All inspections: South London and Maudsley NHS Foundation Trust

South London and Maudsley NHS Foundation Trust provides mental healthcare services for adults and children in South London, mainly in the London Boroughs of Southwark, Lambeth, Lewisham and Croydon. This inspection was of acute mental health wards and psychiatric intensive care units for adults of working age. We carried out an unannounced focused inspection of 3 acute wards for adults of working age and 1 psychiatric intensive care unit, in the Ladywell unit in Lewisham, Lambeth hospital and the Maudsley hospital.

We were aware of a number of self-harm related deaths and serious incidents for inpatients at the trust many of whom were detained under the Mental Health Act (MHA). We looked at 8 deaths that were related to self-harm between August 2020 and October 2022. For each serious incident the trust investigation processes identified a series of care and delivery recommendations and actions to improve care and treatment. We wanted to see how the trust implemented these improvements to care and treatment to ensure patient safety and minimising the repetition of poor practice. We also wanted to review if learning from serious incidents and specific recommendations and actions had been fully completed and embedded across the services.

We inspected the following 4 wards, Virginia Woolf ward in the Ladywell Unit, Lewisham; Leo ward at Lambeth Hospital; and ES1 ward and Ruskin ward at the Maudsley Hospital. Following the inspection visits we had video interviews with the ward managers of Jim Birley Unit and John Dickson Ward at the Maudsley Hospital, Gresham 1 ward at the Bethlem Royal hospital, and Clare Ward at the Ladywell Unit.

The core service is registered to provide the following regulated activities: treatment of disorder disease or injury; diagnostic and screening procedures; and assessment or medical treatment of person admitted under the Mental Health Act (MHA). The trust acute wards for adults of working age and psychiatric intensive care units were last inspected in May – June 2021. The overall rating for the core service was good. Safe was rated as requires improvement, effective, caring, responsive and well-led were rated as good. The trust also had a well-led inspection in June 2021 where it was rated as good overall.

This was a focused inspection. We looked at aspects of the safe and well-led domains. We did not rerate the overall service as a result of this inspection. The previous rating of good remains which was the rating at the last comprehensive inspection in May-June 2021. We found:

We looked at aspects of the safe and well-led domains. We did not rerate the overall service as a result of this inspection. The rating of this overall core service remained good.
Service improvements had taken place as a result of learning from serious incidents. Wards applied identified recommendations and completed actions in a timely manner.
Ward environments were safe and clean. There was an improvement in escalation processes for staff when they were short staffed or needed additional support. On all wards the observation, ligature risk mitigation and patient search processes had improved in response to learning from incidents, and there was improved verbal and written communication between staff at shift handovers.
Most staff were well informed about learning from incidents. The trust had developed training and competencies for staff covering ligatures, observations, and patient searches to support staff in learning lessons from previous incidents.
Considerable work had been undertaken to improve staffing recruitment and retention on the wards, although this remained a challenge.
Improvements had been made to the Ladywell Unit ward environments and the exterior area including easier access for emergency vehicles.
Senior staff investigated incidents thoroughly involving patients and their families. The trust had started to implement the new Patient Safety Incidents Response Framework and had plans to improve the timeliness and quality of serious incident reviews.

However:

The trust did not always meet its targets for compliance with mandatory training in basic and immediate life support, safeguarding training at level 3, the National Early Warning Score, Seni Lewis, and fire warden training.
There was varied quality and consistency of risk assessments and care plans on Virginia Woolf, Leo and ES1 wards, making records hard to follow for staff not familiar with the wards. For some patients there were no care plans about key areas rated as high risk such as neglect and self-harm. Triggers and protective factors identified in risk assessments, were not always included in patients’ care plans.
On ES1 ward we had concerns about levels of patient violence and aggression towards other patients and staff, and this was impacting on staff and patients’ morale.
The trust did not always complete serious incident reviews promptly, leading to delays in implementing learning from serious incidents. A small number of actions from serious incident reviews had not been completed within the timescales set including providing training to staff on breaking bad news, and regular emergency scenario training on some wards.
We found staff had less clear knowledge of learning from incidents that had taken place in directorates other than the one in which they worked.
Staff and patients said that the withdrawal of the activity coordinator role in Southwark, was having an impact on patients’ wellbeing on the ward.
The trust should consider improving support for staff coming back to work after being on leave after an incident.

How we carried out the inspection

This inspection was unannounced. Prior to the inspection, we reviewed records held by the CQC relating to this service. The CQC data analyst team completed a thematic review of deaths and serious incidents resulting from self-harm for patients detained under the Mental Health Act between August 2020 and October 2022. We visited and inspected 3 acute wards for adults of working age, and a psychiatric intensive care ward over 3 locations. This was followed by video call interviews with ward managers from 4 further wards and the deputy chief nurse.

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

During the inspection visit, the inspection team:

toured the service environment
observed how staff were caring for patients
observed 2 multidisciplinary handover meetings
spoke with 6 patients who were using the service
spoke with the 8 ward managers, a clinical service lead, and a matron
spoke with 17 other staff members across the multidisciplinary teams including a consultant psychiatrist, registered nurses, clinical support workers, a pharmacist, an administrator, student nurses and bank (as and when) staff.
reviewed 24 patient care and treatment records
looked at documents related to the running of the service

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.

This was an unannounced focused inspection of the child and adolescent mental health services’ (CAMHS) psychiatric intensive care unit (PICU) ward at the Bethlem Royal Hospital. The CAMHS PICU inpatient service offers assessment, management and treatment for children and young people aged 12 up to their 18th birthday. The ward can accommodate up to 7 male and female young people. At the time of the inspection, the ward had reduced their admissions and was only admitting up to 3 young people.

We carried out this inspection to see if improvements had been made following a serious incident which occurred on the ward in June 2023.

During this inspection we looked at the safe, effective and well led domains. We did not rate the service at this inspection as we only inspected one ward - the CAMHS PICU. We did not inspect the other child and adolescent mental health wards provided by the trust.

We found:

The clinic room was not well maintained. Staff did not always ensure medicines were stored properly or in date. Assurance processes including medicines management audits had not identified the need for improvements.
Simulation training to support staff to know how to respond in a clinical emergency did not appear to help individual staff understand clearly how they needed to improve to perform this role competently. This did not provide assurance that staff felt confident and would be able to respond to a medical emergency.
Learning from incidents was not routinely discussed at team meetings to ensure learning was shared although staff had access to reflective practice sessions.
The service needed to improve some areas of the ward environment. For example, an up-to-date ligature risk assessment was not kept in an accessible area for all staff to use. The ward did not have a designated female lounge to comply with mixed sex accommodation guidance.

However, we found several areas of good practice:

The ward had enough nursing and medical staff to keep the current number of young people admitted safe. Recruitment of nursing staff was ongoing. Staff had received most of the basic training to keep people safe from avoidable harm.
Young people and family members told us staff treated them with compassion and kindness. Staff understood the individual needs of young people and supported them to understand and manage their care and treatment.
Staff used the positive behavioural support (PBS) model to understand young peoples’ behaviours which challenge.
Staff reported that morale had improved on the ward. Staff felt able to raise concerns with the wider team and senior managers.

We carried out this unannounced comprehensive inspection to follow up on concerns found at our last inspection of 2019, when we rated the trust overall as requires improvement.

We inspected the three inpatient rehabilitation wards; Heather Close (24 beds), Tony Hillis Unit (15 beds) and Westways (18 beds) .

Our rating of services stayed the same. We rated them as requires improvement because:

There was insufficient oversight of performance and quality on the three rehabilitation wards, to pick up on inconsistent blanket restrictions, and key performance indicators specific to the rehabilitation pathway.
Care plans for patients on Heather Close and Tony Hillis Unit were not available in a format that patients could easily understand, with clear goals set to work towards developing independence skills and discharge. On Westways this issue had been addressed through the use of a ward round action plan.
Patients gave varying reports about the meals provided on the wards particularly to meet dietary and cultural needs. There were insufficient opportunities for self catering on the wards.
Although there were procedures in place to enable patients to develop self administration of medicines on the wards, at the time of the inspection no patients had progressed beyond the first stage of this process.
Emergency grab bags on the wards only included one size of airway tube to enable resuscitation (although this was reviewed immediately following the inspection).
Some staff spoke of a need for improvement in the culture between staff at Heather Close, to ensure that all staff felt valued and respected.
The layouts on Heather Close and Westways made it difficult for patients to focus on activities held in the dining room or lounge areas.
Staff retention and vacancies on the wards had been an issue, leading to significant use of bank (as and when) staff which impacted on the relationships developed with patients.
Staff on the wards noted that they were sometimes under pressure to admit patients that they did not think were ready for rehabilitation, leading to longer lengths of stay.

However:

There were improvements in the development of a clear strategy for rehabilitation across the service, and in introducing rehabilitation goals for patients to work towards.
Each ward had a positive atmosphere and we saw good interactions between staff and patients, particularly on Tony Hillis Unit. In-reach and in-house peer support workers were making a difference to patients’ support.
There was good involvement of relatives/carers across the wards when patients consented to this. There was effective participation of patients and relatives in ward rounds.
There was an effective multi-disciplinary team mix on each ward and we found significant improvements in physical health support for patients.
There was a low use of physical interventions, and reduced blanket restrictions had been put in place across the wards.
We found improvements around the management of medicines, and clinic rooms across the wards. Patients were able to have conversations about their medicines with staff as needed and staff monitored patients’ physical health care providing support.
On Heather Close the psychologist was piloting virtual reality headsets for patients experiencing anxiety, as well as for staff wellbeing interventions. Staff at Tony Hillis Unit continued to facilitate a group in conjunction with the forensic personality disorder community team to support patients with substance misuse problems alongside their mental health problems.
Staff at Heather Close continued to involve patients in chairing their Care Programme Approach meetings co-producing the questions they would ask to facilitate the meeting.

How we carried out the inspection

This inspection was unannounced. It involved a three-day visit to the wards and was followed up by interviews with carers and a video call meeting with senior managers.

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

During the inspection visit, the inspection team:

toured the service environment
observed how staff were caring for patients
conducted a structured short observational framework for inspection to observe the ward culture on one ward
observed 2 multidisciplinary handover meetings, part of a ward round, a referrals meeting and a care improvement service meeting
observed some patient activities including a music appreciation group
spoke with 9 patients who were using the service
spoke with 11 relatives/carers of patients using the service
spoke with the 2 ward managers, a practice development nurse and clinical charge nurse
spoke with 30 other staff members across the multidisciplinary teams including consultant psychiatrists, speciality doctors, occupational therapists, clinical psychologists, activity coordinators, registered nurses, clinical support workers, a pharmacist, a peer support worker, a housekeeper, student nurses and bank (as and when) staff
reviewed 15 patient care and treatment records
reviewed 32 patient medication administration records
looked at documents related to the running of the service
spoke with the service directors for Lewisham and Croydon, and the South London Partnership programme director for the complex care pathway.

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

Patients told us that staff provided them with help, emotional support and advice when they needed it. They said that staff were sensitive to them, and gave them space when they needed to be alone. Although they said that there were often changes in staff, patients noted that staff were generally cheerful, listened to them and did not speak over them.

Patients said staff treated them well and behaved appropriately towards them knocking and waiting for an answer before entering their bedroom, to respect their privacy and dignity. They said that they were shown around the wards on admission, and given a welcome pack with information about the wards.

Patients generally felt safe on the wards, and had a primary nurse who they had regular contact with. They said that staff were available to support them, although they were often busy, and had a lot of records to complete. They said that staff involved them in making decisions about their care.

Patients and their family members told us how they had made progress since being at the service through the support and care of the staff. Most knew how to contact an advocate if they wished to, and how to make complaints or suggestions about the wards. Some patients were frustrated with the length of time they had been on a rehabilitation ward.

There were mixed reports about the quality and choices of food available on the wards. In general patients were satisfied with activities available to them on the wards. On Tony Hillis Unit, patients told us that there were few activities available at weekends.

South London and Maudsley trust had 4 wards for older people with mental health problems, we visited all 4 as part of this inspection. Hayworth ward and Aubrey Lewis 1 ward mostly had patients with non-organic disorders compared with Chelsham house and Greenvale ward who had patients with organic disorders. Greenvale ward was more integrated into the community and mainly had patients with advanced dementia and patients who were on end of life care.

This was an unannounced comprehensive inspection. The last inspection of this core service was in 2017 and there was one requirement notice issued around staff completion of mandatory training, regulation 12.

We rated this service as good because:

All wards were clean, well equipped, well furnished, well maintained and fit for purpose. The service had enough nursing and medical staff, who knew the patients and received basic training to keep patients safe from avoidable harm. The service had progressed in reducing staff vacancies.
The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health.
Staff assessed the physical and mental health of all patients on admission. They developed individual care plans, which they reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs, were personalised, holistic and recovery-oriented, and had direct views from patients.
Staff provided a range of care and treatment interventions suitable for the patient group and consistent with national guidance on best practice. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives. Patients had access to drama therapy. On Chelsham ward patients had access to sensory machines.
Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Patient records showed that staff assessed and recorded capacity clearly for patients who might have impaired mental capacity.
The service managed beds well. This meant that a bed was available when needed and that patients were not moved between wards unless this was for their benefit. Managers worked with social care teams to find appropriate community care home placements for patients with advanced care needs.
Leaders had the skills, knowledge, and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.
Staff said they felt respected, supported, and valued. They reported that the trust provided opportunities for career progression.

However:

The ligature risk audits did not reflect all the potential ligature risks. For example, there were plastic bags and metal bins placed in the communal area bathrooms in the wards, which could pose a ligature risk. The trust had considered alternative methods for disposing of clinical waste to avoid the use of plastic bags on the ward, but this needed to be kept under review.
Whilst the completion of mandatory training had improved, some staff still had to complete their mandatory training courses, specifically fire warden training, manual handling training, completion of national early warning scores for physical health checks and safeguarding training. The trust were aware of when staff needed to complete their training and had systems in place to remind them.
There were still some improvements which had been identified but still needed to be made the ward environments, such as replacing the windows on Greenvale ward and providing an accessible female only bath on Aubrey Lewis 1 ward. There were plans in place for this to happen. Female patients on Hayworth ward had identified that the ward could benefit from more female toilets.
Patient menus were not accessible or an easy read version.
Patients did not always receive neurological observations after they had sustained a fall.

We carried out an unannounced, out of hours, focused inspection of Nelson Ward – the trust’s female acute ward. We carried out this inspection following concerns we had about two serious incidents that happened on the ward in June 2022.

During this inspection we only looked at specific areas concerning assessing and manging risks to patients, learning from serious incidents, safe staffing, staff compassion and kindness and governance arrangements. We did not rate the service at this inspection as we only inspected parts of three key questions on one ward.

