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

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.

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.

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.

Background to the inspection

Burntwood Villas is a locked step-down mental health rehabilitation unit within a specialist forensic pathway for up to 15 patients. The service is comprised of three units. Burntwood Villa accommodates up to eight male and female patients. Staff are present at this service at all times. Fairways and Redwood are semi-independent properties that are checked by staff once per shift. Fairways is a three-bedroom house and Redwood, has four bedrooms. One house is for females and the other males only.

This was an unannounced focused inspection, which we undertook following receipt of the investigation report into the death of a patient in August 2020. The trust had commissioned an independently chaired investigation into the death. The report of the investigation identified several failings in patient care, including care planning, physical health care, communication with primary care, lack of a rehabilitation focus and medicine management.

We re-rated the core service following this inspection as we identified breaches of regulations that limited the ratings for three key questions, Safe, Effective and Well-led, to Requires improvement. The previous rating of Good overall went down to Requires Improvement.

How we carried out this inspection

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

During the inspection visit, the inspection team:

observed how staff were caring for patients
observed staff use of PPE
spoke with two patients who were using the service
spoke with the GP for the service
spoke with the ward manager
spoke with 12 other staff members across the multidisciplinary team including consultant psychiatrist, occupational therapist, clinical psychologist, registered nurses and recovery workers
reviewed six care and treatment records of patients
looked at some documents relating to the running of the service

Overall Summary

The service did not consistently admit patients in accordance with its inclusion and exclusion criteria, as stated in the operational policy, and some patients whose presentation had changed had not transferred to more appropriate settings in a timely manner. The trust was aware of the need to transfer some patients, and it was in the process of finding placements for them.”. Some patients had higher care needs on admission, this placed an additional burden on staff because the service had not been adequately resourced to meet the physical and mental health needs/requirements of patients who fell outside of its scope.
Patient acuity was high, as a result staff were not able to provide a rehabilitation model in line with the operational policy. Activities and therapeutic interventions were minimal and additional staff were needed to care for patients safely. We shared our concerns with the trust who responded promptly by increasing staffing and pausing admissions. The trust also assured us they would thoroughly review the care pathway for patients as well as staff skill mix going forwards.
Although there was a new multidisciplinary team in place, who were committed to delivering a high-quality rehabilitation service the governance arrangements were not effective in ensuring that this was delivered. Staff did not feel their concerns were acted on and significant risks faced by the service were not consistently documented or addressed.
Fire risks were identified through an annual risk assessment and fire drills carried out, but risks were not consistently documented or acted on promptly, placing patients and staff at risk. The nurse call alarm was not well maintained and did not work adequately on the day of our inspection.
Staff did not always follow infection prevention and control policies. Two of four staff were not wearing face masks appropriately when the inspection team arrived at the service.

However;

The ward environments were clean and well furnished, staff received appropriate mandatory training and followed good practice with respect to safeguarding, reported incidents and shared learning when things went wrong. Staff managed challenging behaviour well and did not use restraint or seclusion on the unit.
Staff assessed and monitored patients’ physical health consistently and regularly. Patients receiving medicine requiring blood monitoring (including clozapine) were able to access regular blood tests and staff regularly asked patients about issues that can affect clozapine blood levels, such as constipation.
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 training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward. The leadership team were mostly new in post but had a good understanding of what a high-quality rehabilitation service should look like.
There were processes in place to ensure learning from incidents, and a recovery plan was in progress addressing gaps in care identified in a serious incident investigation report.

Avalon Ward is a 15-bed national, specialist service providing care and treatment for male and female patients experiencing severe eating disorders over the age of 18. During the Covid-19 pandemic temporary changes had been made to the ward to reduce the number of beds from 20 to 15 for a six-month period. This was to enable Wisteria Ward, a specialist eating disorder service providing care and treatment for young people aged 11 to 18 years of age to re-open five beds in August 2020. Modifications had been made to Avalon Ward to close off part of the ward to accommodate Wisteria. We did not inspect Wisteria Ward as part of this review.

Avalon Ward received Quality Network for Eating Disorders (QED) accreditation for the period 26 June 2020 to 26 December 2020.

We undertook this inspection due to information of concern we had received about Avalon Ward. The information received described how staff were not always supportive or encouraging of patients, that staff could be rude and abrupt and that this could impact on the patients’ recovery. We were informed that some staff did not understand how to care for patients with eating disorders at mealtimes, that incorrect portion sizes were sometimes given and that on occasion meals ordered were replaced due to error or unavailability. We were told there was limited access to therapy on the ward, that patients did not always know who their keyworker was and that patients were not always orientated on to the ward. We also looked at some of the issues identified during the previous inspection in September 2019 around physical health observations and ligature risks. We looked at personal protective equipment (PPE) arrangements to ensure staff had adequate PPE to minimise the risk of transmission of Covid-19, and that social distancing and isolation arrangements were in place where necessary.

This was an unannounced focused inspection of Avalon Ward. We did not re-rate this core service following this inspection. The existing rating of Requires Improvement overall remained the same.

As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent on the ward to prevent cross infection. Two inspectors and a CQC specialist advisor visited the unit on 11 August 2020 for half a day to complete essential checks. Whilst on site we wore the appropriate PPE and followed local infection control procedures. The remainder of our inspection activity was conducted off-site. This included staff interviews over the telephone and analysis of evidence and documents. Our final telephone staff interview was completed on the 27 August 2020

We found:

The service had suitable infection control arrangements in place.
Staff assessed and managed risks to patients, ligature risks had been assessed and staff knew where they were. Staff undertook observations on patients’ physical health and escalated concerns when required.
Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice.
Most staff treated patients with compassion and kindness. Patients and family members described particular staff in very positive terms. The manager had taken appropriate action in line with trust policies to address concerns relating to staff attitude towards patients.
The service treated concerns and complaints seriously, investigated them and invited patients and/or their carers to discuss their concerns with management.

However:

Patients had not always received the meal which they had ordered from the catering department. Ward staff had not escalated this to the catering contractor, except on one occasion. Staff did not always serve the correct portion size to patients at mealtimes.
Patients reported that some staff were unhelpful and inexperienced at supporting them during mealtimes. Whilst a training course on therapeutic eating had been established and was being rolled out, the service had not kept records of attendance. There was limited support from a qualified dietitian due to temporary arrangements to cover maternity leave.

Patients reported that a small number of staff had been rude and on occasion had shouted at them including at mealtimes. The provider was aware of this and taking steps to address poor and unprofessional behaviour by specific staff and improve overall staff engagement with patients.

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

During the inspection visit, the inspection team:

observed how staff were caring for patients
observed staff use of PPE and infection control/isolation arrangements
spoke with 10 patients who were using the service
spoke with family members of two patients who were using the service
spoke with the ward manager
spoke with 15 other staff members across the multi-disciplinary team including medical staff, dietitian, clinical psychologist, registered nursing staff and non-registered nursing staff.

