medicines to patients.

• The trust continually worked towards recruiting sufficient staff to support patients, but this proved more difficult in some boroughs. Staff were skilled in their roles and received specialist training, especially in caring for patients with a personality disorder, from the psychology teams. Staff supervision within the teams had improved since our last inspection, in March 2016. Staff received regular management and clinical supervision to develop their skills and check their wellbeing.

• Staff demonstrated excellent working relationships with teams, both internal and external to the trust, to ensure a smooth, holistic pathway of care for patients. Staff offered interventions aimed at improving patients’ social networks, education and employment. Patients attended the recovery college provided by the trust to complete courses such as mindfulness and understanding self-harm. Patients also attended the recovery cafés in Merton and Wandsworth to meet with their peers in the evenings and weekends.

• Staff worked with some patients to develop care plans that were holistic, person-centred and recovery focused. The teams provided care and treatments based on national guidance that promoted patients’ holistic care and included receiving psychological therapies. Staff worked to improve the physical health of patients and actively monitored the effects of medicines.

• Patients praised clinical psychologists, psychiatrists and care coordinators within the teams. For example, patients said that they would not be able to cope without the staff in the teams. Staff spoke with patients in a meaningful way and could calm patients down when in distress. Staff involved patients and, when appropriate, carers in decisions about care.

• The services had clear acceptance and referral criteria for who they would offer a service to and clear care pathways for patients depending on their mental health needs. Most teams met waiting time standards. When patients did not attend their appointments, staff actively followed them up.

• Staff described the trust’s vision and strategy and understood how this applied in their work. Most staff were positive about the teams that they worked for. They felt confident in the leadership of the community teams. Managers could easily access information about their teams and use this to drive improvement. Senior management regularly monitored the safety and quality of services.

However:

• At the last inspection in March 2016, we found that the trust did not ensure staff updated patient risk assessments regularly and after incidents. At this inspection, although we found that this had improved, staff did not always fully review and update risk assessments after a transfer from another team or after an incident in 19% of records we reviewed.
• Patients reported that when they rang the trust’s contact centre to speak to their care coordinator they often struggled to get through. This was especially an issue in Kingston, Richmond and Merton. As a result, patients may not have been able to get hold of their care coordinator quickly.
• Caseloads in the Wandsworth early intervention service were higher than nationally recommended levels.

• Staff did not always keep records of when they had explained to patients their rights and conditions in respect of Community Treatment Orders.