We found that:

Staff did not always record observations of patients in line with the policy. Intermittent observations were recorded at regular and predictable intervals. There was a risk that the patients would know when observations would take place and they could plan any actions around this.
Staff did not always record action taken as a result of deterioration in a patient’s physical health or why no action had been taken in response to elevated results. Some patients had high risk physical health issues. There was a risk that staff could not safely identify when a patient’s physical health was deteriorating.
The ward layout was safe, but parts of the ward needed some maintenance and repair work. Plans to move the acute wards to a new location were in place for next year.
Our findings from the other key questions demonstrated that whilst governance processes operated effectively at team level, improvements were still needed. Staff needed to ensure the audit regarding engagement and observations was enhanced to include how intermittent observations should be carried out.

However,

The ward had enough nursing staff, who knew the patients and received training to keep people safe from avoidable harm.
The service managed patient safety incidents appropriately. Staff recognised incidents and reported them suitably. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
Patients told us staff treated patients with compassion and kindness. Staff understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.

We carried out this announced comprehensive inspection of the acute wards for adults of working age and psychiatric intensive care unit (PICU) and community services for adults of working age services provided by this trust as part of our continual checks on the safety and quality of healthcare services. At our last inspection we rated the provider as good.

We also inspected the well-led key question for the trust overall. We inspected two services, inspected and rated one as good (acute and PICU) and one as requires improvement (community mental health services for adults). Overall, we rated effective, caring, responsive, and well-led as 'good' but safe was rated as 'requires improvement'.

The trust serves a population of 1.3 million people across the London boroughs of Croydon, Lambeth, Lewisham and Southwark, and employs more than 5,000 staff. Staff provide services to around 41,000 patients in the community and in 716 inpatient beds across 52 inpatient wards. The trust has a turnover of £503 million and broke even in 2020/2021.

The trust provides the following core services:    

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

Long stay/rehabilitation mental health wards for working age adults 

Wards for older people with mental health problems 

Child and adolescent mental health wards 

Forensic inpatient/secure wards 

Wards for people with learning disabilities or autism  

Mental health crisis services and health-based places of safety 

Community-based mental health services for older people 

Community-based mental health services for adults of working age 

Community services for people with learning disabilities or autism 

Specialist community mental health services for children and young people 

The trust also provides the following specialist services: 

Specialist eating disorder services  

Specialist neuropsychiatric services

Substance misuse services

Other national specialist services

We did not inspect long stay/rehabilitation mental health wards for working age adults (previously rated requires improvement) because the services had not had time to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection. We are monitoring the progress of improvements to services and will re-inspect them when appropriate.

Our rating of services stayed the same. We rated them as good because:

We rated effective, caring and responsive as good and we rated safe as requires improvement. We rated well-led for the trust overall as good.

We rated acute wards for adults of working age and psychiatric intensive care unit as good and community-based mental health services for adults of working age as requires improvement. In rating the trust, we included the existing ratings of the fourteen previously inspected services.

Since the last inspection there had been significant changes to the executive leadership team at the trust and the new members had settled into their roles and were working together effectively. The trust had appointed a chief executive, chief operating officer, chief nurse, and director of communications, stakeholder engagement and public affairs. The trust had also appointed a new board level director of corporate affairs. The trust reviewed leadership capability and capacity on an ongoing basis. The new appointments had given them an opportunity to review how they carried out business and make further improvements.

Since the last inspection the board had a new chair and one new non-executive director. At this inspection we found the trust had an ambitious board, with a wide range of skills and experience who demonstrated dedication and commitment to improving the care delivered to patients by the trust. The non-executive directors all had experience as senior leaders in a range of organisations and brought skills such as a knowledge of finance and investment, strategic development, research, population health, working in partnership and transforming services. The non-executive directors were well supported and challenged effectively by the team of governors.

Board members had completed board development days to better understand and further develop each person’s roles and responsibilities in relation to the strategic direction of the trust. The board understood the plans for the development of the trust both internally and externally and recognised the complexity of achieving their strategic aims.

There was high quality, effective leadership at all levels of the organisation. There were regular board visits to services. Senior staff across the trust modelled open and transparent behaviour. Staff we spoke with during the core service inspections felt supported, valued and respected. Staff spoke about improvements in the culture and felt the trust leaders were more visible and present since we last inspected the trust in 2019.

The trust leadership demonstrated a high level of awareness of the priorities and challenges facing the trust and how these were being addressed. The trust leadership had demonstrated an ability to adapt at a fast-changing pace during the COVID-19 national pandemic. The trust had developed a very pro-active vaccination programme with a high uptake from staff and patients. At the time of the inspection over 85% of all staff had received their first vaccine. Staff provided information and advice to eligible patients regarding the COVID-19 vaccines to alleviate concerns and encourage uptake.

Since the last inspection the trust had embedded the divisional structures and borough-based working for local services. This had strengthened their multi-disciplinary working within each of the trust directorates. They had also further developed their ability to work in partnership with other stakeholders to meet the healthcare needs of the local populations and develop new responsive models of care.

The trust had also strengthened its input into the South London Mental Health and Community Partnership (SLP). The SLP focused on delivering mental health services across south London in partnership with two other NHS trusts. The three trusts collaborated effectively to improve the quality of services, learn from each other, and share functions to maximise the effective use of resources. The SLP had been successful in developing new models of care and ensuring patients were treated in services closer to their homes. The SLP was also involved in provider collaboratives for forensic services, CAMHS, and specialist eating disorder services in south London. The provider collaboratives were responsible for commissioning these services for the population of south London, including from the independent health sector.

The trust collaborated effectively with a range of external partners. The trust worked within a very complex landscape across four London boroughs, four clinical commissioning groups, local alliances, and two integrated care systems. The chief executive had recently led a London-wide project looking at emergency department admissions for children and young people in crisis.

Leaders spoke with insight about the need to work collaboratively to improve existing services. There was a high level of awareness of the need to improve access and flow for a number of its community and inpatient services. It recognised that while the trust could make changes within its own services, long term solutions would only be achieved through partnership working. Managers engaged actively with other local health and social care providers alongside other stakeholders to ensure that an integrated health and care system was commissioned and provided to meet the needs of the local population. For example, the trust was supporting GPs to develop the skills to manage shared care arrangements. The trust was also working within boroughs to support partners in the development of housing, employment and other services to enable people with mental health needs to live successfully in the community.

The trust was committed to working with the local communities. The trust was leading a national piece of work to eliminate the unacceptable racial disparity for patients in terms of access to services, experience of service, and clinical outcomes through the development of the Patient and Carer Race Equality Framework (PCREF). Once developed this will be rolled out across all the mental health trusts. To address patients’ social and digital exclusion during the pandemic, the trust had worked with the Maudsley Charity to provide digital support and equipment where possible and had set up a telephone befriending service provided by volunteers.

On 16 June 2021, following extensive consultation facilitated by voluntary organisations, the trust alongside the two other South London mental health and community trusts, and councillors from the 12 boroughs participated in the South London Listens Summit. They made pledges to help prevent and address a crisis in mental health services. These included support for young people’s and perinatal mental health, better access to services, work and wages, and addressing social isolation. The trusts introduced mental health champions in every borough and forming mental health hubs to talk and share information. There were 350 community leaders trained as champions, and a social isolation, loneliness, and inclusion strategy was being developed.

The trust had begun the process of developing their five-year ambitions for 2021–2026 as their previous strategy was reaching its end. This included a 12-week engagement programme with staff, local communities, and external partners, to identify key ambitions. The engagement programme was also seeking feedback from service users, carers and governors. The trust had identified early strategic themes linked to the needs of the organisation, the local populations and the health and care system. The senior leadership team was confident in its capability to deliver on the development and implementation of the strategy.

The trust had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees and team meetings. The board was operating well with quality being a key focus. Sub-committees were working well and governance throughout the services had improved.

Leaders understood the risks within their services and were able to report them and escalate them where required. The board assurance framework was used actively by the board. The risk registers and board assurance framework clearly described how risks would be mitigated and progress was closely monitored. The senior leadership recognised the need to clearly link the framework to the strategic ambitions of the trust. Risks identified in the inspections were already known by the trust and being addressed. The trust, through its audit committee and board development, reviewed its risk appetite annually, and undertook horizon scanning to identify new and emerging areas of risk. There was a balance between workforce, finance and service performance risks.

The standards of cleanliness and maintenance had improved since the last inspection in 2019. The quality of environmental risk assessments had improved. The trust was working hard to improve the quality of the buildings in which it provided care to patients. This included the development of a new centre for children and young people’s mental health services which would bring together leading experts. The Douglas Bennett House development was due to complete in 2023 and will create eight new adult inpatient wards. The leadership team were aware that The Ladywell Centre was not fit for purpose and some estates work had taken place to improve facilities and safety for patients whilst it remains in use.

The trust had responded positively to the previous inspection and worked to make the necessary improvements. For example, we saw progress on physical health monitoring for inpatients and in the community. The trust continued to be part of the physical healthcare work with the Mind and Body Programme, which was committed to providing a programme of work to join up and deliver excellent mental and physical healthcare, research and education to treat the whole person. The Integrating our Mental and Physical Healthcare Systems project (IMPHS) launched in 2019 and was a three-year project focused on closing the mortality gap for people accessing services by improving the physical healthcare on offer to them. The IMPHS project team worked closely with physical health leads to support the trust’s physical health strategy. We saw examples of where improvements had taken place in supporting patients to manage their physical health. Staff working in the clozapine clinic had access to point of care testing facilities. This ensured that patients could have physical health monitoring completed and medicines supplied within a 20-minute appointment. The trust continued to convey a clear message about ensuring the right physical health care in the right place at the right time delivered by the right person. There was still room for improvement in the recording of physical health monitoring on some inpatient wards.

The trust continued to focus on improving patient safety by reducing violence and aggression and the use of restrictive practices. The promoting safe and therapeutic services (PSTS) redesign was on-going and the trust envisioned this would have an impact in the future. This included community involvement in the development of the programme. Ward staff participated in the trust’s restrictive interventions reduction programme including use of the safety huddles, monitoring of low-level incidents, and the use of the Dynamic Appraisal of Situational Aggression tool. The trust was aiming to eliminate prone restraint of patients by training relevant staff to administer rapid tranquilisation in the deltoid muscle (in the arm). The trust had a quality priority to reduce incidents of violence on all wards by 50% and stop prone restraint. Whilst achieving these targets was proving hard, the work was ongoing and closely monitored. There was also a quality improvement project focused on reducing restrictive practice.

The trust had focused on improving patient and carer involvement since the last inspection. The trust’s 2019/2020 quality report said there had been an increase in the number of patients and carers attending the trust board and sub-committees. All quality improvement workstreams at the trust were coproduced, codesigned or had patient and/or carer involvement in projects. They were supported by the trust’s patient and public involvement (PPI) leads. Patients and carers were able to join the trust’s involvement register with support and opportunities in place to undertake paid tasks. Since the previous inspection, the scope of work undertaken by those on the register had significantly expanded. The trust had committed to improving identification of patient’s carers, and membership of the Triangle of Care scheme (promoting partnership between patients, carers and staff). Patients, staff and carers were able to meet with members of the trust’s leadership team to give feedback. Patient stories were routinely presented at board meetings. 

The trust leadership had actively engaged with staff. The chief executive held regular open meetings with staff and during Covid-19. The chief executive and trust chair had held weekly broadcasts since March 2020, these had been twice weekly during the first national lockdown. These were used to share key messages with staff. In 2020, the trust had introduced the Listening into Action (LiA) programme with the aim of ‘making [the trust] a GREAT place to work’. The LiA programme was focused on quick and positive improvements for staff. The trust had conducted a survey which over 60% of staff completed to identify areas for improvement. They had taken action to address issues raised including reviewing the disciplinary procedure and rewarding staff for their work during the pandemic with an extra annual leave day.

Quality improvement was well embedded across the trust and over 1,000 staff had been trained in the methodology. During the inspection staff spoke about the quality improvement projects taking place within their services. Monthly performance and quality meetings took place for both inpatient and community services and management systems were in place and reported through the various sub-committees to the trust board. However, some further work was needed to ensure learning from quality improvement projects was shared across the four boroughs.

Staff provided care that was personalised, holistic and recovery orientated. Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. Staff tried to proactively involve families and carers in patient care although this had proved challenging during the COVID-19 restrictions. Staff understood how to protect patients from abuse and the services worked with other agencies to do so.

Processes for identifying and managing financial risk were well understood by the board. The board had a track record of ensuring financial control totals were delivered. The finance department was considered to have strength and was resilient. The trust had received bridging capital from the NHS, to funds its two large estate modernisation projects pending the sale of other trust assets. At the time of the inspection the trust told us that it had not yet finalised the terms and timing of the repayments. However, the formal loan agreement was signed following the inspection. In addition, the trust was planning to invest £12m capital in 2021- 2022 on digital and smaller estates maintenance and development projects.

At a national and international level there was a strong research base and system-leading research was taking place. Opportunities for research were explored and supported. Staff at the trust were heavily involved in innovative research and development work and were regularly published in clinical journals. The Pears Maudsley Centre for Children and Young Peoples was bringing together leading experts in care and research from the trust and another leading organisation in the field. The two organisations were working together to create a centre of care for young people. There was a focus on the potential of research to identify mental health difficulties early and transform treatment and care of children and young people in the UK and internationally.

However:

Due to the COVID-19 pandemic some face-to-face mandatory training had not been delivered. This resulted in trust-wide poor compliance for certain short courses which could impact on patient safety. The trust leadership were aware of this and had various mitigating actions in place to improve compliance by July 2021.

Whilst the trust had a workforce strategy and the executive team had succeeded in reducing the trust-wide vacancy rate, staff recruitment and retention was still an issue. There were a high number of nursing vacancies (21.3%) and staff turnover was also high (11%). Some staff on the acute wards told us escorted patients’ leave was sometimes cancelled or postponed due to staff shortages although the frequency was not accurately monitored.

At the time of the inspection there were significant bed pressures across the trust. Patient flow remained a significant challenge for the trust and the trust had appointed a flow director and flow leads who had daily contact with the inpatient wards. The trust had significantly reduced out-of-area placements as part of the multi-year patient flow programme although these had started to increase again. Whilst male patients in the psychiatric intensive care units were now moving to an acute ward when this was clinically appropriate, there were still challenges for female patients. There was a quality improvement project in place to address this and these moves were being prioritised.

Within community services some teams reported high caseloads, waiting lists for non-urgent referrals and some long waits for some individual psychological therapies. However, the community services were implementing a redesign programme which aligned to the NHS Mental Health Implementation Plan. Staff were enthusiastic about the change programme and could see the value of the intended outcome and how this aligned with their work. The aim of this service redesign was to speed up patient access and flow through services, reduce staff vacancies, increase multidisciplinary teams (MDTs) and improve outcomes for patients and patient experience.