looked at eight care and treatment records of patients

looked at some documents relating to the running of the service

We found a mixed picture on the two wards in terms of the quality and safety of the care provided. While on Avalon Ward, the eating disorder ward for adults, we found that care and treatment had improved since our last inspection, we identified several areas of concern regarding the care provided to the young people on Wisteria Ward. The trust had identified and highlighted concerns to us following a serious incident on Wisteria Ward before our inspection and had stopped admissions until they were satisfied that they could provide safe and effective care.
Bedrooms on Wisteria Ward had ligature points, which were not included in the ward ligature risk audit. Three staff we spoke with on Wisteria Ward were not aware of the potential ligature risks in the bedrooms. Two temporary staff did not know where the ligature cutters were kept. The trust took immediate action to update the ligature risk audit and ensure all temporary staff were informed about the location of the ligature cutters during their induction. Where young people were assessed as at risk of self-harm staff took action to protect them by increasing levels of observation, risk assessments were of good quality on both wards.
Some practices on Wisteria Ward were overly restrictive. Staff locked young people’s bedroom doors for long periods throughout the week and were unable to explain the rationale for these restrictions. Restrictions were not based on individual needs. Staff locked away young peoples’ care plans, explaining they were protecting patient confidentiality, but this meant that young people’s involvement in their care was not promoted.
Staff on Wisteria Ward did not fully understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff did not follow good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
Staff on Wisteria Ward were not always responsive to young people’s feedback. Staff and young people complained that food was not always of good quality. This had not been escalated to catering services. Although following a similar complaint from patients on Avalon Ward, staff had raised their concerns with the caterers and were taking steps to make improvements. Staff on Wisteria Ward did not keep a record of the weekly community meetings. This meant that any feedback the young people gave could not be followed up with an identified action.
Although governance arrangements worked well on Avalon Ward and supported the delivery of high-quality care, Wisteria Ward needed to make improvements to their systems and processes to ensure they were well led. The trust had taken action to strengthen governance systems on Wisteria Ward since a serious incident earlier in the year, but these still needed further embedding. The team’s local recovery plan did not include some of the risks and ineffective practice we found during this inspection. Audits of assessments of competence in under 16s had not been completed, although they were part of the ward recovery plan.
Although staff had made improvements in monitoring and recording patients and young people’s vital signs since the last inspection, in March 2017, we found that when staff decided not to escalate concerns about patients with elevated scores on the modified early warning score charts, they did not always record why action was not being taken. Information on physical health monitoring scores was stored in three different parts of the patient records, which could lead to errors in transferring data or in finding accurate information when needed. The trust took immediate steps to address this with staff and ensure decisions not to escalate certain scores were recorded in patients’ care plans or progress notes. There was no evidence that patients came to harm as a result.
Staff morale on Wisteria Ward was low, there was a lack of clear leadership on the ward and the multidisciplinary team needed to work better together to ensure young people achieved the best outcomes.
There was high use of bank staff, particularly on Wisteria Ward, some of whom lacked experience of eating disorders. The ward had an on-going recruitment programme to fill all their vacancies.

However:

The trust had made improvements to the recording of patient and young peoples’ risk management plans since our last inspection in March 2017. Staff completed detailed risk assessments for patients and updated them after incidents. Risk management plans contained information specific to patients’ physical and mental health needs. Staff knew what safety incidents to report and how to report them.
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 for eating disorders. Staff on Avalon Ward supported patients with particular physical health conditions well.
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 with those outside the ward who would have a role in providing aftercare.
Staff treated patients with compassion and kindness. On Avalon Ward, they actively involved patients and families and carers in care decisions. Staff and patients had co-produced a welcome video for patients and staff to orientate them to the ward. The manager hoped to start using this video soon for new patients. The occupational therapist had developed a voting system for patients to have a say about what groups and activities they would like on the ward.
Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, staff worked with community services and acute care health specialists to optimise the care pathway for patients with an eating disorder.

Since the inspection in February 2018, the trust had taken steps to improve the recording of physical health observations of patients following rapid tranquilisation. Staff across all wards had recorded necessary checks in-line with trust policy in all but one of records we reviewed. Similarly, improvements had been made in the recording of patients’ physical health. Staff escalated deterioration in patients’ health in accordance with trust guidance.
The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
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 a 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 would have 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.
The trust was rated as good for caring, responsive and well-led at the last inspection in 2018. We did not reinspect these key questions at the current inspection. The ratings remained the same.

However:

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.
Mental Health Act forms confirming the legal authority to administer certain medicines were not easily accessible to staff at the point of medicines administration.
There was no contingency plan in place to enable the provision of psychological therapies to patients on the acute wards when the clinical psychologist was absent for an extended period.
Although the trust was actively working to reduce this through implementing the safety in motion programme, a high proportion of patient restraints took place in the prone position

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.

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.

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.

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.

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

We rated all six services we inspected as good. Following this inspection all the trust’s services were rated good overall.

We rated well-led for the trust overall as good.

The trust had made considerable improvements since the last comprehensive inspection in March 2016. The community-based mental health services for working age adults, long stay/rehabilitation mental health wards for working age adults and child and adolescent mental health wards had all improved their ratings overall and/or in individual key questions. The trust had met all requirement notices made following the March 2016 inspection and a focused inspection in September 2017 in those services we inspected.

Whilst there had been a number of changes in executive directors, the trust was well-led and the senior team were committed to improving services to meet the mental health needs of local communities. The trust had an open and transparent culture and staff were able to raise concerns. Staff were committed to the working for the trust and felt well supported by their managers and colleagues. An award winning intranet provided accessible information to staff and supported overall engagement.

The trust was outward looking and engaged well with external partners and stakeholders. The trust was working well with the two other South London mental health trusts through the South London Partnership and this was supporting the introduction of new models of care. The trust was actively engaged in the work of the sustainability and transformation partnership.

The trust encouraged innovation to improve patient care. Recent developments included a service aimed at preventing admission to hospital, and the introduction of crisis cafes, which were very well liked by service users. More than 40 quality improvement initiatives had been completed by staff or were under way across the trust.

The trust had effective structures, systems and processes in place to support the governance of the trust, including financial governance. Managers had easy access to performance information to enable them to make improvements. Staff could add local risks to service line risk registers. Risk registers reflected the risks staff told us about. Senior leaders had good oversight of risks. There was an open and positive culture in respect of reporting incidents. Lessons learned were disseminated to staff and used to improve services.
The trust was making good progress with the recruitment and retention of staff. A detailed review of staffing levels on inpatient wards had led to an increase in staffing on most wards. A caseload weighting tool in the community mental health teams was helping to ensure caseloads for individual staff were manageable.
The trust had a focus on equality and diversity and was supporting the development of staff diversity networks. The trust provided effective communication support to deaf service users through the employment of deaf nursing staff, the provision of British Sign Language interpreters and videos on the trust website. The trust worked well with local communities, including black and minority ethnic communities and schools, to promote and support mental health initiatives. The trust board had a diverse membership. The trust had set up an expert working group to look at the disproportionate number of black men detained under the Mental Health Act.

However:

Staff did not always follow best practice to ensure the safety of patients after they had received rapid tranquillisation. When patients declined checks of their clinical vital signs, staff did not always return to make further attempts to record these observations. When staff carried out routine checks of patients’ vital signs, they did not always escalate results to senior nursing staff or a doctor when indicated by the scoring tool or record why they had not done so.

Staff did not always store information on patient electronic records consistently so that it could be found easily by others. The patient records system in the substance misuse service was difficult to navigate and staff stored information in different places, which made it difficult to find. The electronic patient record system in the CAMHS community teams was difficult for staff to use and it was easy to input information into the wrong place. Staff in community teams reported regularly being unable to access patient records when the server was down for short periods. Clinical staff found IT support was not always timely and accessible.

The trust had not consulted effectively with staff around changes to mental health rehabilitation services that had been made. Staff were unhappy with the and the way they had been involved in discussions about the changes. They continued to be anxious about the future of the service and morale was low.

Some trust services missed an opportunity to learn from informal or local complaints as they did not keep a record of the complaints to support managers to identify patterns and trends.

The trust needed to continue to work on the new trust strategy that would provide clear direction and underpin the delivery of high quality sustainable care. Further work was needed to fully implement the leadership development programme for ward and team leaders and managers.

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.

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.

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.

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

The trust had made improvements since the last inspection.

Patients were involved in their care planning and staff supported them to give their views and develop objectives. Patient care plans were personalised and holistic.

The ward planned for patients’ discharge and worked well with both internal and external agencies. The ward did not experience delayed discharges and had reduced the average length of stay on the ward considerably in the previous year.

Staff were caring and supportive of patients. Patients were allocated a care team and regularly met with named nurses for one-to-one sessions. Staff had a good understanding of the individual needs of patients, including their personal, cultural, social and religious needs.

Patients were supported to live healthier lives and had access to physiotherapists and dietitians to help improve fitness and diet.

Staff followed good practice in medicines management. Medicines were stored safely. The implementation of electronic prescribing and medicine administration records had led to a significant reduction in omitted medicine doses. Ward areas and furnishings were visibly clean. Clinical equipment was checked, calibrated and kept clean and ready for use.