Within most teams, staff completed risk assessments for each patient using the trust’s risk assessment tool and reviewed this regularly, including after any incident. Information was detailed and up-to-date and showed evidence of patient involvement. However, we found examples where patient records were not up-to-date and risk assessments were not reviewed. Team managers were aware of the issues with recording and updating risk assessments and providing support to improve the performance of staff and this was reported at the directorate’s performance and quality meetings.

The trust had improved waits for Mental Health Act assessments since 2019 and had built strong relationships with the police, ambulance services and approved mental health professionals. However, many services still reported long waits for assessment with an average of 12 days. The trust held regular forums with the associated police borough commanders where this issue was continually reviewed. Within the service redesign there was a crisis care programme which included a workstream focusing on improving the MHA assessment pathway. The trust was leading on a system-wide MHA assessment summit in summer 2021 with a goal to develop an action plan to further review and address MHA assessment delays.

The trust was working to improve its culture but recognised there was more work to do. Despite the trust’s equalities strategy, the commitment from the trust leadership for the organisation to be anti-racist, a race equality conference taking place, the progress with staff networks and many other actions there still was considerable ongoing work required to improve the experience of some Black, Asian and Minority Ethnic (BAME) staff working for the trust. One of the trust’s key actions from the Workforce and Organisational Development Strategy (2020 to 2023) was to establish a BAME Leadership Academy Programme specifically focusing on talent management, succession planning and career development for staff from a BAME background. The aim of the programme was to create greater levels of sustainable inclusion by addressing the social, organisational and psychological barriers restricting BAME staff from progressing. The trust had made improvements in the results of the Work Force Equality Standard (WRES) and NHS Staff Survey but there was more to do. In particular BAME staff were still overrepresented in comparison to white staff in formal disciplinary procedures.

Incidents and complaints were investigated, and lessons were shared with staff to minimise the risk of them happening again. However, the quality of the serious incident reports was variable; some were well written, others were less well written and lacked clear terms of reference.

The trust had a learning from deaths process in place and this was led by a member of the executive. Staff in services told us that learning from deaths and serious incidents was shared. The documented findings presented to the board were brief and it was not always clear whether learning had taken place. There were plans to strengthen this and share the learning more widely.

Compliance with the duty of candour could be improved, as the trust's own internal audit found that only 37% of letters to patients and families following incidents included a clear documented apology. In response to this the trust was planning an animated film regarding duty of candour with the communications team and a bulletin on the topic had been issued to staff in April 2020. There were plans for a re-audit to take place in October 2021. Staff told us they knew how to deliver duty of candour and were supported to do so when required.

Some staff experienced problems with IT equipment, such as mobile telephones and laptop computers, and significant delays in having these issues addressed. Staff also reported new starters had long waiting times for equipment and access to the trust’s electronic systems.

How we carried out the inspection

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic including on site and remote interviews by phone or online.

We visited 10 out of the trust’s 47 community based mental health teams which included a mix of assessment and liaison, early intervention and promoting recovery teams. For adults of working age and psychiatric intensive care units (PICUs) we also used a sampling approach. We inspected 10 of the 22 wards operational at the time of the inspection.

During the community services inspection, the inspection team:

observed a handover meeting for one community-based team
observed a zoning meeting for one community-based team
observed a referral meeting for one community-based team
observed a team meeting for one community-based team
conducted a tour of the environment for seven community-based teams
conducted a tour of the clinic rooms for three community-based teams
spoke with one occupational therapist, five registered nurses and two social workers, three care coordinators, and four senior practitioners
spoke with a psychotherapist and three clinical psychologists
spoke with a senior clinical pharmacist and a pharmacy technician
spoke with the four mental health advocates
spoke with five consultant psychiatrists and one GP trainee
spoke with five team managers, three team leaders, three modern matrons, three clinical service leads, one general manager of services and one deputy director
spoke with 31 patients and 10 carers over the 10 teams
looked at 55 patient care and treatment records
reviewed documents relating to the running of the service
carried out an anonymous staff survey for all staff in the teams inspected, for which we received 12 responses.

For the adults of working age and PICUs inspection, the inspection team:

visited 10 inpatient wards, and looked at the environment, medicines and observed interactions between staff and patients
attended staff handover meetings on eight wards
spoke with 23 patients by telephone and met with 6 patients in person
spoke with nine relatives/carers of patients on the wards
spoke with 46 members of staff in person or by telephone or video conference, including ward managers, registered and non-registered nurses, doctors, occupational therapists, psychologists, domestic staff, an activities coordinator, a psychotherapist and a pharmacist
carried out an anonymous staff survey for all staff on the wards inspected, for which we received 36 responses
looked at the care records of 69 patients
looked at 53 medicines administration records for patients
reviewed the recent incident reports for this service
reviewed specific policies and documentation relevant to this core service

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

What people who use the service say

Patients told us that staff treated them with compassion and kindness. They said that staff respected patients’ privacy and dignity. Patients said staff were attentive, non-judgemental and caring and tailored care to individual needs. Patients also reported staff provided help, emotional support and advice when they needed it. Patients said staff treated them well and were responsive to their needs.

This was a short notice announced focused inspection of Jim Birley Unit.

We carried out this inspection to follow up on concerns about the safety and quality of the service being provided following three serious incidents relating to the ward.

Jim Birley Unit is an acute mental health ward for 18 female adults of working age which is now based at the Maudsley Hospital following relocation from the Ladywell Unit.

As this was a focused inspection, we did not inspect and rate all domains. During this current inspection, we rated Safe as requires improvement. The ratings from the previous acute mental health wards for adults of working age inspection published in July 2019 remain in place for the other domains. The overall rating of requires improvement remains for this core service. We used CQC’s interim methodology for monitoring services during the COVID-19 Pandemic. In this case we did not visit the ward itself, but attended an office at the Maudsley Hospital where we could access patient records from the ward.

We found:

We found significant gaps in the recording of vital signs and physical health checks in patient records we inspected, although we recommended that this needed attention in the previous inspection report published in July 2019.
The service had systems and processes in place for safely prescribing medicines. However, we saw evidence that medicines administration was not always recorded fully.
There were not enough staff with current training in basic and immediate life support.
Staff told us that they would benefit from more training in managing patients’ physical health needs and records, and in supporting patients with substance misuse and addiction.
We found that some patients did not have current risk assessments and care plans at the time of three serious incidents in September and October 2020, although this was a requirement in the previous inspection report published in July 2019. The trust had identified this and implemented change to address this. During this inspection we found that current and recently discharge patients had up-to-date care plans and risk assessments in place.
There had been a period of instability in the staffing group when the ward reopened at a new site with a new staff group in July 2020. Staff said most issues, such as lack of manager and nursing vacancies, had been addressed, but that communication amongst the staff team could still be improved.

However:

Most patients said that staff were supportive, helpful and approachable. Two patients in particular praised the staff support on the ward. Patients who had been discharged from the ward said that they had been involved in making decisions about their ongoing support once discharged.
Staff said that they had received significant support from the ward leadership and service leads following recent serious incidents. Staff had developed lessons learned and implemented these as a team. For example, improved night checks on patients at risk and an improved format for staff handover meetings to ensure that all staff were aware of their areas of responsibility.
A nurse had been appointed for family and carer support in the last four months, holding virtual carers and family surgeries each week. Staff noted that patients’ families attended more frequently now that they could do so remotely.
The ward had an activities coordinator and occupational therapist who provided a range of activities on the ward. These included exercise groups, women’s health and wellbeing, therapeutic and recreational groups.

How we carried out the inspection

During this inspection we:

spoke with 13 members of staff by telephone or video conference, including the ward manager, three doctors, three registered nurses, three non-registered nurses, occupational therapist, activities coordinator, and a pharmacist
spoke with five patients by telephone (one currently on the ward, and four recently discharged from the ward)
spoke with one relative of a current patient by telephone
looked at the care records of twenty patients including those recently discharged from the ward
reviewed the recent incident reports made by the ward
reviewed specific policies and documentation relevant to this inspection activity

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

Patients said that staff were supportive, helpful and approachable. Four of five patients we spoke with said that they felt safe and comfortable on the ward. They said the ward was kept clean and they had sufficient access to food, drink and activities. Several patients told us that their leave to go out of the ward had been restricted due to the COVID-19 pandemic.

Two patients in particular praised the staff support on the ward, one noting that staff had provided them with very thorough support with a physical health condition. Patients who had been discharged from the ward said that they had been involved in making decisions about their ongoing support once discharged. Patients said that although staff were often busy, patients were able to get support from nurses and doctors when needed.

All but one patient said that staff administered their medicines to them safely. One previous patient said that the ward had not been kept clean enough, and there were insufficiently healthy meal options.

South London and Maudsley NHS Foundation Trust provide specialist child and adolescent mental health services (CAMHS) community teams for children and young people up to the age of 18 across the boroughs of Southwark, Lewisham, Lambeth and Croydon. The trust provides a diverse range of specialist outpatient services some of which are national specialist services supporting children and young people with a wide range of disorders including autism, learning disabilities, eating disorders, self-harm, substance abuse and emotional disorders.

This inspection primarily focussed on the specialist community teams supporting children, young people and their families from the four local boroughs, crisis services, and National and Specialist services for people with complex autism associated neurodevelopmental disorders (SCAAND).

Following the last CQC inspection of this core service in January 2016, this core service was rated Goodacross all domains. However, SCAAND and centralised crisis services were not included. The current responsive focussed inspection, only includes ratings for Caring, Responsive, and Well-Led for this core service, as we did not inspect all areas of the other two domains. We used CQC’s interim methodology for monitoring services during the COVID -19 pandemic.

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?

As part of this inspection, we:

• Visited one CAMHS service office in the London borough of Lewisham, to look at 34 care records of young people currently using, or recently discharged from CAMHS services (including seven from SCAAND services, six from crisis services, and 21 from the four local borough teams).

• Had telephone conversations with 12 young people who were currently or had recently been using the local borough services.

• Had telephone conversations with 47 parents/carers of young people who were currently or had recently been using the services (38 from local borough services, and nine from SCAAND services).

• Had telephone/video conversations with 75 multidisciplinary staff (25 from local borough teams, 21 from crisis services, and 29 from SCAAND teams). These included doctors, nurses, psychologists, therapists (including psychotherapists, family, behavioural, occupational and speech and language therapists), trainees, and administrators.

• Had video conversations with 13 senior managers/directors with responsibility for

these services.

• Had telephone/video conversations with seven Special Education Needs Coordinators (SENCO workers) working in schools in the local boroughs.

The Service for Complex Autism & Associated Neurodevelopmental Disorders (SCAAND) is a national service. It is commissioned by NHS England with some Clinical Commissioning Group (CCG) contracts. Patients tend to have multiple co-morbidities. There are four clinical service ‘streams’ and a senior leadership team. Referrals are jointly screened and allocated to one of four streams. These are Neuropsychiatry, Intellectual Disabilities (IDT), Autism and Related Disorders (ARD) and the Autism and Intellectual Disabilities Intensive Intervention Team (AID-IIT).

The SLAM CAMHS Crisis Hub, a centralised team in place for approximately 18 months, includes four services. These are a Response team, Enhanced Treatment Service, Crisis Line, and CAMHS Bed Management team. They are in place to enhance the quality of crisis intervention within the boroughs of Southwark, Lambeth, Lewisham and Croydon. They provide a range of short-term community-based assessment and treatment options for up to two weeks and advice and support to parents/carers in partnership with various internal and external agencies.

We did not re-rate Safe and Effective for this core service as this was a focussed inspection which did not look at all sections within those domains. The rating of Good from the previous inspection across those two domains still applies.

The service provided safe care. The number of children and young people on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each young person the time they needed. For young people who required urgent care, staff managed access well to ensure they were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved children, young people, families and carers in care decisions. Children, young people and parents/carers were involved in the design and delivery of the service.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the children and young people. Staff engaged in clinical audit to evaluate the quality of care they provided.
The teams included or had access to the full range of specialists required to meet the needs of children and young people under their care. Staff from different disciplines worked together as a team to benefit children and young people. Managers ensured that these staff received training, supervision and appraisal. The teams had effective working relationships with other relevant teams within and outside of the trust.
Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
The enhanced treatment service had developed an alternative model to young people being admitted to hospital, published in various professional publications. It demonstrated creative ways of working with young people, involving them in the service, and in training CAMHS staff.

The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
The service was well-led and the governance processes ensured that procedures relating to the work of the service ran smoothly.
Leaders had the skills, knowledge and experience to perform their roles. Most staff said they felt respected, supported and valued, and that they had received appropriate support in adapting to new ways of working during the COVID-19 pandemic.

However:

Some children and young people had significant waits for assessment and treatment. There were long waits for treatment of trauma, obsessive compulsive disorder, attention deficit hyperactivity disorder and for autism assessments (which had been exacerbated by COVID-19 restrictions).

Many parents/carers told us that they had not received communication or support whilst waiting for assessment or treatment. Staff were aware of this and had taken steps to contact people on the waiting list in recent months.
Parents/carers told us that they were not always given enough support or signposted to support available to them outside of working hours.
There was a lack of consistency in where staff recorded information about children and young people’s care and treatment in care records. This could lead to delay in locating the most up-to-date information by a team member if needed promptly.

Although young people said staff discussed care with them, we did not find evidence of the child or young person’s views documented in the care records.

Some teams were struggling with ongoing staff recruitment and retention issues and insufficient funding to meet the needs of children and young people living in their area. Croydon teams in particular had experienced recent disinvestment. Some staff spoke of their frustration in having limited resources to focus on prevention and early identification of mental health issues in children and young people.

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

The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to continue making the necessary changes to provide high quality care to their local communities. Since the last inspection, the chair had retired unexpectedly and the deputy chair was acting during the interim while a new permanent chair was appointed. The non-executive directors felt that they were working closely and effectively with the executive directors and were well supported by the interim chair. The chief executive was retiring and a replacement appointed with a well-planned handover due to take place. The new chief executive was coming from a neighbouring trust and so was already familiar with the trust and local partnerships. A director of people and organisational development had been appointed working across two neighbouring trusts.
Since the last inspection, the directorate structures and borough-based working for local services had become more embedded. The directorate structures ensured clinical leaders had manageable spans of control. The numbers of matrons across the organisation had been increased to support teams to provide high quality care. This was leading to improved partnership working to address challenges in boroughs with partners to meet the needs of local people.
The board had improved oversight of operational issues. The governance processes had been strengthened with each directorate having a monthly quality and performance review. Links with wards and teams were also being strengthened. This was supported by a business information system which made information available in an accessible format at all levels of the organisation. This was enabling achievements and concerns to be escalated appropriately. The trust was identifying problem areas and work was, for the most part, underway to resolve matters.
The trust’s active participation in the South London Partnership was continuing to deliver new models of care for patients receiving national and specialist services. This meant that patients were receiving their care closer to home. The success of this work was leading to discussions with clinical commissioning groups about the transfer of budgets for local services.
Since the last inspection the trust had launched its strategy ‘Changing lives’. This recognised the needs of the population in the four London boroughs. The strategy also aligned to national priorities and the Five Year Forward View for Mental Health. The strategy stated how the trust will meet the aims of providing high quality services; working in partnership; being a great place to work; promoting innovation and providing value. The strategy had been presented using a range of formats including an excellent film following the lives of five patients and their clinicians talking about how the work of the trust had helped them to improve their lives.
The trust was making progress with their quality improvement programme and had set ambitious targets for the next three years. At this inspection, most of the wards and teams we visited spoke with enthusiasm about the quality improvement projects that were taking place. On inpatient wards we saw positive examples of reductions in violence and aggression linked to the ‘four steps to safety’ programme. Over 1000 staff had been trained in QI. Patients and carers were active participants in many of the projects. However, further work was needed to ensure that projects were available on the QI intranet so they could be shared between teams.
Staff engagement remained a high priority for the trust. An ambitious programme of leadership walkabouts was continuing to promote good communication. This meant that the leadership team had a good understanding of the challenges being faced by staff working in front-line services and were working to address them. This was particularly apparent in the service transformation work being carried out in adult community mental health services. The trust promoted staff to speak up through the Freedom to Speak Up Guardian and at this inspection there was an improved awareness of this role.
The trust, since the last inspection had continued to develop and deliver an equalities strategy. There had been a focus on BME staff experience led by the BME staff network. The trust had plans in place to improve the workforce race equality standards through offering leadership development for BME staff; having BME staff on recruitment panels for all band 7 posts and above; introducing a checklist to enable managers to reflect on whether alternative approaches could take place prior to a disciplinary process. Other networks were less well developed but were being supported to grow. This included an LGBTQ network and one for staff with lived experience.

However:

The inspection took place at a time when change was happening for the board and executive leadership team. Whilst it was positive to see the progress that had taken place, further work was needed to ensure effective leadership across wards and teams and for the improvements across the trust to be further embedded.
Although the trust had continued with their workforce strategy, staffing remained an issue. There were still a high number of nursing vacancies and staff turnover. Some staff and patients on acute wards told us that patient leave was often cancelled or postponed. Some wards did not have a permanent consultant psychiatrist, although locum arrangements were in place.
The trust had improved the experience of working age adults from the local communities who were on the acute care pathway, either as inpatients or under the care of the adult community mental health teams. However, there was more to do to deliver sustainable change. Patients were affected by the ongoing extreme pressures on the acute care pathway. Bed occupancy was above 100% on most wards, which meant staff may not have been able to manage the care of patients safely. There was not always a bed available for someone who needed one. The trust had 300 patients in out-of-area beds between February 2018 and December 2018. We found six incidents where patients in psychiatric intensive care units were ready for discharge to acute wards but were unable to transfer due to the lack of acute beds. This meant patients experienced care at a higher level of security than what was needed.
There were a few safety issues particularly on the acute inpatient wards that needed to be addressed to ensure the environments were safe and clean; that patients had their physical health monitored after the administration of rapid tranquilisation; that patient risk assessments were kept updated.
Whilst learning from incidents had improved within services and boroughs, there was still scope to further develop the shared learnin

Our rating of this service went down. We rated it as requires improvement because:

Whilst improvements had been made and embedded on each of the units since the previous inspection, more work was required to address some of the concerns from last time and we identified some new concerns.
The three inpatient mental health rehabilitation services had not clearly defined the model of rehabilitation they were using and how they would deliver a recovery orientated approach. Whilst they described themselves as being predominantly high dependency rehabilitation units there were varying lengths of stay within each service. However, work was taking place through the South London Partnership to define an integrated complex care pathway and identify models of care to optimise the inpatient rehabilitation service.
Patients care plans lacked any meaningful planning for recovery, including achievable goals designed to support patients towards discharge.
Governance meetings on each ward were still being embedded so they were used effectively to improve the safety and quality of the service for patients.
Whilst staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice they did not always discharge these well. Staff did not always know when they should explain a patients’ rights to them and the recording of this was sporadic. Staff at Heather Close had not ensured that some patients had legally consented to medication prescribed to them or that it had been appropriately authorised by a second opinion doctor.
Whilst the wards were working to minimise the use of blanket restrictions, staff at the Tony Hillis Unit were confused about recent reductions in restrictions and how to apply these appropriately to meet the individual needs of each patient.
Although work was underway to make improvements, patients were not satisfied with the quality of food or the choices available to them. Patients could be supported further to self-cater.
Staff had limited understanding on how to support the needs of patients with protected characteristics and there was little information available to these patients to make them feel welcomed onto the wards.

However:

All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Improvements had been made in terms of how ligature risks were managed. Maintenance repairs were reported and undertaken within reasonable timescales. Fire safety arrangements at Heather Close had also been addressed, in terms of signage and ensuring fire doors were not wedged open.
Staff assessed and managed risks to patients and themselves. Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. As a result, they used restraint only after attempts at de-escalation had failed and this was very rare. The ward staff participated in the provider’s restrictive interventions reduction programme. We found improvements had been made in the observation arrangements of patients as well as ensuring that adequate precautions were taken if a patient went absent without authorisation.
Staff understood how to protect patients from abuse and/or exploitation and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and/or exploitation and they knew how to apply it. The environments were suitable for mixed gender and appropriate security arrangements had been put in place by the trust.
Staff assessed the physical and mental health of all patients on admission. Care plans had improved and were reviewed regularly through multidisciplinary discussion and updated as needed.
Staff actively engaged with commissioners, GPs, social care organisations and other secondary care services. This ensured that staff could plan, develop and deliver the service to meet the needs of the patients.
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 at Westways and Tony Hillis and patients’ views were incorporated, even when they differed from the clinical teams. All units actively sought patient feedback on the quality of care provided. Staff supported patients to make a formal complaint if they needed to.
Staff involved families and carers and invited them to attend patient review meetings. Staff at Westways were establishing a family/carer user group to better understand their views.
Staff helped patients with communication advocacy and spiritual support.
Staff engaged actively in quality improvement activities and national accreditation schemes.

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

Although the trust had made improvements since our last inspection in July 2018, there were still areas that required improvement.
The trust had continued with their recruitment drive. However, staffing remained an issue. Some wards had high number of nursing vacancies and some wards had consultant psychiatrist and ward manager vacancies. Some wards had high staff turnover rates. This impacted on the stability of teams and the consistency of patient care and experience.
The service needed to improve bed management on the acute wards and PICUs. Bed occupancy was above 100% on most wards. In the last 12 months, the trust had 300 patients in out-of-area beds. There were six incidents where patients in PICUs were ready for discharge to acute wards but were unable to transfer due to lack of acute beds. This meant patients experienced care at a higher level of security than what was needed.
At the last inspection in July 2018, there was not always a bed available for patients returning from leave. At this inspection, although the number of incidents had decreased significantly, and senior managers had good oversight, there were still four occasions where a bed was not available when patients returned from leave.
Although improvements had been made to the environmental risk assessments, the trust had not ensured all environmental risk assessments had timescales for identified work that needed to take place. The trust did not have clear information about who was going to take responsibility for these actions. The use of plastic bin bags, which can present a safety risk for some patients, in communal areas across the acute wards was not consistent. Plastic bags in communal areas were not always identified on the wards’ environmental risk assessment.
Although most wards carried out physical health checks on patients after they received rapid tranquilisation, in line with national guidelines and trust policy, we found three examples where this was not always the case.
Some of the wards were not clean or well-maintained, especially in bathrooms and toilets.
The service did not always provide support to staff to ensure they had the necessary skills to support patients. Not all staff had access to autism training despite caring for some patients with autism on the wards. The trust had recently established an autism training programme for acute/PICU wards, but staff from some wards had not yet been provided with the training. Supervision had improved since our last inspection, however, it remained low on some wards.
Managers did not always ensure that lessons learned from the investigation of incidents and adverse events that happened on the PICUs was communicated across boroughs.
Some wards did not always follow the trust safeguarding policy. We found examples on ES1 and Eden Ward, where safeguarding alerts had not been escalated.
On some wards, staff did not always request an opinion from a second opinion appointed doctor in a timely manner. Not all patients’ physical health treatment was included on their certificate of consent to treatment, therefore it was not clear from the records what legal authority was relied upon to permit this treatment.
Although improvements had been made in supporting patients with specific physical health needs, we still found examples where recording of blood glucose monitoring and fluid charts were incomplete.

However:

The trust had made improvements in many areas identified at the previous inspection. These areas included ensuring all patient restraints were recorded in sufficient detail, improved recording of patient observations and incident reporting, appropriate checking of emergency equipment, ensuring that patient information was not visible to other patients on Nelson Ward, and ensuring that staff on Croydon PICU and Aubrey Lewis 2 demonstrated kindness and compassion in their interactions towards patients.
Most staff told us that the trust’s move to a borough-based structure had improved their way of working. Staff said senior managers were much more visible and approachable on the wards. Senior managers said they had better oversight of the wards, and communication had improved from ward to board. Staff told us that the culture had also improved since the last inspection, in particular the trust promoted a more positive and open culture.
At the last inspection in July 2018, whilst governance systems and processes could identify the wards at risk of not delivering high quality care and treatment, appropriate support had not been put in place. At this inspection, improvements had been made. We found the trust had implemented support plans for wards that needed to improve. Managers had a greater oversight of the wards, which led to less variation in the quality and safety of care and treatment being delivered between wards.
The trust had worked hard to implement plans to reduce the number of patients being restrained. Since our last inspection in July 2018, the proportion of restraints that involved patients being restrained in the prone position had decreased. Staff were aware of the provider’s restrictive interventions reduction programme.
At our previous inspection in August 2018, staff restricted patients on Johnson Ward’s access to drinking water. At this inspection, we found that this was not the case on any of the wards we visited.
The trust had made improvements to delayed patient discharges since our last inspection in July 2018. There had been a 17% decrease in the number of delayed discharges and staff were proactive in addressing barriers to patients being discharged.
Most care plans were personalised, holistic and recovery orientated. We saw good examples of care plans that included needs such as mental health, physical health, LGBT+ and accessing the community.
Staff treated patients, families and carers with compassion and kindness. Staff demonstrated a good understanding of patients’ and carers’ needs and interacted with them in a respectful and responsive way.

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

Although staff kept detailed records of patients’ care and treatment, they had not always ensured that key risk assessment and risk management documents were up to date. These documents were not always accurate in relation to the patient’s current circumstances or risks.
At the last inspection in July 2017, patients identified as in need of a Mental Health Act assessment were not assessed promptly. During this inspection, this remained an issue. There were still delays with patients getting Mental Health Act assessments done in a timely manner. However, the trust was monitoring this closely and working with the local authorities and police to make ongoing improvements. They had also given a clear message that assessments should never be cancelled due to difficulties in accessing a bed.
Although there had been improvement since our last inspection, the Croydon assessment and liaison team was unable to meet their target for assessing non-urgent referrals within 28 days and the team had a long waiting list of over 550 non-urgent cases.However, the teams did have systems in place to monitor patients on the waiting list.
The trust did not have effective medicine management audits, monitoring of prescribing and prescription stationery management.

However:

The service provided safe care. The premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided. The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
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.
The service was easy to access. Staff assessed and treated patients who required urgent care promptly and most patients who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude patients who would have benefitted from care. Governance processes ensured that that procedures relating to the work of the service ran smoothly.

We rated this service as good because:

The service provided safe care. Staff assessed and managed risk well and followed good practice with respect to safeguarding and management of medicines. Managers investigated incidents appropriately, shared lessons learned with the wider service, and gave patients honest information and suitable support.

Staff developed holistic, recovery-oriented care and treatment informed by a comprehensive assessment. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.

The teams included or had access to the full range of specialists required to meet the needs of patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation. Staff directed patients to other services when appropriate and, if required, supported them to access services, such as local children’s centres.

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 respected their privacy and dignity. They understood the complex individual needs of patients preparing for motherhood, and as new mothers, and supported them to manage their mental health, and develop parenting skills. They actively involved patients and families and carers in care decisions.

The service was easy to access. Staff assessed and treated patients who required urgent care promptly. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff followed up patients who missed appointments.

The service was well-led, and governance processes ensured that procedures relating to the work of the service ran smoothly. Staff were encouraged to be involved in research and innovative practices.

However:

Staffing vacancies and poor staff retention were having an impact on the consistency of support for patients and led to increased stress on the remaining staff. However, recruitment was taking place specifically for the service and they were also using regular temporary staff where possible. One community perinatal team had waiting times for non-urgent appointments to see a doctor of over four weeks although urgent appointments were available.

Although it did not compromise safety because staff mitigated the risks, the physical environment of the mother and baby unit was not ideally suited to support high quality care. There was a lack of ensuite facilities, the nursery was too small, the garden space was not safe for use by all patients, and there was not enough space for patients to meet with visitors. The trust had a long-term estate plan but these shortfalls could not be addressed quickly. In the Southwark, Lambeth and Lewisham perinatal community teams, there were insufficient rooms available to meet with patients. Whilst appointments had not been cancelled, staff had to plan carefully to ensure everyone was seen.

There were long waits for psychological therapies in the community perinatal teams, which did not always meet the recommended timeframes of assessing patients within two weeks and providing treatment within four weeks. In two boroughs patients were waiting up to 16 weeks. More clinical psychologists were being recruited and assistant psychologists were offering more group work in the interim period.

Whilst average numbers of staff receiving regular supervision across the services was over 80% there were a few areas where this had gone lower. For example, in March 2019 this had fallen to 67% in the MBU. However, all staff felt well supported by their managers and had regular access to reflective practice. The MBU manager was aware of levels of supervision and was working to ensure they were consistently within the trust target.

Staff had made improvements on the ward since our responsive inspection in February 2018 and were no longer in breach of regulations. Staff completed patients’ risk assessments and risk management plans and updated them when required. Staff completed patients’ physical health monitoring charts when required.

Since the previous focused inspection in February 2018 the service had made improvements in several areas. This included improvements in systems, which supported the sharing of lessons learned from incidents with all staff; ensuring patients received regular individual time with a nurse; making sure staff were aware of feedback from patient satisfaction surveys; better communication with patients’ care coordinators; and providing more activities for patients at the weekend.

The service managed environmental and patient risks well. The trust had completed a new ligature risk assessment for the ward. Staff knew how to manage the identified risks and protect patients from avoidable harm.

The service had enough staff to provide the right care and treatment to patients and their families. The service had reduced staff vacancies by recruiting new staff since the previous inspection in February 2018. The trust had made improvements to how bank and agency staff were booked. Bank and agency staff received a better induction when they first worked in the service. The service provided mandatory training in key skills to all staff and made sure they completed it.