At our previous inspection in March 2016, we identified that staff did not always address identified patient risks in risk management plans. At this inspection we saw improvement. Patients received a comprehensive assessment on admission with effective multi-disciplinary input. The ward assessed risk and physical health on an individualised basis. Plans were in place to address and mitigate risks.

At the last inspection in March 2016, we found that the patients were not supported to access programmes of therapeutic activities to promote their rehabilitation. At this inspection, we found significant improvement. The ward supported patients to become more independent and prepare them for discharge into the community. The service provided a wide range of psychological interventions, occupational therapy, leisure and vocational activities. The ward adapted this on a regular basis to meet the needs of patients.

At the last inspection in March 2016, we found that the trust had not supported managers to develop the leadership skills to implement a recovery orientated approach to care on all rehabilitation wards. At this inspection, we found the trust supported the ward manager for Phoenix Ward to ensure staff were aware of the aims and objectives for patients across the ward. The manager was attending a development course for black and minority ethnic staff.

The ward had made considerable progress in ensuring that all staff received appropriate clinical and managerial supervision. Staff supervision rates had risen by 40% since the last inspection in March 2016. Eighty five per cent of planned supervision took place. All staff had received an annual appraisal.

However:

Records of complaints and safeguarding referrals were not kept at a local level. Whilst staff had a good understanding of the trust processes for both, the ward did not have appropriate systems to monitor the progression of these concerns.

Staff were unsure about the future of the service and felt this had not been communicated well by senior leaders in the trust. The morale of some staff was low as a consequence.

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

Wards were led by skilled, knowledgeable and experienced managers. Ward managers had easy access to detailed information about the performance of their ward that helped identify shortfalls and supported their commitment to drive improvements in patient care. Staff took part in quality improvement initiatives aimed at reducing waste, reducing violence and aggression on the wards and improving the physical health and well-being of patients.

Staff treated patients with kindness and compassion and offered support to carers. Patients described staff in positive terms highlighting their caring, friendly and supportive approach. Two wards ran weekly family clinics to support patients and carers and Lavender Ward had a full time carer support worker in post. Staff enabled patients to give feedback about their care and experience via real time feedback devices and in regular community meetings. Staff acted on feedback.

Staff came from diverse backgrounds and offered support to patients that took account of their spiritual, cultural and religious needs. Some staff wore rainbow lanyards, which showed the wards were trying to be inclusive and supported patients to discuss their sexuality. A former transgender patient provided training for staff on Lilacs Ward on how to care for transgender patients.

Staffing levels had been increased across all wards to make them safer and ensure that patients could go on leave and have regular one to one time with staff. Staff planned patient discharges proactively.

The wards had improved reporting of incidents and restraints and had introduced strategies to reduce violence and aggression and restrictive practices on the wards. Staff learned from complaints and serious incidents and made improvements so as to reduce the risk of reoccurrence.

Patients had a comprehensive physical health assessment shortly after admission. Staff promoted healthier lives and supported patients to stop smoking and improve levels of exercise and diet.

On Rose Ward, patients were provided with coloured cards that they could use to indicate to staff how distressed they felt and what could help them. The cards helped patients who were unable to verbalise their distress and risks.

However:

Staff did not always record patients’ physical observations, or attempts to take clinical observations, after rapid tranquilisation had been administered, in line with trust policy and national guidance. Staff on the PICU recorded patient refusals to have physical observations but did not record revisiting the patient and trying to complete these observations a second time.

Staff did not always record patients’ physical health observations with the correct frequency and when scores were elevated did not always escalate the concern to a senior nurse or medical staff.

Five wards had 23 beds, more than the 18 beds recommended by the Royal College of Psychiatrists.

Although most patients’ risk assessments were detailed and updated following risk events; nine of the 36 we reviewed were not.

Medicines were not always stored at the correct temperature. When this was identified, staff did not record whether they had escalated this to a pharmacist or were taking steps to address it.
Some staff had not yet completed mandatory training related to risk assessment (RATE training) and medicines management (for allied health professionals). There were low staff appraisal rates for nursing staff on Ward 1 and Ward 3.
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. Doctors did not document discussions with patients about treatment options in detail when obtaining consent to treatment from patients.
On Lavender Ward, some patients were prescribed medicines to aid sleep for several weeks. There was no record that these ‘as required’ medicines were reviewed frequently enough, in line with trust policy and best practice guidance, and continued to be required by the patient.
Although the trust was actively recruiting more clinical psychologists, in the meantime patients had limited access to a clinical psychologist.

Very few staff in this core service said they were aware of the Freedom to Speak Up Guardian service and how to make contact.

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.

Because this was an unannounced focused inspection of one ward, we have not revised the ratings for the core service.

We found the following areas for improvement:

Staffing levels on the ward were not sufficient to ensure patient safety or to ensure that patients’ needs were met. Patients reported that they would like more interaction with staff on the ward. They frequently had to wait for some time for staff to meet their needs.
Following a serious incident involving a ligature anchor point, some adaptations had been made to minimise future incidents. However, further adaptations had not been made to high risk potential ligature anchor points. Staff had not mitigated the high risk ligature anchor points on the ward sufficiently to ensure that patients were safe.
Staff had stored medicines at the incorrect temperature on a number of occasions. There was no record that they had taken any action each time the room temperature was above 25 degrees.

It was possible for male patients to enter the female part of the ward unobserved by staff.

All patients had their property searched when they returned from leave. Searches were not based on individual patient risks.

Infection control stickers were available to attach to medical equipment when it had been disinfected, but staff had not been used them.

The average bed occupancy level on Ward 2 was 111%. This was above the trust average for acute wards. When patients were on leave, their bed was occupied by another patient.
Patients’ care plans did not record that patients had been involved in their development. Patients’ care plans were written in a generalised way.

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

The ward was in the process of introducing the Dynamic Appraisal of Situational Aggression (DASA). The DASA is an assessment tool to assist in the prediction of violence and aggression.
Patients found staff caring and compassionate and reported that they were listened to and involved in their care and treatment.
Risk assessments for patients were thorough and detailed. The multi-disciplinary team used a RAG rating (red, amber, green) system to indicate the level of risk regarding clients.

The new ward manager had a positive impact on the staff team and quality of care on the ward.

We rated specialist eating disorder services as good overall because

Avalon ward had made improvements since our last inspection in October 2015. When the ward was last inspected in 2015, we found that the clinic room was disorganised and unclean. During this inspection we found that the clinic rooms on the ward were clean and well organised.

When Avalon ward was last inspected, we found that not all staff had completed their mandatory training. During the current inspection we found, that the staff training completion rate was 90%. Wisteria ward and the Eating Disorders Day Unit the training completion rates were over 80%. Staff had access to a wide range of specialist training.

Both Avalon and Wisteria wards admitted patients from across the country and were able to care for patients with complex health needs. Avalon ward had high dependency beds.

Avalon and Wisteria wards complied with National Health Service (NHS) guidance on same sex inpatient accommodation.

Avalon and Wisteria wards had nursing vacancies and there was regular use of agency staff. There was a low number of unfilled shifts. Managers ensured that the wards were staffed safely. Recruitment was a priority for the trust and there was an ongoing recruitment campaign.

The services used a range of outcome measures to determine the efficacy of the care and treatment provided. Managers had regular forums during which they could review the quality and safety of the service.

Patients' voices were evident in their care plans.They participated in meetings and received information about their care. Patients were able to give real time feedback about their experience of care and treatment whilst on the wards.

Parents of patients on Wisteria ward could attend a parent’s group. Patients were able to personalise their bedrooms and had access to outside space

There were doctors available to attend the wards day and night in an emergency. A full range of mental health professionals provided input into the three services. Patients were offered a range of psychological therapies. Patient treatment was evidence based and followed national guidelines.

Staff morale in all services was high.

However, we found the following issues that the trust needs to improve:

During the current inspection we found that on both Avalon and Wisteria wards, that the temperature of the medicine fridge was not being monitored in line with trust policy. The fridge temperature range on both wards was above the recommended range on a number of occasions. On Avalon ward this had happened on 21 ocasions between January 2017 and February 2017. On Wisteria ward this had happened on 31 occasions during the same time period. Staff could not be assured that medicines had been stored at the optimum temperature at all times.