Patients gave positive feedback about permanent staff. Staff were supportive and kind when interacting with and caring for patients. Records showed patients were involved in decisions about their care. Staff offered families and carers support and skills training.

Staff worked to meet the diverse needs of patients on the ward. The ward was accessible to patients with physical disabilities. Staff ensured patients had access to appropriate spiritual support and facilitated access to places of worship. Staff could obtain the support of interpreters when this was needed. Staff supported LGBT+ patients on the ward.

Staff were positive about the support they received from their colleagues and the trust. The trust provided staff with training and professional development opportunities. Senior managers were visible in the service.

The service was committed to providing high quality evidence-based care to patients. Staff were involved in various quality improvement and research projects and applied findings to practice improving the care delivered to people with eating disorders both on the ward and in community settings. The service was innovative and had devised new models of care for people with eating disorders, which were being rolled out nationally. One community based team had won a national award. The ward was accredited with the Quality Network for Eating Disorders.

However:

Although the service provided staff with specific training related to their role, the service did not have a formal eating disorders competency framework for staff. Consequently, there was a risk that staff did not have all of the specialist skills they needed to care for a patient with an eating disorder.

Staff did not always record incidents of restraint to include information about the type of restraint, position of restraint, members of staff involved, length of time and that the patient received a physical check for any injuries.

The ward had not increased the dietitian and social worker input on the ward since our last inspection. They were reviewing the roles to determine how best to fill any gaps identified.

Some staff had not received regular monthly supervision. Although 87% of staff received supervision as planned in March and April 2018, the figure had fallen to 70% in May and 65% in June, below the trust target for clinical supervision compliance of 85%.

Some patients felt they were not as involved in their care as they would have liked. Staff did not give all patients a copy of their care plan or an induction to the ward on admission. Some patients said staff did not always respond or act on their feedback about improvements needed to their care or the ward.

Although staff completed weekly audits in a number of key areas, it not clear how staff used audit findings to make improvements.

During this inspection, we found that services had addressed all of the issues that caused us to rate it as requires improvement in safe following the September 2015 inspection.

Staff completed full risk assessments for patients and managed risk well. Staff developed crisis care plans with patients. Staff kept patient risks under continuous review at twice daily team meetings. Staff completed documentation, including initial risk assessments and physical health assessments to a good standard.

The service had introduced a purpose-built health-based place of safety since the 2015 inspection, which provided patients with a high-quality environment. There was a dedicated staff team, 24 hours per day and seven days a week. There were good facilities for children and young people and parents could stay overnight.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training in how to recognise and report abuse and they knew how and when to report their safeguarding concerns.

Staff supported patients to live healthier lives, and receive support for their physical health. Two nurses ran weekly physical health clinics in each home treatment team. Staff in the health-based place of safety received specialised physical health training to reduce admissions to emergency departments in local acute hospitals.

The service had enough skilled and experienced staff to support patients in a crisis. Staff of different disciplines worked together as a team for the benefit of patients. The home treatment teams ran a specialist training programme for all staff, which included suicide prevention and family interventions.

Patients were positive about staff and the service. For example, patients said staff provided good support when they were experiencing a crisis.

Staff did all they could to keep patients at home during a crisis and prevent admission to hospital. The crisis assessment team, consisting of a nurse and a police officer, accepted referrals from the ambulance service and police. They had been successful in reducing admissions to acute hospital emergency departments of patients in crisis.

Staff understood arrangements for working with other teams within the trust and externally to meet the needs of patients in crisis. The home treatment teams and health-based place of safety had multi-agency arrangements in place, to monitor and agree the governance of crisis services.

Home treatment teams and the health-based place of safety staff worked towards improving quality within the service. Staff had implemented a quality improvement project introducing patient reported outcome measures to incorporate into patients’ care planning.

However:

Although staff usually managed patients’ medicines safely, staff sometimes did not package and label the patient’s medicines when they left them at the patient’s home. Staff did not always follow the trust policy for assessing and recording the suitability of the patient’s own medicines before these were administered.

Although, there had been a significant decrease in the number of hours patients spent in the health-based place of safety, at the time of the inspection data showed that nearly a quarter of patients had breached the 24-hour target length of stay in May 2018. This was monitored very closely by the trust.

The patient section 132 rights poster displayed in the health-based place of safety assessment rooms did not clearly explain patients’ rights and could have been misleading.

Capacity assessments for consent to treatment, in the health-based place of safety, lacked detail. Staff did not clearly demonstrate how they had arrived at their decision.

Staff in some teams were not aware of the trust’s Freedom to Speak Up Guardian or how to contact them.

Our overall rating for community-based mental health services for older people stayed the same. We rated it as good because:

The leadership, governance and culture of the service actively encouraged the delivery of person-centred care. The service had capable managers at all levels with the right skills and abilities to run a service providing high-quality, compassionate, sustainable care.

Services were very well-led and allowed staff to be creative and innovative in their approach to care and treatment. Evidence was used to develop new tools and effective services. Quality improvement initiatives and research had led to the development of new ways of working. Innovations had been shared with other health services and professionals both nationally and internationally.

Services took account of the diverse needs of patients and carers. The memory service in Lambeth and Southwark was working towards increasing the number of black and minority ethnic people being referred to the service. Staff from the service had piloted an innovative series of sessions on dementia for children in schools as a way of raising awareness among local communities. Staff were sensitive to the needs of LGBT+ patients. Premises were accessible to people with mobility problems and staff saw patients at home when this was more appropriate.

Staff worked actively to reduce prescriptions of anti-psychotic medicines and medicines that had an adverse effect on memory.

Staff were compassionate, respectful and responsive to the needs of patients and carers. Feedback from patients and carers was very positive and staff were continuing to consider ways in which they could involve patients and carers in decisions about the services.

Staff of different kinds worked together as a team to benefit patients. A full range of experienced professionals worked across the teams and were able to provide the necessary interventions to patients. Staff worked well together both within their teams and with other teams to ensure that patients received the support they needed in a timely manner. Teams referred patients to other services when this was appropriate.

The service had enough staff with the right, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staff had manageable caseloads and were able to respond promptly when an urgent assessment was needed. Work had been done to improve the waiting times for an assessment at Croydon memory service. All memory services were working hard to decrease their referral to diagnosis times, so that they could reach a six-week referral to treatment target by 2020.

The service had made improvements to the quality of patient risk assessments since our last inspection in September 2015. Staff used a comprehensive risk assessment tool, which prompted them to cover all areas of risk in sufficient detail including how to safely manage the identified risks. Risk assessments were easily accessible to staff and stored in an appropriate place on the electronic patient record. Teams managed patient risk well. They used regular zoning meetings to identify and focus on patients at high risk.

Staff had made improvements to the way they transported medicines and disposed of sharps. Although a few staff in one team did not always follow trust policy in respect of the disposal of clinical waste this was promptly addressed by managers.

Similarly, improvements had been made in lone working procedures, the application of the Mental Capacity Act, compliance with safeguarding procedures and to patient waiting areas in Lambeth. Work had also taken place to improve patient crisis plans. These were now in place and patients knew who to contact in an emergency.

However:

Whilst the trust was using technology to support mobile working in some teams this had not yet been rolled out across all the teams. Staff told us that they had to return to the office at the end of the day to complete patient care and treatment records, which was not an effective use of their time and may have had a negative impact on the quality of record keeping.’

Whilst patient care plans identified all aspect of patients’ care, they were not particularly accessible to patients who were living to dementia. The trust was in the process of improving care plans in terms of accessibility to their patient group during the time of our inspection. Similarly, standard methods for giving feedback about the service did not take into account the particular needs of patients with dementia or offer them suitable alternatives.

The recording of staff supervision in Lewisham older adult CMHT was inaccurate and resulted in under reporting. It was difficult for the team manager to be assured about the frequency of supervision taking place in the team without access to full records.

Teams were not routinely discussing incidents and complaints at their business meetings as a way of learning and promoting improvements.

We rated it as good because:

Staff completed a comprehensive mental and physical health assessment on each patient shortly after they were admitted. Care plans were personalised, holistic and recovery oriented, and included patients’ views and multi-disciplinary input from the ward team. Staff completed patient risk assessments promptly when patients were admitted to the ward, and put in place detailed management plans. These were updated after incidents.
Staff interacted with patients in a positive, respectful and discreet manner, and there was a calm and relaxed atmosphere on the ward. Most patients reported that staff treated them well and described staff as friendly, caring and supportive.
Staff were clear about the criteria for admission to the unit and actively planned for patients’ discharge from the time of admission. They worked collaboratively with community mental health teams, rehabilitation teams and local social services. Delayed discharges were monitored and escalated when necessary.
Although there remained staff vacancies on the ward, the trust had undertaken a recruitment campaign to attract nurses with a range of different skills to work on the ward and ensure safe staffing levels. The trust had recruited learning disability nurses, physical health nurses and registered mental health nurses. Multidisciplinary staff received the specialist training they needed to provide effective care and treatment to patients. The staff team had an in-depth knowledge of the patient group. It was anticipated that the ward would be fully staffed by September 2018.
Staff stored medicines securely and administered them in accordance with national guidelines. They recognised, reported and investigated medicines incidents, and shared learning from incidents to reduce the number of future medicines errors.
The service-controlled infection risk well. Staff kept equipment and the premises clean. The ward was visibly clean, tidy and well maintained.
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with staff. Patients knew how to make a complaint.
Governance structures in the service helped ensure that learning from incidents and complaints was shared effectively with staff and information was passed from ward to trust board and vice versa. Managers maintained oversight of the quality of the service.

However:

Although staff told us that they were receiving regular supervision, there were many gaps in records of their clinical supervision, indicating that they did not always receive the support needed in carrying out their duties effectively. This may have impacted on the quality of care provided to patients.
Although the service had suitable premises and equipment, some areas of the ward, identified as a risk due to poor visibility, were not consistently monitored by staff to mitigate the risks to patients. Staff had not identified expired items in one of the ward’s clinic rooms, indicating that staff were not checking these regularly. It should be noted that almost all patients on this ward were informal, and would not normally be considered at high risk of suicide or self-harm.
No patients were given keys to their bedrooms on the ward, which meant that they had to rely on staff to lock and unlock their rooms.
There were limited opportunities for patients and their family members to give feedback about the service they received. This was a missed opportunity to involve patients and carers in making improvements to the patient experience.
Incidents relating to the service were not always categorised accurately, to ensure that appropriate learning was shared with staff within the trust.

The trust had failed to make improvements in relation to some matters we said the trust must address at the last inspection in January and February 2017. The trust had systems in place to identify wards who may need additional support, but had not ensured this support was in place to enable wards to make the necessary improvements in the quality of care and treatment.

The trust had not ensured that all environmental risks relating to ligature anchor points, blind spots and the use of plastic bin liners were included in environmental risk assessments and that staff were aware of these risks and how to mitigate them.

The trust had not embedded plans to reduce patient restraint and prone restraint, in particular. Staff in many of the wards were not using the ‘four steps to safety’ approach, which had been adopted as a quality improvement initiative to reduce violence and aggression and associated restrictive practices, including restraint.

Staff did not always carry out physical health checks after administering intra-muscular medicines for rapid tranquilisation. Patients receiving rapid tranquilisation are at risk of seizures, airway obstruction, excessive sedation and cardiac arrest. The failure to carry out checks in line with national guidelines and trust policy put patients at risk of avoidable harm.

The service had a high number of delayed patient discharges. On some wards, staff failed to effectively plan for patients’ discharges and failed to work pro-actively to ensure that patients could be discharged as soon as they were ready. In the past 12 months, the trust had not been able to provide a bed for four patients returning from authorised leave and 27 patients returning from unauthorised leave. Thirty one patients altogether had had to sleep on sofas or in other temporary facilities.

Staff did not always appropriately record patient safety incidents. Many staff were not aware of serious incidents that had taken place on other wards or across the trust or learning from these incidents. Team meetings where incidents and complaints were discussed had not taken place consistently across all the wards.

The service did not provide adequate support to staff to ensure they had the necessary skills to support patients effectively. Although staff had access to training in caring for people with learning disabilities this did not include patients with autism, although staff told us that patients with autism were admitted to the wards. Managers had not held supervision meetings with staff as frequently as they should to provide support and monitor the effectiveness of their work.

Some wards had high levels of staff vacancies, a high turnover of managers or interim managers. This had an impact on the stability of teams, consistency of care provided and patient experience.

Staff did not always provide adequate support to patients with specific physical health needs. We found examples of staff not taking regular blood tests when these were required and staff failing to act on concerns that a patient was not drinking enough. Patients on Johnson PICU did not have unrestricted access to drinking water, creating a risk of dehydration, particularly in hot weather. Some emergency equipment was out of date and although this was recognised by staff, they had not identified it in time to replace the equipment before the expiry date.

However:

The trust had made improvements in many areas identified at the previous inspection. These areas included providing information about fire safety procedures and evacuation, carrying out fire drills, improved pest control, and a reduction in patients going absent without authorised leave.

The trust had improved safeguarding procedures since the previous inspection in 2017. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training in how to recognise and report abuse and knew how to apply it in their everyday work.

The trust provided statutory and mandatory training in key skills to all staff and made sure everyone completed it. There had been an increase in the number of staff who had completed training in the Mental Capacity Act. Most staff had completed the trust’s new annual performance appraisal or were booked to do so. Staff at the Ladywell Unit had received specialist training in cognitive behavioural therapy to enable to them to provide better support for people with emotionally unstable personality disorders.

Although patients on two wards reported poor attitudes amongst some staff, most staff were kind and compassionate. We observed positive, caring and supportive interactions between staff and patients throughout the inspection.

Many staff had received training in quality improvement and some wards were implementing creative and innovative approaches to care delivery. Innovations included using video conferencing to encourage community staff to become more engaged in multidisciplinary team meetings, the introduction of care planning surgeries, weekly health and well-being clinics and the introduction of electronic observation recording. The new sensory room, with light projection and soft furnishing, and art work on ES1 had won an award in 2018.

Staff actively encouraged patients and carers to be involved in care planning and sought their views on a range of aspects of their care and treatment. Staff acted on feedback from patients and carers to make improvements to the service. Some wards had identified staff who took a lead on carers’ involvement. Four wards held monthly carers’ forums. The trust facilitated service user and carer advisory groups as a way of involving them in the development of the service.

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

At this inspection we rated one service we inspected as inadequate and five services as good. When these ratings were combined with the other existing ratings from previous inspections, one of the trust services was rated inadequate, one was rated requires improvement, 11 were rated good, one was inspected but not rated and one had not been inspected.

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

The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to make the necessary changes to provide high quality care to their local communities.

The trust was participating very effectively in local care systems to drive progress to achieve integrated care. This was most developed in Lambeth but was also in progress in the other boroughs. The trust’s active participation in the South London Partnership was delivering new models of care for patients receiving national and specialist services. This meant that patients were receiving their care closer to home.