On Avalon ward, results of checks on the physical health of patients were not always up dated promptly in patients’ electronic records.There was a risk that staff would not escalate concerns to medical staff quickly when needed.

Staff on Avalon had not always updated patients’ risk assessments after incidents. Nor had they reviewed patients’ risk assessments before they went on leave. The lack of regular updates meant that staff might not be able to respond appropriately.

Visitors to Avalon ward found that there were delays in being able to come onto the ward. Visitors pushed a door bell to let staff know they wanted to enter the ward. The door did not open automatically. Out of hours, visitors to the ward had been left outside the building and had waited for an extended period of time before they were allowed into the building.

The ligature risk assessment for Avalon and Wisteria ward was not accurate. The assessments had not identified all the potential ligature risks on the wards. This was brought to the attention of the trust on the day of inspection. The trust updated and reviewed the ligature risk assessments for both wards immediately after the inspection.

The blood glucose monitoring equipment on Avalon ward had not been calibrated in line with trust policy.

On Wisteria ward, patients’ dignity and privacy was not always maintained. There was a whiteboard with patient details in the nurses office that could be seen by visitors to the ward. This was brought to the attention of the trust who said they would take action to remedy this. The patients’ bedroom doors had windows but there were no curtains. One patient bedroom had insufficient privacy film on the window. This meant that anybody who walked past the window could see into the bedroom.

On Avalon and Wisteria wards the appropriate Mental Health Act documentation was in place. This information was held electronically. However, staff could not readily access this information because they were held on two separate electronic databases. There were no paper copies of the T2 or T3 forms with the medicine cards. For one patient, there was no up to date copy of the T3 form in the electronic record and for another patient the most recent T2 did not have all the medicines prescribed for the patient noted on it. We asked a member staff to find this authorisation to administer these medicines but were unable to do so. Staff who administer medicine for a mental disorder to a patient detained under the Mental Health Act must be satisfied that there is legal authority to do so.

Staff were supposed to have 1-1 supervision sessions with their manager on a monthly basis and were supposed to have an annual appraisal. The supervision rate on Wisteria ward was low (71%). Not all staff on that ward had recieved an annual appraisal. Seventy five per cent of staff on Wisteria ward had received an annual appraisal.

The patients and staff expressed concerns regarding the quality of the food that was being served on the wards.

The wards did not have information available that reflected the diversity of the patient group. For example, there was no information regarding culture, sexuality, religion or gender on the wards.
The MDT (multi-disciplinary team) on Wisteria ward had not had regular business meetings for a period of three months due to staff sickness. This meant that information was not shared easily within the team.

After the inspection in September 2016, we have changed the overall rating for the trust from requires improvement to good because:

In March 2016, we rated 7 of the 10 core services as good.
In response to the September 2016 inspection findings, we have changed the ratings of one more core service from requires improvement to good. This is the core service for community based mental health services for older people.

Also after the September 2016 inspection, we have changed ratings of the following key questions from requires improvement to good:

the effective key question for wards for older people with mental health problems,
and the effective domain for mental health crisis services.
In the services we inspected, the trust had acted to meet the requirement notices we issued after our inspection in March 2016.
We also carried out a ‘well led’ review and found that the trust had continued to strengthen its senior leadership team and refine the trust governance processes.

However:

Following the March 2016 inspection, we rated two other core services as requires improvement. These are the rehabilitation wards for working age adults and community based mental health services for adults of working age. We also rated the safe domain as requires improvement for forensic services and child and adolescent mental health wards. The trust has provided clear action plans explaining the changes taking place over a longer timescale. The Care Quality Commission will return at a later date to re-inspect these services.

The full report of the inspection carried out in March 2016 can be found here at http://www.cqc.org.uk/provider/RQY

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

Following our inspection in March 2016, we rated the service as good for safe, caring, responsive and well led.
During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective as requires improvement following the March 2016 inspection.
The mental health crisis services and health based places of safety were now meeting Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

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.

We rated wards older people with mental health problems as good overall because:

Following our inspection in March 2016, we rated the service as good for safe, caring, responsive and well led.
During this most recent inspection, we found that the service had addressed the issues that had caused us to rate effective as requires improvement following the March 2016 inspection.
The inpatient wards for older people with mental health problems were now meeting Regulation 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

The majority of patients on Bluebell ward came from London and the south of England. The ward had a mix of hearing and deaf staff. All staff were proficient in british sign language (BSL).The staff were skilled and there was high completion rate of mandatory training
There were systems in place to ensure that learning from incidents took place throughout the service. The ward had robust systems for dealing with complaints. Patients had complained about the admission of hearing patients onto Bluebell ward due to bed pressures in other parts of the trust. The trust had revised their protocol for admitting hearing patients onto the ward. They had put in additional safeguards.
The ward had robust processes to manage medicines.
Bluebell ward had nursing vacancies and there was regular use of bank and agency staff. The ward tried to use bank and agency staff who could sign. This meant that bank and agency staff could communicate with the deaf patients and staff.
The comments from the patients using the service were generally positive. The patients were partners in their care and their voices were evident in their care plans. They participated in meetings and received information about their care.
The staff were responsive to the needs of patients and supported patients to access spiritual support. The ward was able to provide patients with cultural and religion specific foods.

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

Sutton, Merton and Richmond teams did not have adequate medicines management arrangements. Medication was not transported securely between the teams base and patient’s homes, medication stock levels were not recorded at the team base. Patients’ risk assessments were not recorded consistently and were not always updated in a timely manner. In Merton, Kingston and Wandsworth, patients were not always receiving regular physical health checks.

Staff in Merton team did not receive regular individual supervision.The administration support for the Kingston team was not operating well which led to patients’ appointments being cancelled and staff being unable to locate patient records.

Senior managers in the trust had not visited the teams. Staff felt isolated from the trust and individual teams were working in silos. There was low staff morale in Kingston and Richmond teams. Staff told us this was because of the transformation process, poor engagement with the trust and the uncertainty about the future of Barnes Hospital. Staff gave feedback on services to the senior management team and felt they were not always taken seriously or treated with respect when they do.

However, staff were professional, caring and showed kindness and respect to patients and their carers. We observed at the Kingston Memory Clinic that patients understood their care, treatment and condition. There was evidence of appropriate involvement of, and provision of support to families and carers. For example teams had good working links with the Alzheimer’s Society.

Arrangements for lone working were in place to ensure staff safety across the service. Arrangements for safeguarding were clear with good systems in place to monitor and follow up concerns.

Practice was evidence based and there was good access to a wide range of interventions. These included anti-psychotic medication for people with dementia and cognitive behavioural therapy for depression. The memory services provided effective post diagnostic interventions and support for both patient’s and carers.

There was effective multi-disciplinary team working within teams. 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. The staff teams displayed effective team working and mutual support.

Staff had manageable caseloads and managers ensured that workloads were evenly distributed across the teams. Referrals were prioritised and dealt with in a timely manner. There were good pathways to the service and patients were promptly allocated to an appropriate staff member. Wandsworth and Sutton took a proactive approach to re-engage with patients who missed appointments. Staff would make telephone calls and clinicians would follow up with home visits.

Patients at Merton attended clinic appointments at the Nelson Health Centre. We observed this was a dementia friendly environment and patients and carers fed back that it was accessible, bright and a pleasant atmosphere. Adjustments were made for patients requiring disabled access, brail on signs and hearing loops. There was easy access to interpreters.

The services had been innovative. At Kingston the psychiatrist had developed a tool for assessing patients with memory difficulties and this was implemented within the team. The admiral nurse developed a family assessment tool which is currently used by the team. The behaviour and communication service at the Wandsworth team had won three awards in service improvement, dementia care and mental health. The Wandsworth team produced their own staff bulletin which shared good practice and commended individual staff. There was leadership within this team.

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.