The trust’s strong academic and research links meant that many patients had access to innovative treatment. The trust had been at the forefront of developing new evidence based practice, including for people with eating disorders, in peri-natal care and in work with people with dementia, leading to improvements in treatment adopted both nationally and internationally.

The trust was making progress with their quality improvement programme and had set ambitious targets for the next three years. The early adopters of this work were understandably from higher performing teams. However, this needed to be embedded in more challenged teams as a way of facilitating improvements.

Staff engagement was (as shown in the staff survey) better than many other similar trusts. An ambitious programme of leadership walkabouts was promoting good communication. The trust promoted staff to speak up through the Freedom to Speak Up Guardian, although some teams were not yet aware of how to access this support and Freedom to Speak Up advocates did not receive specific training for their role. The trust was aware that there were groups, teams and individuals where deep-seated concerns still needed to be resolved.

The trust was working with the BME staff network to implement a range of measures to improve career progression and address discrimination for BME staff. It was recognised that this would take more time to fully implement and begin to have a positive effect on performance against the workforce race equality standard.

The trust had many excellent examples of working with people who use services and carers. This was supported by an active involvement register and a wide range of opportunities for volunteers. The trust was also looking to extend the number of peer workers. Staff were proactive in addressing the needs of people with protected characteristics. Staff enabled access to services for patients with physical disabilities, took account of individual’s cultural and religious needs and provided information in accessible formats. The trust worked in partnership with local BME communities to improve the design and delivery of services. Many staff were sensitive to the needs of LGBT+ people and the trust had developed a new policy to address needs of young people who were transgender.

The governors were performing their role well and holding non-executive directors to account. This had significantly improved since the last inspection and reflected the desire of the board to be open and transparent.

The trust had systems in place to identify risk and the board assurance framework had recognised the pressures on the acute care pathway. In addition, a system was in place to identify the performance of wards and teams using a range of indicators. However, there was a disconnect between these systems and the front-line services. This meant that where services needed to improve across the acute care pathway, targeted support had not been delivered.

The quality of the investigation reports following a serious incident were of a high standard and provided the necessary insight into where improvements were needed but further work was needed to ensure this learning was embedded across the trust.

The trust was actively engaged in pioneering and developing digital innovations. This included the piloting of electronic observations and a personal health record to digitally engage patients in their care.

The trust had made significant improvements to care environments since the comprehensive inspection in September 2015. This was particularly noticeable in the introduction of a single, centralised, purpose-built health-based place of safety at the Maudsley Hospital. The facility had a dedicated space for children and young people and provision for their parents to stay overnight. A psychiatric intensive care unit had won an award for the design of a new sensory room for patients and commissioned art work for the ward, which created a more therapeutic environment.

However:

At the time of the inspection, adult patients from the local communities being supported on the acute care pathway, either as an inpatient or by adult community mental health teams, could not be assured of receiving consistently high standards of care. These unwarranted variations in standards of care had a negative impact on the largest group of patients receiving care and treatment from the trust. We have taken enforcement action to ensure services improve.

The quality of leadership at a ward and team level varied and was a key factor in whether the service was operating well. The trust was aware of these variations and that some leaders needed more support to enable them to deliver a high-quality service. The trust had not ensured that the necessary support had been put into place. The trust anticipated that the recently introduced restructure of the operational directorates, resulting in smaller spans of control and increased levels of professional input, would deliver the support needed to make required improvements.

There had been breaches of fundamental standards of care on the acute inpatient wards, which had not been appropriately escalated to senior leaders in the trust. The flow of patients into and out of the acute care pathway was poor. Bed occupancy was above 100% on most of the acute wards. There was not always a bed available for someone who needed one. Some patients were sleeping on couches or in seclusion rooms rather than in a bed. This was unsafe and compromised the dignity of the patients. In the previous year there were over 30 incidents of this happening. Governance systems had not identified this unacceptable practice, or a few other serious shortfalls such as staff not always carrying out physical health checks on patients after they were administered intra-muscular rapid tranquilisation. This put patients at risk of avoidable harm.

The communication with wards and teams did not always happen effectively. Whilst the governance system included the expectation that each ward or team would have a quality governance meeting, these were not always happening regularly or including all staff. Information was not always shared consistently, which meant there were teams who did not have access to adequate learning from incidents, complaints or other methods of assurance such as clinical audits.

Staff did not always identify and report patient safety incidents, which prevented them from being investigated in promptly and prevented staff from learning from them. Environmental risk assessments were not always thorough and significant potential risks to patients had not been identified and therefore mitigated.

At the last inspection in September 2015, we rated the service as requires improvement because of concerns about the completion of patient risk assessments and the quality of meals provided to patients. At this inspection, we found that the trust had made improvements and addressed both concerns.

The service managed patient risk well. Staff had completed individual patient risk assessments and kept these updated. Staff were aware of areas of the ward where incidents took place and managers adjusted how the ward was run in order to mitigate risks.

The service had a strong focus on relational security and staff were committed to minimising the use of restrictive practices such as restraint and seclusion. Staff used the ‘four steps to safety’ approach to reduce incidents of violence and aggression and consequently the need for physical restraint and seclusion.

Although patients had somewhat mixed views about the meals provided, there had been an improvement in quality after a new meal provider had been contracted. Patients and staff gave regular feedback to the contractor about meals and their views were considered. Patients on some wards could self-cater and made their own choices about which meals to prepare.

The service engaged and involved patients in the care they received. This included a focus on collaborative risk assessments. Staff responded to issues raised by patients in community meetings. Each ward had a patient representative who attended regular meetings with senior managers to discuss issues that mattered to patients on individual wards. As a result of feedback from patients, mobile phone access had been arranged for patients on the wards.

The service provided a range of evidence based therapies. Patients had access to social activities and a fully equipped gym and sports hall. Staff supported patients to develop the skills they needed to live independently. Patients had the opportunity to work in the unit shop, café, or library and were paid for this.

Patients told us that most staff treated them with respect, kindness and compassion. This was supported by our observations of staff interactions with patients. Staff across the service, including the senior management team, had a good understanding of the individual needs of specific patients. Staff understood safeguarding procedures and took steps to protect patients from possible abuse.

The service met the cultural, religious and spiritual needs of patients. Patients had access to interpreters, when needed, and information was available in community languages.

Patients and staff spoke positively about the senior management team within the service. Staff reflected the trust values in their work, and recovery was a strong theme of the service.

The forensic service was part of the South London Partnership with two neighbouring mental health trusts. The trust had been able to bring back 37 patients to south London from services in other parts of the country, meaning they could receive care closer to their communities, families and friends. Overall, the South London Partnership had repatriated 63 patients to south London from other parts of the country.

However:

Although the trust was actively involved in recruiting new staff, some wards had high numbers of vacancies and shifts were not always filled by bank or agency staff. On 22 occasions in a six-month period this led to patients’ leave being cancelled due to staff shortages.

Although the number of restraints carried out by staff had reduced considerably, staff did not record patient restraints in sufficient detail to enable further learning and development and keep an accurate record of events.

Nursing and support staff on Effra Ward were not invited to the ward’s monthly business meeting. This meant there was a risk they were not effectively learning lessons from incidents that occurred on the ward or in the service as a whole, which were discussed at this meeting.

Where clinical audits identified areas for improvement staff had not always put action plans in place to address these areas.

We found the following issues the trust needs to improve:

There were a number of concerns regarding care records for patients. Staff did not record all known risks affecting patients in their risk assessments so that all staff were aware of actions to take to protect patients from potentially avoidable harm. There were also gaps and errors in the physical health monitoring for patients, which might prevent appropriate escalation to see a doctor when needed. Not all patients had a completed care plan, or were offered a copy of this.
There had been a high turnover of staff on the ward, which impacted on the staff team and patient care, and involved high levels of bank or agency staff working on the ward. Patients told us that they did not have the opportunity to meet with their primary nurse at least weekly.
While patients spoke positively about permanent ward staff, they had concerns about some bank staff providing cover on the ward, and inconsistencies in the support provided by them. We found that new bank or agency staff had not completed the dining room induction, created with patient involvement to ensure that patients had consistent support at mealtimes. Systems for booking bank or agency staff did not ensure that appropriately experienced staff were selected.
There were some gaps in communication between staff on the wards, availability of health and safety documentation, and consistent implementation of improvements agreed for the ward. Ward staff were not aware of the results of recent patient satisfaction surveys, or learning from recent incidents.
Patients were not always provided with sufficient information about the ward on admission.
Some patients complained about insufficient activities available to them at weekends, when the occupational therapy building was closed. Staff and patients indicated that dietitian and social worker input on the ward was not always sufficient, and there was limited communication between staff and patients’ care coordinators, which could facilitate smoother transition on discharge.

However, we found the following areas of good practice:

The service offered therapies in line with national guidance and provided dietitian, social work, psychology, and occupational therapy support. The multidisciplinary team met regularly to discuss patient care and involved patients and their families in discussions, when patients consented.
A weekly timetable included a range of activities that supported the recovery and wellbeing of patients. Patients had access to fresh air, with a garden available to them.
Patients gave very positive feedback about permanent staff and we saw that staff were supportive and kind when interacting with patients. We observed staff supporting patients well during a mealtime. Records showed patients were involved in decisions about their care. Relatives and carers were offered support and skills training.
The number of nurses on each shift during the day and night was sufficient, and there was adequate medical cover. Plans to manage risks were outlined at daily handover meetings, and staff were trained in safeguarding procedures.
All areas of the ward were visibly clean, with appropriate infection control systems in place.
The ward received appropriate pharmacy support, to ensure medicines were stored, and managed safely.
Staff had implemented a quality improvement project known as four steps to safety on the ward, to improve patients’ experience, and reduce the need for physical interventions. Staff described various quality improvement projects they were undertaking on the ward including working on a new induction pack for patients. Staff took part in clinical audits, and were supported to develop their skills in this area.
The ward had accreditation under the Quality Network for Eating Disorders which was due for renewal in September 2018.

Following this inspection, we rated community-based mental health services for adults of working age provided by South London and Maudsley NHS Foundation Trust as requires improvement because:

In the previous six months, there were 11 incidents when patients identified as in need of a Mental Health Act assessment, were not assessed promptly. This was due to a lack of hospital beds, complicated further by issues beyond the trust's control including the availability of AMHPs and the police. This placed patients and others at potential risk, and a significant responsibility on care coordinators in managing their needs in the community.
In September 2015, the trust did not have a consistent approach to ensuring that risk screens and assessments had the detail necessary for all care professionals. At the current inspection 26% of the 131 patients’ risk assessments we looked at did not have a current risk assessment and management plan in place. This was a particular concern in the early intervention team in Lambeth, where six of seven records we looked at did not have current risk assessments and risk management plans. Staff did not always review patients’ risk assessments after changes to their circumstances such as discharge from hospital, transfer from another team, or following risk events, which placed patients at potential risk of harm.
There were no care plans available in 31% of 16 patient records we reviewed in the early intervention teams. In some teams, care plans were not always completed in full to ensure that patients received appropriate support. In September 2015, we recommended that the trust ensure that patients were routinely involved with developing their care plans, and offered copies of the plans, and that this be recorded. This was still not happening in most community teams we inspected at the current inspection.
Patients referred to the Croydon assessment and liaison (A&L) team were not being seen within trust target timescales. This left some of them waiting up to 18 weeks for an assessment, thereby increasing chances of deterioration and putting them at greater risk of avoidable harm.
In some teams, patients were waiting for approximately one year for individual psychological therapies.
There were low rates of completion of training in annual basic life support, infection control and fire safety in several teams.
Staff did not always record that they had explained to patients on community treatment orders, their rights, in accordance with the Mental Health Act (MHA) Code of Practice. There were also some inaccuracies in capacity to consent records kept with patients’ medication administration records.

Staff in some early intervention teams had caseload sizes in excess of the nationally recommended maximum number. This created pressure on the teams and potentially affected the quality of care that patients received.

The trust was working to improve relationships between the community teams, wards, and home treatment teams. However, community team staff did not always keep in regular contact with patients admitted to wards and ward staff.

There were barriers to effective patient movement along the care pathway. Patient transfers between teams were sometimes delayed because specialist teams lacked appropriate or sufficient staff, or staff were unclear about the referral criteria and thresholds of different teams. Staff experienced difficulties accessing funding for specialist placements for patients and sometimes had to make repeated applications.
Although governance systems were in place, they were not always effective in bringing about timely improvements to systems to monitor risk assessments and care plans, identify when these were out of date, and address long waiting times.

However:

We rated Well-led as good, despite the core service having three domains that were rated as requires improvement. This was because service managers were aware of the issues we found relating to risk assessments and care plans, and working to address them. They had also taken proactive steps to address long waiting times in the Croydon A&L team, and regarding delays in Mental Health Act assessments.
In September 2015, the trust did not have safe systems for transporting medicines, medical waste and sharps, and not all equipment used in teams was safe and in working order. During the current inspection, we found that regular checks were in place to ensure that equipment was serviced, and new bags and arrangements were provided to transport medicines, waste and sharps safely. In September 2015, we recommended that the trust ensure that all staff follow the lone working policy to ensure their safety. Staff were following the policy during our current inspection.
In September 2015 we recommended that the trust should ensure full staffing of the south Southwark A&L team, and that vacancies across the recovery teams should be filled. At the current visit we found that the trust had put in place a recruitment and retention strategy, and there was a marked improvement in the numbers of permanent staff recruited to these teams, although this continued to be a challenge. In September 2015, we also recommended that the trust monitor the number of changes patients were having of care coordinators in the recovery teams to keep this to a minimum. At the current inspection, we found that the trust collected information on the changes to patients’ care coordinators, indicating an improvement in this area. However, this was still a challenge in some teams due to vacancies and long-term sickness of staff.

In September 2015 we recommended that the trust should ensure all staff know how to signpost patients to local advocacy services when needed. At the current inspection we found that staff made information available to patients on local advocacy groups.
The trust offered patients the opportunity to participate in innovative treatments. For example, patients who met the research criteria could participate in trials of a new digital therapy. The therapy aimed to assist patients to understand and control their thoughts.

Staff used case discussion and formulation meetings to improve the quality of care and treatment for patients. Staff fed-back to their teams about successful interventions with patients. Patients described staff as accessible, caring and respectful. They told us staff listened to them and gave them time to discuss issues of concern. The trust collected data on patients’ experiences of services and staff used feedback to improve each service.
There were clear governance structures in place for each clinical academic group overseeing community services, and a wide range of quality improvement projects in place encouraging staff to be actively involved in improving services.
Patients were able to access a number of groups held within the community including a 'Hearing Voices Group’ that was co-facilitated by patients.

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

The wards had addressed the issues that had caused us to rate effective, caring, and responsive as requires improvement following the September 2015 inspection. Although they had addressed issues from the previous inspection under safe, it remained as requires improvement as we identified some new concerns.