We rated child and adolescent inpatient mental health services as good because:

Staff were kind and treated children and young people with dignity and respect. Young people were able to participate actively in decisions about their care and in decisions about the running of the ward. Staff undertook a comprehensive assessment of the physical and mental health of each young person on admission and these were monitored throughout their stay.

The ward provided a comprehensive range of treatments using medication and therapies in accordance with best practice from bodies such as the national institute for health and care excellence. Care and treatment was provided by a team of qualified doctors, nurses, social workers and therapists, all of whom showed a good knowledge and understanding of the young people. Staff received specialist training for their role, including a psycho-social interventions course, dialectical behavioural therapy training and training on the Children’s Act 1989.

Young people had access to quiet areas of the ward. Outside there was a courtyard where young people could play games. The trust had adapted a bedroom and bathroom for young people with disabilities. Young people could continue with their education at an on-site school.

The manager supported staff to raise concerns. The views of young people and their families were collected and reviewed to measure the quality of the service.

However, staff were not recognising that when young people were using the low stimulus room that this was seclusion and so the correct safeguards including medical and nursing reviews were not in place. . Staff supervision records were not being stored appropriately.

We have given an overall rating of requires improvement to South West London and St George’s Mental Health NHS Trust.

We have rated three of the ten services that we inspected as requires improvement and seven as good. The services that require improvement are the community based mental health services for adults of working age and for older people and the rehabilitation mental health wards for working age adults.

The main areas for improvement were as follows:

The trust had not ensured that the wards providing rehabilitation were supporting patients to achieve greater independence. The exception to this was Burntwood Villa where there was a well developed model of rehabilitation.
In the forensic service and the child and adolescent mental health ward the trust was not recognising when they were secluding patients. This meant that the appropriate safeguards in terms of regular observations and medical review were not in place to keep people safe.
Across a number of wards and teams staff were not being supported with regular one to one supervision. This often reflected the workload of the team and because some managers in the community were responsible for supervising too many staff.
The trust had restructured the administrative support to teams in Kingston into a central hub. The implementation of this change was having ongoing negative consequences with patients not receiving appointment letters, delays in information reaching GPs and staff in the trust not being able to access patient information they needed for outpatient appointments. Whilst improvements were underway there were still more needed to ensure a safe service.
The maintaining of up to date risk assessments across a number of teams needed to be improved. They also had to be stored consistently so they can be located when needed. This meant there was a risk of staff not safely supporting patients with their individual risks.
There were significant challenges in the community services for working age adults, especially the recovery teams where staff morale was lower and staff were worried about meeting the complex needs of the patients on their caseloads.

Despite these areas for improvement there was much for the trust to be proud of as follows:

The senior executive team were committed to improving services and providing a high standard of care for patients.
Most staff said how much they enjoyed working for the trust and valued the leadership provided by the senior team. Many specifically mentioned the role played by the chief executive.
Most staff we met were caring, professional and in manay cases innovative in their work.
The culture of the trust was largely healthy with patients and staff feeling able to raise issues they felt needed to improve without fear of retribution.
The trust board provided effective challenge and helped to ensure the trust met its strategic objectives.
There were robust ward to board governance processes in place that supported managers throughout the trust to identify when improvements needed to take place.
The trust was working with local communities to overcome the stigma of mental illness and make services more accessible.
There had been significant improvements in the acute care pathway. Whilst demand was still very high and this presented a daily challenge, patients had an improved level of support to access the services they clinically needed.
Staff had access to a wide range of opportunities for learning and development, which was helping many people to make progress with their career whilst also improving the care they delivered.

There were many areas of ongoing work within the trust. This included an active staff recruitment campaign. There were also other developments to improve patient and staff engagement. These will need time to progress but the inspection team agreed that the trust had the necessary leadership in place to take this forward.

We will be working with the trust to agree an action plan to address the issues we found during our inspection.

We rated the acute wards for adults of working age and the psychiatric intensive care unit as good because:

Staff treated patients with dignity and respect. Staff made sure that patients, their carers and families were involved in their care and treatment. Patients had access to independent advocates to support them to raise issues concerning their care and treatment and staff referred patients to advocacy services when required

Staff followed best practice when undertaking the care and treatment of patients. Staff closely monitored the physical health of patients and systems were in place to promptly respond to patients’ health needs.

Despite obvious bed pressures to find enough beds for all patients who needed to be admitted to hospital effective systems were in place to deal with these challenges. Efficient systems were in place to plan and facilitate the discharge of patients.

Wards were clean and well maintained with good furnishings and sufficient facilities to ensure that patients’ needs were met. There was good infection control.

There were sufficient staff on the wards for wards to be safe and to ensure that patients had leave and attend activities to support their recovery. Staff were properly qualified and experienced to undertake their duties and to support patients’ needs. Staff on the wards received good support from management, were supervised and encouraged to develop their skills and knowledge.

Wards were well run by managers who delivered effective leadership to support and motivate their staff. Managers put effective systems in place to help monitor and improve standards. Systems were in place to ensure that staff promptly reported any incidents on the ward and that they then took any actions required to respond to them.

However, not all wards met targets for mandatory staff training. Some care plans for patients’ lacked detail in stating their wishes and preferences. Staff did not always ensure where detained patients had not initially understood their legal rights that they then repeated this information sufficiently promptly. Several patients felt that staff were too busy to spend time with them. Staff did not always store or administer medications in accordance with best practice or trust policy. The toilet facilities on one ward compromised patients’ dignity. There was scope for more activities to be provided at the weekend.

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

Young people and their families were treated as partners in their care. Staff treated young people and their families with kindness, dignity and respect.

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.

There were clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was apparent across the services.

Most young people, children and families could access services promptly. There were robust systems in place to manage referrals and waiting lists. However, in one area, there was a waiting list for treatment and this team was not meeting local targets. Staff worked to ensure young people attended their appointments. Numbers of patients who did not attend were closely monitored

However, the processes for assessing and managing the risk for young people identified as low risk were inconsistent across the teams. The local arrangements for lone working and for managing incidents of violence were being reviewed but this work needed to be fully implemented.

The interview rooms at the Kingston service were not sufficiently sound proofed to avoid confidential conversations being overheard. Support was needed for the administrative staff while they were going through changes in how their work was delivered.

We rated South West London and St George’s Mental Health NHS Trust forensic inpatient wards as good because:

The wards were clean and safe. Procedures and practices were in place for the management of infection control. Staff of all disciplines had a good understanding of relational security and staff were committed to minimising the use of restraint and seclusion in the service.

Staff assessed risks to patients were on admission, regularly reviewed these and linked them to their plan of care. 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. There were enough suitably qualified and trained staff to provide care and treatment to a good standard. The multi-disciplinary teams were pro-actively involved in patient care, support and treatment.

Patients had access to a variety of psychological therapies either on a one to one basis or in a group setting. Psychologists, occupational therapists and exercise therapists were part of the multi-disciplinary team and were actively involved as part of their treatment. Both individual clinicians and the senior management team within the service had a good understanding of the effectiveness of the care and treatment, which they delivered.

We saw kind and caring interactions between staff and patients on all the wards. Staff demonstrated a good understanding of patient’s individual needs and preferences. Staff made every effort to maximise people’s dignity. Patients had access to an independent advocacy service. The majority of patients told us they felt safe.

There were different forums for patients to be consulted on their views and to feed back their experiences about how the service was run. Patients spoke positively about the wide range of therapeutic, educational and physical therapies that were offered. There was a robust complaints procedure in place. Patients knew how to complain. Complaints were responded to according to the trust policy.

Staff were provided with regular supervision, annual appraisals and had access to mandatory and specialist training and training provided within the trust.

Staff were aware of and had a good understanding of the trust’s vision and values and how these were implemented in everyday practice. The culture within the service was open and transparent, staff morale was good and Senior managers within the service were visible and accessible to staff and patients.

However:

Time management practices being used on Halswell and Turner wards were not recognised as seclusion practices and patients subject to these practices did not meet the safeguards set out in the MHA Code of Practice.
Patients on Halswell, Ruby and Turner wards reported that fresh air breaks did not take place regularly, and that on occasions leave was cancelled due to insufficient staff on duty. There was no evidence that this was being monitored or recorded by the staff.