At the inspection in September 2015, we found unpleasant odours by toilet areas at Greenvale and Chelsham House. At the current inspection there was an improvement in the standard of cleanliness, with no lasting odours.
At the previous inspection in September 2015, we found that risk assessments were not completed in sufficient detail so that they could be used by care professionals supporting patients. At the current inspection there was an improvement in the level of detail recorded in risk assessments.

At the previous inspection in September 2015, in Greenvale the wheelchairs were not all fitted with footrests and that staff did not always move patients safely. At the current inspection all wheelchairs were intact and well maintained and appropriate hoisting equipment was available for staff.

At the previous inspection in September 2015, medicines on Greenvale and Ann Moss specialist care unit were sometimes unavailable to use when needed. At the current inspection there was improved medicines management at these units, including dedicated trust pharmacy provision.
At the previous inspection in September 2015, we found that staff supporting patients with dementia did not have current training in dementia care. At the current inspection, dementia training was being provided both by distance learning and at ward level. Staff displayed a good understanding of meeting the needs of patients with dementia. The trust had also taken steps to recruit to vacancies across the wards, and improved staff cover of shifts.

At the previous inspection in September 2015, we found that patients and their relatives were not always involved in assessments. At the current inspection there was an improvement in the recording of patients’ and carers’ involvement in care planning and assessments. Staff were using a new care planning system. Psychologists produced formulations with patients, their relatives and members of the multi-disciplinary ward teams, to develop a better understanding of the best way to support individual patients.

At the previous inspection in September 2015, we found that staff required support to improve their communication and interactions especially at mealtimes. At the current inspection we observed that the vast majority of staff supported patients in a caring way, including at mealtimes. The meal experience had improved, and some patients were involved in setting tables.

At the previous inspection in September 2015, we found that care was not always delivered in a manner that considered privacy and dignity, including same gender care and failing to close observation windows on bedroom doors when they were not needed. At the current inspection, care was provided within gender specific areas. Staff closed observation windows when not in use, and further protected patient privacy by closing curtains fitted around them.

At the previous inspection in September 2015, we recommended an improvement in the accuracy of recording of food and fluid charts for patients assessed to be at risk of dehydration and malnutrition. During the current inspection, there was improved recording to ensure patients’ food and fluid intake was monitored accurately.
At the previous inspection in September 2015, we recommended that, when staff explain to patients their rights under section 132 of the Mental Health Act, this is recorded, and that staff give patients a copy of their section 17 leave form. At the current inspection staff kept records of when detained patients’ rights were read to them and these were audited. We also found that staff offered patients copies of their leave forms.
Staff were implementing a number of quality improvement initiatives. These included Four Steps to Safety, a system for safer care with an aim to reduce violence and aggression. On Hayworth ward, the occupational therapy team had developed a ‘this is me’ booklet that they prepared with patients to go with them when they left the ward. The booklet contained information about the person’s life and areas of interest and included photographs. Other quality improvement projects included implementing electronic observations for health monitoring, reductions in enhanced observations, research into the cognitive effects of physical health medicines, and twinning wards with general hospital wards for older people.
The trust provided a service user and carer advisory group, which involved patients and carers with experience of the trust’s older adults’ services. The group provided opportunities to review current practice, recruitment, staff training and support each other. The trust’s psychologists also offered support to patients’ relatives as part of their role on each ward.

However:

There were gaps in mandatory training for staff in mandatory areas including intermediate life support, basic life support, and fire safety.
In two cases staff had not recorded patients’ vital signs after they had administered rapid tranquilisation to the patients.
Staff had no records of blind spots on each ward, to ensure that they paid particular attention to these risk areas.
There were gaps in staff supervision on some of the wards.
We observed two occasions when staff carried out clinical observations in a communal area, without giving patients the option of doing this in a private area such as the ward clinic room or their bedroom.

Ward managers were not aware of the issues recorded on the service’s risk register, and there was room for further development in links between senior management and ward level.

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

Although the trust had addressed the most serious issues that had caused us to rate safe as inadequate following the September 2015 inspection, we still rated safe as requires improvement following this most recent inspection.

Following the last inspection in September 2015, we rated effective and well-led as requires improvement. At this most recent inspection, we found that although some issues of concern had been addressed and others had improved, the work was not fully embedded. In addition we identified new concerns and an area of concern which had deteriorated since the inspection of September 2015.
At the inspections in September 2015 and May 2016, we found that some wards had significant staff shortages, which had an impact on patient care. At the current inspection in January 2017, we found that, despite significant efforts by the trust to improve staff recruitment, there was a high number of nursing vacancies on some wards. This led to cancelled escorted patient leave and patient activities.
During the inspection in September 2015, we found that trust governance processes were not sufficiently robust to identify where improvements needed to be made. At the current inspection, we found that although a new governance structure had been put in place it was too early to determine how effective this would be in ensuring quality and safety in the acute care pathway. The new arrangements and processes were not embedded enough to identify all of the areas where improvements were needed.
During the last inspection in September 2015, we found that not all staff were receiving regular supervision and recommended that the trust made improvements. At the current inspection, we found that staff supervision was still not always taking place in line with the trust policy. This meant that there was risk that some staff were not receiving appropriate professional support to enable them to carry out their duties safely and effectively.

More than 360 patient restraints in the last seven months involved patients being restrained in a prone position. There was no detailed plan in place to reduce the use of prone restraint.
Staff on the acute wards at the Bethlem Royal Hospital did not always recognise safeguarding incidents and therefore follow trust safeguarding procedures.
Staff on the psychiatric intensive care units (PICUs) had not recognised and addressed a number of ligature risks on the ward.
On some PICUs information available to staff about fire safety procedures was not up to date. This put patients and staff at potential risk in the event of a fire.
Not all staff had completed mandatory training. Planned training for staff in working with people with autism and learning disabilities was being rolled out across the wards.
Ward environments at the Ladywell Unit were either too hot or too cold making it unpleasant for patients and staff. Pest control at the Maudsley Hospital was not completely effective. The seclusion rooms in Johnson and Eden PICUs were in need of repair.
Patients transferred to Clare ward at the weekend had to wait until Monday for their leave to be reviewed, which meant they could be restricted to the ward unnecessarily. Patients on several wards were not always clear that they could ask for a hot drink at night. Some patients had difficulty accessing secure storage for their belongings, and had lost possessions.
Powell ward had a much higher rate of detained patients going absent from authorised leave than other wards. Two patients had gone absent without leave from Johnson PICU over the garden fence.
Confidential patient information was visible to other patients and visitors on some wards.
During the last inspection in September 2015, we found that some patients did not have care plans that met their individual needs. Although this had improved considerably on the acute wards, the care plans of some patients, particularly on the PICUs, were very general in nature and not individualised.
The acute wards for adults of working age and psychiatric intensive care units were not meeting Regulations 12, 13, 17 and 18 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

However:

Following our inspection in March 2016, we rated the acute wards for adults of working age and PICUs as good for caring and responsive. During the current inspection we found that the services remained good in these areas. The trust had also taken action to make the acute wards and PICUs safer since the inspections of September 2015 and May 2016 and had successfully addressed many of the areas of concern we had identified at that time
At the inspection in September 2015, we found that some wards had emergency resuscitation bags that did not contain the listed emergency equipment or in some cases this equipment was present but out of date. When we visited in January 2017, we found all required emergency equipment and medication was in place and in date.

At the inspection in September 2015, we found there were not always enough alarms for staff on the wards. At the last inspection in May 2016, we found that the alarm system on Gresham 1 ward was not working. When we visited in January 2017, we found that all the wards had appropriate alarms available and they were in good working order.

At the inspection in September 2015, we found that individual patient risk assessments were not fully completed or not updated with current information about risks. At the inspection in January 2017, we found staff completed risk assessments and the assessments were regularly reviewed. The trust was rolling out a new risk assessment template, which was working well.

During the inspection of the trust in September 2015, we found that although staff carried out regular physical health monitoring of patients they did not always escalate risks and concerns to a doctor when needed. At the current inspection, we found that staff escalated concerns about patients’ physical health promptly.

During the inspection in September 2015, we found that incidents of restraint were not being accurately recorded. At the inspection in January 2017, we found that staff recorded more detailed information that allowed the trust to accurately monitor how restraint was used.
At the inspection in September 2015, we found that staff on Lambeth Triage were not clear about the meaning of seclusion, sometimes did not recognise that they were secluding patients in their bedrooms and therefore did not follow trust seclusion procedures. During the January 2017 inspection we found that staff on Lambeth Triage understood the meaning of seclusion and if patients were prevented from leaving their rooms for a period of time the seclusion policy was followed.
At the inspection in September 2015, we found that drugs fridge temperatures were not always being monitored. At the current inspection we found on the acute wards and three of the four PICUs that fridge temperatures were being regularly monitored and recorded.
During the inspection of September 2015, we found that an environmental risk on ES1 was not managed appropriately. At the inspection in January 2017 we found that staff were mitigating the risk posed to patients by a staircase in the garden.
During the last inspection in September 2015, we found that some patients on the acute wards did not have care plans that met their individual needs. At the current inspection, we found that overall, the quality of care plans had improved on the acute wards. Most patients had care plans in place that were holistic, patient centred and recovery orientated.
At the inspection in September 2015 we found that temporary staff did not always have a timely local induction. At the current inspection we found that temporary staff completed a brief induction when working on a ward for the first time.

During the last inspection in September 2015, we found that not all patients had their status under the Mental Health Act (MHA) recorded correctly; it was not always clear whether patients had their rights explained to them as this was not recorded; and many staff had not completed training in the MHA. During the current inspection we found that all of these areas had been successfully addressed.
During the last inspection in September 2015, we found that informal patients were not given clear information about their rights. During the current inspection we found staff provided informal patients with accurate information about their rights.
At the inspection in September 2015 we found that many staff had not received training in the Mental Capacity Act (MCA) and did not understand their responsibilities in relation to it. At the current inspection we found that the majority of staff had completed training in the MCA and understood how it applied in practice.
At the inspections in September 2015 and May 2016 we found that observation windows in patient bedroom doors were regularly left open. At the current inspection we found that staff kept viewing panels and exterior curtains closed, maintaining patients’ privacy and dignity.

At the inspection in September 2015, we found that patients did not always have access to therapeutic activities and the gym. During the current inspection we found that the wards provided a range of activities to patients including access to the gym.
At the inspection in May 2016, we found that there was not always enough private space for patients to meet with independent advocates. During the current inspection we found there were rooms available for patients to meet privately with advocates.
Staff assessed the physical health needs of patients well. Many physical health care plans were very detailed and provided clear guidance to staff on how best to support patients with long term conditions, such as diabetes. Staff actively supported patients to stop smoking and provided good access to nicotine replacement therapy with a range of products available to patients.
Good working relationships between ward staff and home treatment teams supported the delivery of effective patient care through the acute care pathway.
The trust had significantly reduced the number of patients being cared for in other hospitals, outside the local area, in the last 15 months. Most patients were on wards located in, or close to, their home boroughs.
The majority of patients described staff as kind and caring. Staff interacted with patients in a respectful manner. They spent time with patients and offered practical and emotional support. Staff understood the individual needs of patients. Staff morale was generally good. Staff felt well supported by managers and colleagues. The trust and ward staff were committed to quality improvement and innovation.

Improvements meant that the acute wards for adults of working age and psychiatric intensive care units were now meeting Regulations 9 and 15 of the Health and Social Care Act (Regulated Activities) Regulations 2014.

We did not rate the trust on this inspection as it was a focussed inspection. We Focussed on three key areas out of the five that we can inspect.

During our inspection we found some areas of good practice as well as some which required improvement.

Areas of good practice included:

Staff demonstrated a caring and positive attitude to both patients and visitors to the wards and showed an understanding and concern for their needs. They effectively monitored patients’ physical health and responded appropriately to any concerns, making referrals for medical treatment when required.
Staff took steps to involve the patients in the planning of their own care and treatment. On AL3, staff met individually with patients to discuss their preferences and goals. During meetings with patients on Gresham 1 staff encouraged patients to talk about how they felt about their treatment and to give their opinions regarding their care.
Staff worked to ensure the safety of all those on both wards. They took steps to reduce the risks of any ligature points and closely monitored and recorded the behaviour of patients. Where patients became unwell staff demonstrated effective skills in reducing the risks of harm to themselves and others.
The environment on both wards was generally clean and well maintained and clinic rooms were tidy and well managed.

Areas where the trust was still making improvements after the previous inspection:
On Gresham 1 some staff and patients expressed concerns that there were not always sufficient numbers of staff to keep the ward safe. The trust was working to recruit staff and there was more to do.
Also, some risk assessments completed by staff lacked detail about the precise nature of the risks to each patient. The trust was working to improve the quality of the risk assessments.

Staff did not always update care plans to reflect the changing needs of patients. Also, while staff on AL3 were recording patients’ views and preferences regarding their care and treatment, the care plans written by staff were still often generic and contained little recovery planning or detail of patients’ opinions or preferences. This was again an area where the trust was aiming to improve.

Areas for improvement were as follows:

On Gresham 1 an alarm system on the ward to identify the location of any incident had not been working for many weeks, despite the fact that staff had repeatedly reported it broken.
On AL3 patients were not able to close the windows on their bedroom doors and staff did not always remember to close them from the outside. This undermined patients’ privacy and dignity. Work was taking place to address this.
On AL3 the condition of many patients’ rooms was poor and did not provide a sufficiently therapeutic environment. On Gresham 1 there were often no areas for patients to meet their advocate in private.
There was also a cockroach infestation on AL3 that staff had not been able to successfully address.

We have given an overall rating to South London and Maudsley NHS Foundation Trust of good.

We have rated two of the eleven core services that we inspected as outstanding, six as good and three as requires improvement.

The trust has much to be proud of and also some significant areas that need to improve. The trust was well led with a dynamic senior leadership team and board. There were also many committed and enthusiastic senior staff throughout the organisation working hard to manage and improve services. The trust recognised that they needed to focus on getting the basics right and the results of the inspection would confirm that this was correct.

The main areas which were positive were as follows:

Most of the staff we met were very caring, professional and worked tirelessly to support the patients using the services provided by the trust.

The trust was supporting patients with their physical health. People had their health assessed in a comprehensive manner and were being supported to have any health care needs addressed.
Staff had access to a wide range of opportunities for learning and development, which was helping many staff to make progress with their career whilst also improving the care they delivered to people using the services.
The trust was very aware of best practice and was using guidance and research to inform their work. This meant patients were receiving high quality care. For example patients had access to a range of psychological therapies alongside their medical treatment.
The trust provided many opportunities for patients to be involved in the running and decision making about services. This input was leading to changes across the services.

There were three services that required improvement and on the acute wards for adults of working age the safety was rated as inadequate. The main areas for improvement were as follows:

The trust had a substantial problem with staff recruitment and retention. There were too few staff to consistently guarantee quality of care especially on the acute wards for working age adults. There were staffing problems in some other areas but these are not as severe.
The trust needed to make improvements across most of its services in the documentation of risk for individual patients. This is to ensure the information was readily available, accurate and being followed.
The trust must improve its practices in relation to restrictive interventions such as the use of restraint and seclusion. They have started to tackle this problem but there is much more to be done. The trust must ensure that staff use restraint only as a last resort, that they minimise the use of restraint in the prone position, that they accurately document and record the use of restrictive interventions.
The trust must also make sure that where it has medical equipment, especially for emergency resuscitation that all the necessary equipment is available, maintained and has parts that are in date.
The trust had a number of environments that were not safe or where the risks were not being robustly mitigated to keep patients safe.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

Since the last inspection of the ward in March 2015 a number of developments had taken place to improve the safety for patients on Fitzmary 2. A refurbishment programme was underway that was replacing some fittings which could be used as ligature anchor points. Also the environment was improving with bathroom facilities being refurbished. Comprehensive risk assessments were being completed when patients were admitted to the ward. Staff had a good understanding of safeguarding procedures and who to contact when they needed to make an alert.

However, there were still some areas where improvements should continue to take place. This included ensuring observations took place as needed and were recorded, keeping risk assessments up to date and ensuring temporary staff working on the ward had a local induction.

We rated South London and Maudsley NHS Foundation Trust community mental health services for people with learning disabilities as outstanding because:

The service was well-resourced with experienced and skilled staff. The service supported staff to develop their knowledge and expertise. The service was linked with the Estia Centre which is a training learning and development resource for adults with learning disabilities and additional mental health needs. This enabled staff to work collaboratively with their peers to develop best practice and work in innovative and pioneering ways.

Staff undertook holistic assessments of people’s needs. They fully took people’s individual learning disabilities and communication needs into account and developed ways of involving them in planning their care and treatment. People’s dignity, independence and confidence in their skills were promoted by the way staff interacted with them and involved them in the process of planning their support.

The service worked in creative ways with people and their carers and made a positive difference to their quality of life. Staff offered people a personalised treatment plan from a wide range of possible pharmacological, psychosocial and psychological interventions. The service monitored how people responded to care and treatment.

Staff worked constructively in partnership with people’s informal carers, relatives and others in their local support network to deliver and develop joined-up care and support to people.

People and their relatives consistently told us staff were kind, polite and sensitive to their needs. Informal carers reported they had received prompt and effective support from the service which had alleviated their stress.

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 and 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 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 some areas waiting lists for assessment and treatment were not meeting national targets.

There was strong leadership at both local team and service level which promoted a positive culture. There was a commitment to continual improvement across the services.

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

The teams were safely staffed and although there was a large volume of referrals this was managed well.The caseloads of the teams were carefully monitored with a structure of handover meetings and robust duty systems.

The care records we looked at all had completed assessments and care plans. There was a good recovery focus in the assessments and the care plans we looked at which reflected the aims of practitioners and patients.

Staff in every team had a good understanding of safeguarding adults and children policies and the procedures to keep people safe from abuse. Staff knew how to report incidents and felt able to do so without fear of reprisals.

Most patients we spoke with were very positive about the care and treatment they had received from the teams. Patients described staff as friendly, kind, helpful, and polite.

The teams were always able to see urgent cases quickly and were always able to get a psychiatrist to see patients where necessary.

There were many examples of innovative practice to support patients to receive a joined up service.

However, medication was not being transported safely by team members. Risk assessments were not always being completed in a thorough manner which could mean that care professionals may not be able to access the appropriate information.

There were still significant numbers of agency staff employed in the assessment teams in South Southwark and Croydon. Although team managers felt confident that they were able to source good agency staff there was a particular problem recruiting to full time posts in South Southwark.

Staff in the recovery teams were concerned about staff vacancies, caseload numbers and the changes as a result of restructuring. The levels of acuity of some patients and the numbers on caseloads meant that some staff said they felt overwhelmed. The staff we spoke with in the Lambeth assessment team and the Croydon recovery teams did not show awareness of the lone working policy.

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

Staff working for home treatment teams were supporting patients with their physical health needs.
Staff in the home treatment teams were very experienced and had access to training to support them develop specific skills to undertake their roles.
Home treatment teams had multi-disciplinary teams that worked well together and worked well with other teams in the trust.
Communication between the police and the health based places of safety had improved.
Staff in the home treatment teams were polite, respectful and kind in their approach.
People who used the service told us that they received high quality care from the teams and that they felt that staff empowered them to reach recovery in their own way. We also spoke with carers, who reported high quality care.
Staff in the health based places of safety were very aware of the need to try and support patients in a manner that maintained their dignity.
Overall there was good morale within the home treatment teams. Staff were aware of the organisations values and reflected these in their work.
Both services used a range of data to monitor their performance.
The trust had made a proposal to commissioners to change the model of provision for the health based places of safety as they were aware that improvements were needed.

However, the facilities at the Lambeth place of safety were not safe due to the risks from ligature anchor points and the environment was not fit for purpose. Lewisham health based place of safety had blind spots in both the observation window and the CCTV camera angle that meant that patient safety could not be guaranteed. Personal and emergency alarm systems at Orchard House where the Lambeth home treatment teams were co-located with other teams were not regularly checked to ensure that they were working in the event that staff needed to request assistance. There were inconsistencies in where risk assessments completed by home treatment teams were held in electronic care records, which meant that it is was possible for staff (especially in other teams) to miss updates in risk information. The environments at the Lambeth and Maudsley health based places of safety did not promote the privacy, dignity and recovery of patients using these facilities. These issues included the location of the nurses office in relation to the room people who used the service would be in, and a lack of soundproofing. The place of safety at Maudsley hospital had a large observation window that did not allow the privacy and dignity of the person using the unit. People who used the health based place of safety at Lambeth hospital did not have access to showering facilities. Access to specific health based places of safety could not be guaranteed. Patients may have to be transported to a health based place of safety which was not in their area or borough by police, which could have impacted on their experience of care.

The trust had made a proposal to centralise the health based places of safety on the Maudsley site with a dedicated team of staff. However in the interim three of the four environments were unsafe or did not promote privacy and dignity.

We gave an overall rating for child and adolescent inpatient mental health services of good because:

Staff were kind and treated the children and young people with dignity and respect.
Young people were able to actively participate in decisions about their care and in decisions regarding the running of the ward.
Most young people were risk assessed and received a comprehensive assessment of their needs on admission to ward and monitored throughout their stay.
The wards had clear systems in place to mitigate risks to young people, such as with regards to medication and safeguarding.
Staffing numbers were usually enough to meet the needs of the children and young people.
Incidents were reported, reviewed and lessons learned through feedback to staff.
Treatment and monitoring were based upon best practice from appropriate bodies, such as the National Institute for Health and Care Excellence (NICE). Young people had access to a range of therapies.
All wards had wide-ranging multi-disciplinary teams and staff were well trained and supported.
Young people were supported to meet their religious, cultural and sexuality needs.
Complaints were responded to and acted upon appropriately.
Regular information was collected and reviewed to measure the quality of the service. Young people were able to give their views on the service.
Staff were committed to improving the service they were delivering. Many staff were undertaking work to try and review and improve care for young people.

However

The trust had high levels of staff vacancies, especially at Woodland House and Acorn Lodge although on a day to day basis they were taking the necessary steps to ensure the children and young people received the necessary care.
Not all records at Acorn Lodge showed up-to-date care plans and risk assessments.
Having two wards co-located in one space at Woodland House made it hard for staff to manage the ward.
Not all staff had received regular one-to-one formal supervision.

We rated the South London and Maudsley NHS Foundation Trust wards for people with autism as outstanding because:

Staff working in the service were acknowledged experts in the assessment, care and treatment of the mental health needs of people with autism spectrum disorder. Staff worked constructively with patients to involve them in planning their care and treatment. The service had a track record of success in reducing the incidence of challenging behaviour and the severity of mental illness symptoms in patients who had very complex needs.

The approach of the service was creative. The mult-discipinary team worked effectively to ensure assessments were holistic. The team developed each patient’s care and treatment from a broad range of possible interventions. There was a focus ensuring that patients discharged from the National Autistic Unit were either prescribed no medicines at all or prescribed the least amount of medicines for their mental health needs. Staff interacted with patients in ways which enhanced their dignity, independence and confidence.

Morale was high with staff describing a positive working environment and constructive working relationships with multi-disciplinary team colleagues. Staff worked effectively with commissioners and other agencies from across the country in relation to the admission and discharge of patients.

We rated South London and Maudsley NHS Foundation Trust’s rehabilitation mental health wards for working age adults as good.

Most patients were positive about the support they received from staff and felt safe on the ward. On Westways ward we observed good interaction between staff and patients where an open dialogue was encouraged. Carers told us it was easy to contact family members on the ward and generally felt happy about the care and treatment. Most staff were responsive, discreet, respectful and provided appropriate emotional support. Patients had access to a wide range of therapeutic activities.

Safe staffing levels were usually in place and patients did not have escorted leave or activities cancelled. Staff mostly felt well led by managers. Staff were well supported with regular supervision and access to a range of learning and development opportunities. Multi-disciplinary teams worked together well across the services.

Staff across the services were aware and had learned lessons from serious untoward incidents. Staff were aware of types of safeguarding concerns and the reporting procedures.

The four rehabilitation wards that were inspected were very different. Westways provided a really good service that met the patients individual needs. The other wards had a range of different issues where improvement was needed. Across most of the units staff were unable to clearly articulate the model of care being delivered and how the service achieved the outcomes for patients using the services. At Heather Close and the Tony Hillis unit blanket restrictions were in place that did not reflect the individual needs of people using the service. Whilst work was taking place to reduce high risk ligature points, the existing risks were not being mitigated and ligature cutters were not readily available in the event they may need to be used. At Heather Close fire safety precautions were not being fully implemented.

We rated South London and Maudsley NHS Foundation Trust forensic inpatient wards as requires improvement because:

Staff did not always complete patients’ risk assessments on admission and these were not regularly updated or reviewed.
Staff were not clear on the procedures for reporting a safeguarding alert.
Patients were dissatisfied with the food and improvements had not taken place.

However the wards were clean and well maintained. Patients said they felt safe on the wards, although their risk assessments were not always up to date. Staff used de-escalation techniques and wards had low incidences of restraint and rapid tranquilisation. The wards had good medicines management practices.

Patients had good access to physical health care services. The wards offered a wide range of psychological therapies and there were good multi-disciplinary teams on site. Staff were supported by regular supervision and appraisals and had to access specialist training.

Most patients said that staff were caring and respectful. Patients said they were involved in their care, although this was not always documented in their care records. Patients were supported with their individual interests and goals.

Patients had access to a range of activities on site, although they said they would like more activities during weekends. There were good facilities available including a library, gym and shop. Most patients said they knew how to make a complaint and would feel comfortable to raise any concerns to staff.

Staff were enthusiastic about their teams, trust and management. Staff had good opportunities to develop within the trust. Staff felt comfortable to raise concerns to managers. The wards demonstrated good examples of quality improvement and innovation.

We rated South London and Maudsley community-based services for older people as good overall because:

The teams were multi-disciplinary and provided staff appropriate for the service who were skilled and had a good understanding of the needs of the patients and carers they were supporting. The care provided reflected current best practice.

The staff were professional, caring and communicated well. The teams were well managed and staff had access to ongoing training and support.

Patients whose needs were urgent were seen promptly and the teams were aware of patients who might not engage and ensured they were supported.

There were some areas for improvement. Most importantly the transportation of medication and sharps between the bases and peoples homes needed to be made safe. Also risk assessments need to be completed to a consistently high standard so professionals can all access this information when needed.

We gave an overall rating for wards for older people with mental health problems of requires improvement because:

At Greenvale and Chelsham House there was a strong smell of urine by toilet areas.
Across the wards for older people, risk assessments were often completed with insufficient detail to ensure staff would know the necessary details.
At Greenvale patients were using wheelchairs without footrests and being lifted without the use of the correct equipment. This meant there was a risk of people getting injured.
At Greenvale and Ann Moss House, medication had run out causing delays in patients receiving medication.
Staff working on the mental health wards for older adults did not feel confident in supporting people with dementia and were not being encouraged to access the training that was available in order to develop the skills to provide this care to a high standard.
Whilst the majority of staff were very caring and thoughtful the structured observations that were done during the inspection showed that some staff did not communicate well with the patients especially during mealtimes.
The food provided for patients was very poor and did not meet people’s individual needs in terms of their preferences and cultural needs. Meals were not always provided in the manner that made this a pleasant event.
Privacy and dignity was not always maintained, for example on Hayworth ward the observation windows in bedroom doors were kept continuously open.

However, the care of people to reduce the risk of falls and pressure ulcers was very good. The reporting and learning from incidents was well established across the wards. Staff had made progress in the use of the Mental Capacity Act. Patients were having comprehensive assessments, multi-disciplinary teams were working together well and sharing knowledge to improve the quality of care delivered. There were good examples of patient and carer engagement through the service user and carer group and on an individual basis on the wards. The wards provided a range of rooms for different activities and a programme of therapeutic activities were provided. Complaints were well managed. Good professional development opportunities and courses were provided for all members of staff. Some wards are undertaking innovative projects to enhance patient care and experience

Acute wards for adults of working age and psychiatric intensive care wards require improvement because:

Staff were not reporting all incidents of restraint and when restraint was recorded, it was not recorded comprehensively according to the Mental Health Act code of practice. This was addressed by the trust immediately after the inspection.
On Eileen Skellern 1 the environmental risk caused by patients having access to an external fire escape had not been mitigated.
Individual risk assessments were not consistently up to date and reflecting the current risks to individuals.
Some wards had significant staff shortages which had an impact on patient care.
On Lambeth triage ward seclusion had not been recognised and so patients were not being properly monitored to ensure their safety.
Emergency resuscitation bags did not all contain the listed emergency equipment or in some cases this equipment was present but out of date.
Patients whose physical health monitoring had identified that their risks were raised had not all been referred for medical input.
Care plans did not consistently reflect identified needs of patients and there was generally poor involvement of patients in care planning reflected in the care plans we saw.
The rights of informal patients was not consistently understood in a way which protected their rights and gave them correct information about their right to leave the wards or refuse medications.
Staff understanding of the Mental Capacity Act was not robust.
Whilst governance processes were in place, they were not identifying the areas where improvements were needed in sufficient detail.

However, we observed kind and compassionate care being delivered. Patients gave positive feedback about their experiences on the ward. The trust valued innovation and using research to improve patient experience. Staff had a good understanding of safeguarding and were well supported by their ward managers. Staff told us that they felt proud to work for the trust.

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.

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