We rated wards for older people with mental health problems provided by South West London and St George’s NHS Trust as good because:

Patients and their relatives and carers described staff as caring and kind and told us they were treated with dignity and respect. We observed many examples of care that met the individual needs and wishes of patients. Patients were able to give feedback on their services through the ward community meetings. Patients and their relatives participated in meetings where their care was discussed. Staff on the wards were very mindful of ensuring patients had their needs and preferences met in terms of their disability, language, religion and culture and supporting their ongoing relationships with those they were close to.

The wards were safe and staff were taking steps to ensure that significant areas of risk such as falls and pressure care were being assessed and managed. The wards were working hard to ensure there were sufficient staff on duty, although on Crocus ward there were more staff working who did not know the patients well. Staff understood safeguarding processes and these were used appropriately. Medicines were well managed and there was good working with the pharmacy team.

Staff completed timely assessments of patients’ needs. They were very aware that most patients had physical health needs and monitored these closely and addressed specific needs as they arose. There was good multi-disciplinary working on both wards and close working relationships with staff from the local community teams. Discharge planning started as soon as the person was admitted.

Staff mostly felt well supported and had access to mandatory training, specialist training, appraisals and team meetings. On Jasmines ward there was regular staff supervision but on Crocus ward this was not taking place regularly.

Managers had access to good information to support them to manage the ward. There was regular contact with senior staff in the trust. Staff felt able to raise concerns although they were not aware of how to use the whistle-blowing process.

There was however a difference between the two wards. The staff team on Jasmines ward was more stable and knew the patients well. There was an excellent programme of therapeutic activities. The ward was very homely and dementia friendly. Staff morale was very positive. Crocus ward was a larger ward with five more beds. There were more staff who did not know the ward as well and this impacted on the consistency of care and meant that regular staff were working extremely hard. There were also less therapeutic activities which meant patients had fewer opportunities to leave the ward and more time when activities were not taking place. Crocus ward was still providing safe care and treatment but needed to make some changes to ensure the care was always of a high quality.

We rated long stay/rehabilitation mental health wards for working age adults as requires improvement.

These services were very mixed. Burntwood Villas demonstrated many very positive examples of supporting patients with their rehabilitation. The other services had progress to make and needed managers with the leadership skills to ensure the services had a recovery orientated approach. Many patients had a longer length of stay than was anticipated in the operational policies for the service. There were significant differences in the support being given to patients to promote their independence. For example at Burntwood Villas patients were accessing educational and work opportunities in the community and in the other services the activities were mainly on the ward and would benefit from having a greater focus on rehabilitation, for example developing more skills such as cooking or progressing towards self-medicating.

In terms of safety on the wards, not all identified risks from risk assessments had management plans in place. At Thrale Road there had been occasions when medication was out of stock and also the temperature of the medication had been too high and this had not been addressed. Nine staff on Phoenix ward were waiting for training on moving and handling including how to use the hoist and the team was supporting two patients with mobility issues. Whilst staffing levels were safe, on Thrale ward regular 1:1 sessions were not always taking place with patients and staff.

Not all staff were having access to regular individual supervision. Access to occupational therapy input varied and this was having an impact on the support available to patients.

However, most patients said there were supported by staff who were caring and respectful. On Phoenix ward a few patients said that the attitude of a few staff needed to improve. The morale of the staff was positive. Governance processes were in place to support the management of the services.

Most patients said they felt involved in their care. We found particularly strong evidence of this at Burntwood Villas. Regular ward community meetings took place and patients were able to suggest improvements to the wards, although at Westmoor House these were not always recorded or followed up. Staff and patients were aware of the advocacy services available and information leaflets about the service, different diagnoses, medication and how to complain were placed at the entrance of the wards and in communal areas.

Staff were aware of how to identify and report an incident and a safeguarding issue. Staff had an understanding of their responsibilities under the duty of candour, being open and transparent and explaining to patients if and when things went wrong. Staff carried out physical health examinations on admission and carried out regular, ongoing physical health monitoring for patients.

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

The trust was providing crisis services which met the guidelines of the mental health crisis care concordat. The principles of this concordat were embedded in the service.

We saw excellent examples of interactions between staff and patients. All the staff we observed were caring, compassionate and kind. The service supported and treated the people using the crisis and home treatment teams and health-based place of safety with respect, warmth and professionalism.

Assessment and management of risk was of a high standard in the home treatment teams. Staff were well equipped to manage risk and skilled in identifying and mitigating risks for patients and staff. In addition, there were adequate numbers of staff to provide care and support to a good standard. The trust was addressing vacancies in permanent employed qualified nurses.

The environments were clean and well presented in all of the home treatment teams, and patients were seen at the home treatment locations if required.

Overall, care planning involved patients and carers and was recovery orientated. Discharge planning was evident across all of the services and collaborative crisis planning was taking place. The teams worked flexibly to engage and work with people in the community, adapting to meet the needs of people and ensuring that visits and appointments were kept. Home visits were rarely cancelled and if changes to visit times were made the teams communicated effectively with patients to share information and promote engagement.

The teams consisted of experienced and knowledgeable staff. Staff said they could access the training they needed to fulfil their roles and were encouraged by local management to access additional training for their development. Staff received feedback from their managers following incidents. This was discussed in supervisions, handovers and team meetings.

Staff had a good understanding of the trust’s vision and values, and how these were implemented in everyday practice. The culture within the service was open and transparent, staff morale was good, and senior managers within the service were visible and accessible to staff and patients.

However, not all staff across the home treatment teams were accessing regular one to one supervision.

Patients we spoke with told us that there were sometimes inconsistencies in staff who visited their homes and this was a challenge for patients and impacted on the experience of care.

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

Work was needed to ensure patients were safe and had their needs met. In some adult community teams there was more work to be done to ensure individual patient risk assessments were up to date and reflected their current risks. The trust needed to monitor waiting times for patients to access psychological therapies when they were ready for this treatment, to ensure this was provided in a timely manner. A small number of patients needed to be allocated to a care co-ordinator.

In a couple of teams more work was needed to encourage patients to attend their appointments or follow them up if they did not attend. The trust must also ensure patients in Kingston receive their appointment details and records of reviews in a timely manner, although work was taking place in order for this to improve. The Wandsworth rehabilitation and recovery team had to ensure that the patients they supported were achieving positive outcomes. A few outpatient interview rooms needed to improve their sound-proofing. Some patients needed a copy of their care plan.

In terms of management, some teams felt they would like to see senior staff more frequently. The performance information used by managers needs to be amended where teams have reconfigured so managers have access to the correct data to inform improvements that need to be made.

However, staff were responsive and respectful to patients and had a good understanding of their individual needs. Staff had established positive relationships with patients and communicated well with relatives and carers. Patients themselves spoke positively about the support they received from staff and felt they were treated with dignity and respect. Patients could give real time feedback to staff.

Patients had access to individual crisis plans and staff were confident about how they would address any safeguarding concerns to keep people safe. There was effective multi-disciplinary team working to support patients with complex needs.

The reconfigured teams were making services more accessible and promoting good work with other teams in the trust and external professionals and organisations. Staff had access to opportunities for learning and development.

The service had a clear action plan in place that focused on improving the care and treatment provided to patients on the ward. There had been improvements in the ward environment and there was an ongoing programme of refurbishment.

The ward admitted patients from across the country and was able to care for patients with complex health needs, through the provision of high dependency beds.

There were systems in place to ensure that learning from incidents took place throughout the service.

Feedback from patients using the service was generally positive. Patients' voices were evident in their care plans. They participated in meetings and received information about their care. Staff took patients’ views into account when appropriate when planning individualised meals.

There was evidence of collaboration between patients and staff. They had worked together to produce a therapeutic eating charter and other information highlighting best practice in care for patients with eating disorders.

The service used a range of outcome measures to determine the efficacy of the care and treatment provided. Staff had working lunches to discuss how best to support and care for patients.

There was a strong focus on original research to improve the care and treatment of patients using the service. The patients and multi-disciplinary team contributed to the work of the St George’s University of London Eating Disorders Research Committee.

Avalon ward had nursing vacancies and there was regular use of agency staff. Recruitment was a priority for the trust and there was an ongoing recruitment campaign.

However, not all staff had completed required statutory and mandatory training or updates of training. Overall, 46% of permanent staff had completed their required training. There were significant shortfalls in fire safety awareness training, basic life support techniques and medicines management training.

Patients’ risk assessments were not always updated after incidents, which meant that staff might not be able to respond appropriately.

Results of checks on the physical health of patients were not always up dated promptly in patients’ electronic records. There was a risk that staff would not escalate concerns to medical staff quickly.

The cleaning records for the ward clinic rooms were not up to date and the rooms and equipment were dusty. A clinical specimen had been stored in the same fridge as medicines and there was a risk of contamination.

Staff had not always checked emergency equipment every day to make sure it was fit for purpose.

Working age adults were being admitted to the wards for older people. This compromised the safety of patients. There had been serious incidents on Crocus ward involving younger adult patients.
The wards for older people did not comply with guidelines for gender separation. Some patients had to walk through communal areas to reach the bathroom, which compromised their privacy and dignity.
Staff carried out a visual check on patients' skin integrity when they were admitted to the wards. They did not carry out a formal assessment of risk of developing a pressure ulcer for every patient. This was contrary to trust policy.

Staff had left patient related information unattended in a ward dining room;
Patient observation records were not always completed or were completed retrospectively;

However, staff carried out assessments of patients' risk of falls and put plans in place to address the risks identified. Staff managed medicines safely. The ward environments had been adapted to make them more suitable for patients with dementia. There were sufficient staff to care for patients safely. Staff had been encouraged to report all incidents. Consequently, there had been an increase in the number of patient falls reported by staff.

Staff assessed patients' needs and put care plans in place to address the needs identified. Patients had good access to physical health care. Several staff had completed specialised training in dementia care. Staff received regular supervision and most had completed an annual appraisal. Multi-disciplinary teams worked well together on the wards.

Ligature risk assessment and management was inconsistent and staff did not always recognise risks or know how to manage risks safely.

On Lilacs ward, patient risk assessments and management plans were not always updated following risk incidents. Staff had not always followed risk management plans.
On Lavender ward some patients were administered ‘as required’ medicines every night. The reasons why patients required these medicines was not always recorded or reviewed.

Some equipment on Lilacs and Lavender wards was not maintained on a regular basis to ensure it was fit for purpose.

On Lilacs ward not all patients were aware of their care plans. Care plans did not address all of the patients needs, and did not reflect their preferences. Many patients were not involved with the development of care plans.

Staff on Lilacs ward in particular lacked understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. There was a risk that they did not recognise when a patient was unable to give consent and did not understand their legal responsibilities.

Staff on several wards did not receive regular supervision.

Patients on Lilacs ward and ward one did not have access to a regular programme of meaningful activities as these were often cancelled or not being provided.

Detained patients on Lavender ward did not always have a consent or authorisation certificate in place.

However, on ward three a harm free care pilot had been conducted. This was now on-going. This looked at medicine errors, violence, self harm and falls. This information was presented in an easy to understand way. All wards, except the PICU, provided mixed sex accommodation. These wards adhered to national guidance by having separate male and female areas. Emergency resuscitation equipment was in place and checked regularly. Where rapid tranquilisation was used physical monitoring of patients took place at regular intervals. Learning from serious incidents led to improvements in care.

On Lilacs ward, a morning multi-disciplinary handover took place every weekday. This enabled continuous medical review of patients without waiting for the next ward round. Some of the wards had recruited peer support workers. The peer support workers were part of the team. They offered insight into what it was like to be a patient. They helped patients orientate themselves to the ward. They also helped staff and patients to work positively together.

In the acute wards for adults of working age and psychiatric intensive care units we found that:

Ligature risk assessment and management was inconsistent and staff did not always recognise risks or know how to manage risks safely.

On Lilacs ward, patient risk assessments and management plans were not always updated following risk incidents. Staff had not always followed risk management plans.
On Lavender ward some patients were administered ‘as required’ medicines every night. The reasons why patients required these medicines was not always recorded or reviewed.
Some equipment on Lilacs and Lavender wards was not maintained on a regular basis to ensure it was fit for purpose.
On Lilacs ward not all patients were aware of their care plans. Care plans did not address all of the patients needs, and did not reflect their preferences. Many patients were not involved with the development of care plans.
Staff on Lilacs ward in particular lacked understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. There was a risk that they did not recognise when a patient was unable to give consent and did not understand their legal responsibilities.
Staff on some acute wards did not receive regular supervision.
Patients on Lilacs ward and ward one did not have access to a regular programme of meaningful activities as these were often cancelled or not being provided.
Detained patients on Lavender ward did not always have a consent or authorisation certificate in place.

In the wards for older people with mental health problems we found:

Working age adults were being admitted to the wards for older people. This compromised the safety of patients. There had been serious incidents on Crocus ward involving younger adult patients.
The wards for older people did not comply with guidelines for gender separation. Some patients had to walk through communal areas to reach the bathroom, which compromised their privacy and dignity.
Staff carried out a visual check on patients' skin integrity when they were admitted to the wards. They did not carry out a formal assessment of risk of developing a pressure ulcer for every patient. This was contrary to trust policy.

However, on ward three a harm free care pilot had been conducted. This looked at medicine errors, violence, self harm and falls. This information was presented in an easy to understand way. All acute adult wards, except the PICU, provided mixed sex accommodation. These wards adhered to national guidance by having separate male and female areas. Emergency resuscitation equipment was in place and checked regularly. Where rapid tranquilisation was used physical monitoring of patients took place at regular intervals. Learning from serious incidents led to improvements in care.

On Lilacs ward, a morning multi-disciplinary handover took place every weekday. This enabled continuous medical review of patients without waiting for the next ward round. Some of the acute inpatient wards had recruited peer support workers. They were part of the team and offered insight into what it was like to be a patient. They helped patients orientate themselves to the ward and helped staff and patients to work positively together.

On the older people’s wards staff carried out assessments of patients' risk of falls and put plans in place to address the risks identified. Staff managed medicines safely. The ward environments had been adapted to make them more suitable for patients with dementia. There were sufficient staff to care for patients safely. Staff had been encouraged to report all incidents and there had been an increase in the number of patient falls reported by staff as a result. Staff assessed patients' needs and put care plans in place to address the needs identified. Patients had good access to physical health care. Several staff had completed specialised training in dementia care. Staff received regular supervision and most had completed an annual appraisal. Multi-disciplinary teams worked well together on the wards

Springfield University Hospital is part of South West London and St George's Mental Health NHS Trust. It provides a range of mental health inpatient and outpatient services including, acute, rehabilitation, older people, eating disorder and forensic services. The trust is responsible for providing all the community and hospital-based psychiatric services to the London Boroughs of Kingston, Merton, Richmond, Sutton and Wandsworth.

We found that the services at Springfield University Hospital were safe, the wards were clean and staff were aware of risks. There were ways to report and learn from incidents, but improvements were needed in assessing and managing risks to people's safety.

Staff interacted with people who used the service in a caring and compassionate way. People and their relatives were involved in planning their own care, although records did not always reflect this. People were engaged in activities they felt were meaningful and therapeutic. Ward staff listened to people’s feedback and involved them in making positive changes.

The Mental Health Act responsibilities were being discharged appropriately. Some actions from previous Mental Health Act monitoring visits had not been fully resolved.

We saw good examples of learning from audits and incidents being shared, and changes to practice being made as a result.

All staff we spoke to on the ward told us they received training for safeguarding children and vulnerable adults as part of their annual mandatory training. They also said they would be confident in reporting safeguarding – either internally or to the local authority.

Staff told us they felt supported by the management on the ward and their immediate managers. Some staff told us they did not always feel involved in conversations about their roles, particularly when organisational changes were taking place.

We found that the recording of rapid tranquilisation on some wards was not being done well. We saw routes of administration being recorded incorrectly, doses of medicines being recorded in progress notes but not on medicines administration records, and patients who were administered these medicines did not have a reason for the use in their progress notes.

We visited the following wards at Springfield University Hospital as part of this inspection:

Ward 1

Core service provided: Psychiatric Intensive Care Unit (PICU)

Male/female/mixed: male

Capacity: 13 beds

Ward 2

Core service provided: Acute admission ward

Male/female/mixed: mixed

Capacity: 18 beds

Ward 3

Core service provided: Acute admission ward

Male/female/mixed: mixed

Capacity: 20 beds

Jupiter Ward

Core service provided: Acute admission ward

Male/female/mixed: mixed

Capacity: 23 beds

Bluebell Ward

Core service provided: Acute admission ward for deaf adults

Male/female/mixed: mixed

Capacity: 16 beds

Corner House

Core service provided: Specialist assessment and treatment unit for deaf children and adolescents aged 8 to 18

Male/female/mixed: mixed

Capacity: 6 beds

Avalon

Core service provided: Eating disorder service

Male/female/mixed: mixed

Capacity: 18 beds

Wisteria Ward

Core service provided: Young poeples eating disorder service

Male/female/mixed: mixed

Capacity: 10 beds

Crocus Ward

Core service provided: Services for older people

Male/female/mixed: mixed

Capacity: 21 beds

Haswell Ward

Core service provided: Medium secure forensic ward

Male/female/mixed: male

Capacity: 16 beds

Hume Ward

Core service provided: Low secure forensic ward

Male/female/mixed: male

Capacity: 16 beds

Phoenix Ward

Core service provided: Secure rehabilitation ward

Male/female/mixed: mixed

Capacity: 18 beds

Ruby Ward

Core service provided: Medium secure forensic ward

Male/female/mixed: female

Capacity: 10 beds

Turner Ward

Core service provided: Medium secure forensic ward

Male/female/mixed: male

Capacity: 18 beds

Seacole Ward

Core service provided: Inpatient OCD service

Male/female/mixed: mixed

Capacity: 13 beds

Aquarius Unit

Core service provided: Child and adolescent mental health service (CAMHS)

Male/female/mixed: mixed

Capacity: 10 beds

This report gives the findings of our inspection of the community mental health services provided by South West London and St George's Mental Health NHS Trust. These services were registered with CQC under 'Trust Headquarters' and this was the first inspection of this location since it was registered.

We visited a number of teams across the five boroughs of Sutton, Merton, Richmond, Kingston and Wandsworth served by the trust. These teams provided care and support for people of all ages living in the community with mental health needs and included:

Child and adolescent mental health services (CAMHS)
Community mental health (CMHT) teams for adults
Crisis and home treatment teams for adults
Community mental health teams for older people (CMHTOP)
Eating disorders out-patient and day services.

Our pharmacist inspectors also visited a Clozaril medication administration clinic and a home treatment team to assess the management of medicines.

We found areas of good practice and many positive interventions across the wide spread of teams we inspected. Some services for older people were seen to be delivering some outstanding specialist intervention work. Positive ongoing work was noted in the teams supporting people with learning disabilities and the services for eating disorders.

Overall, people told us they felt well supported and said that staff were hard working and committed to their work.

Areas for improvement included:

Ensuring that comprehensive risk management plans were consistently put in place within the mental health services for adults and older people.
Improving the quality of care planning for adults with mental health needs living in the community.
Ensuring that, after referral, people using the service were able to contact a named member of staff about their care and support.

South West London and St George’s Mental Health NHS Trust provides integrated mental health and social care services to the communities of Kingston, Merton, Richmond, Sutton and Wandsworth.The trust also offers a number of specialist regional and national services. These include the National Deaf Services, which support Deaf people with mental health needs, an Eating Disorders Service, and the Behavioural Cognitive Psychotherapy Unit, which provides treatment and support for people with obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) services.

The trust operates from over 90 sites (most of which offer services covered under the Trust Headquarters registration) with three main inpatient sites. The trust currently employs about 2,300 staff, serving a population of just over 1 million people, having 460,000 patient contacts a year. The trust has an annual budget of £156 million and is nearing its final stages towards achieving Foundation Trust status.

The trust has three acute inpatient services at Springfield Hospital in Tooting, Tolworth Hospital in Surbiton and Queen Mary’s Hospital in Roehampton. The trust also has other inpatient services at Hayden House in Battersea, Westmoor House in Roehampton and Thrale Road in Wandsworth.

CQC has inspected all of the trust’s locations in the last two years. Inspections of the acute services at Tolworth Hospital resulted in compliance actions. The trust had prepared action plans in both these areas and we checked their progress as part of this inspection.

During our visit we held focus groups with a range of staff (qualified and in training nurses and doctors, allied health professionals, Associate Hospital Managers and the trade unions). We talked with carers and/or family members, observed how people were being cared for, and reviewed patients’ care and treatment records. We visited the three hospital locations and community bases.

We carried out unannounced visits on 21 March to Ward 3 at Springfield Hospital and 1 May 2014 to Seacole Ward at Springfield Hospital.

During this inspection we visited the following services:

Springfield University Hospital

Core service provided: Five acute admission wards; two specialist deaf services; one Health Based Place of Safety; two eating disorder wards; one ward for older people; five long stay/forensic/secure service; and one child and adolescent mental health service.

The wards are a mix of same sex and mixed accommodation.

Capacity: 250 beds

Queen Mary's Hospital

Core service provided: Three acute admission wards.

The wards are a mix of same sex and mixed accommodation.

Capacity: 67 beds

Tolworth Hospital

Core service provided: Two wards for older people; one acute admission ward.

The wards are all mixed sex accommodation.

Capacity: 48 beds

As part of the inspection we met with key members of staff and executives. In these meetings it was clear that the trust board were aware of the progress required to become a Foundation Trust. Members of the board gave us a clear account of the challenges they faced and the journey they had been on to put quality at the front of the agenda which, in their view, it had not been in place when they took up office. During the inspection it was clear that there was still some required work, for example some of the front line staff we met with did not understand some of the initiatives which have been put in place to improve quality. Board members, in general, recognised this to be the case.

CQC were assured that the members of the board had a good recognition of the current position of the quality within the trust.

We found that the non-executive directors were a strong and effective group who had a good knowledge of their role and who exercised their duties effectively.

People using the service told us, and we observed, that the trust’s staff were caring and had a good approach to patient care, and interacted positively and compassionately with people. Much of the care delivered followed best practice and we also saw examples, where no guidance existed, of the trust's staff working with the National Institute for Health and Care Excellence to produce this.

We found that the trust's staff had completed mandatory training; however we also noted that in several clinical areas training for the specific needs of the people using the services was not available. Many of the staff working in older people’s services had not undertaken training in dementia care and this was having an impact on the quality of care received by people using this service.

The working relationship between inpatient and community services was well established across trust's service areas. We also saw good examples of people using services being engaged and involved in the planning and review of their care.

We found that application of the Mental Health Act across the services was good. People were lawfully detained and had their rights read to them at the appropriate times. We noted that some of the actions identified in the monitoring of the Mental Health Act had not been completed by the trust.

There had been concerns about compliance with the rapid tranquilisation policy. However, the trust had identified this in an audit and was making improvements. We confirmed this when we looked at records on four separate wards.

We looked at records for people prescribed medicines ‘as required’. We saw patients who were administered as required lorazepam and promethazine with no record in their progress notes as to why it was being given. This meant it could not be checked if these medicines were being used appropriately.

The planning and delivery of care in some clinical areas did not meet the service users individual needs or ensure their welfare and safety as we found comprehensive management plans were not consistently being put in place for people using the service where a risk to themselves or others had been identified.

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.

All Inspections

Ward 1

Ward 2

Ward 3

Jupiter Ward

Bluebell Ward

Corner House

Avalon

Wisteria Ward

Crocus Ward

Haswell Ward

Hume Ward

Phoenix Ward

Ruby Ward

Turner Ward

Seacole Ward

Aquarius Unit

Springfield University Hospital

Queen Mary's Hospital

Tolworth Hospital