North East London NHS Foundation Trust

Updated 26 August 2022

We inspected North East London Foundation Trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall.

We carried out short notice announced inspections of acute wards for adults of working age and psychiatric intensive care units and mental health crisis services and health-based places of safety. We also carried out a short notice announced focused inspection of specialist community mental health services for children and young people in Kent.

We chose these three core services to see if there had been improvements since our last inspection in June 2019.

The trust provides the following mental health services, which we did not inspect this time:

• Child and adolescent mental health wards
• Forensic inpatient/secure wards (low secure)
• Wards for older people with mental health problems
• Wards for people with a learning disability or autism
• Community-based mental health services for adults of working age
• Community-based mental health services for older adults
• Community-based mental health services for people with a learning disability or autism

The trust also provides the following community health services, which we did not inspect at this time:

• Community end of life care
• Community health services for adults
• Community health services for children, young people and families
• Community inpatient services
• Urgent Care

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

Our rating of well led improved; we rated the trust as good. Our rating of effective, caring and responsive stayed the same; we rated the trust as good. Our rating for safe also stayed the same; we rated the trust as requires improvement.

Our ratings for the acute wards for adults of working age and psychiatric intensive care units and mental health crisis services and health-based places of safety core services core services improved, we rated both as good overall. We did not re-rate specialist community mental health services for children and young people following our focused inspection in Kent. In rating the trust, we took into account the current ratings of the mental health and community health services which were not inspected this time.

The core service inspections and well-led review took place at a challenging time for the trust. In terms of the leadership there was an interim chair and chief executive in place. The trust was managing the recovery from the pandemic and learning to live with COVID-19.

Despite these challenges we found the trust had made significant progress since the last inspection:

• The culture of the organisation was much improved. Throughout our inspection we heard from staff who spoke positively about the changes which had taken place and the move away from a culture of blame. The previous interim chief executive was described as a ‘breath of fresh air’ who led this cultural shift. The current leadership including the interim chair and chief executive had continued to embed this approach. The trust was working to promote a ‘just and compassionate culture’. There was a recognition that there was still much more to do but the progress was evident.
• Staff felt more confident to ‘speak up’. The speaking up arrangements were working well. Themes were being appropriately reported through to the board so improvements could be made. Whilst many of the services delivered by the trust were under extreme pressure, staff from different professions felt able to escalate concerns about patient safety.
• The senior executive leadership team was working together in a cohesive manner. There had been some significant changes in the team including a new executive chief nursing officer, new executive director of people and culture and promoted executive director of finance). The executive team were benefitting from ongoing external facilitation to support team building. All the members of the senior leadership team described healthy and productive working arrangements. This had also led to improved working with the non-executive directors and the effective operation of the board.
• The representation of allied health professionals in the senior leadership team had improved. The executive chief nursing officer was also the executive director for allied health professionals and psychological professionals. We heard from a range of professionals throughout the inspection who felt this arrangement was working well.
• The governance arrangements had been strengthened since the last inspection. The people & culture and finance & investment sub committees of the board had been developed. There had been a review of all the trust committees with the aim of ensuring these were operating effectively. There was a recognition that there was still more to do and that the number of internally facing committees could be further slimmed down to avoid duplication and reduce the amount of time operational staff spent in meetings.
• Staff working for the trust put people who used services at the forefront and were committed to providing the best service possible. There was tremendous enthusiasm, commitment and pride in the work of the trust.
• The trust had really ‘stepped up’ during the pandemic delivering services to meet the needs of local communities including vaccination services, step-down beds to support acute hospital discharges, the development of the Nightingale Hospital site and long-covid clinics. The trust had also worked effectively to ensure the appropriate guidance, equipment and new ways of working were implemented in order to keep patients and staff as safe as possible. The ongoing digital transformation and use of mobile equipment had supported ongoing flexible working arrangements which were well received by staff.
• The trust had delivered high levels of engagement and was learning from what went well in order to deliver ongoing effective communication. Throughout the inspection we heard about the visibility and accessibility of senior leaders and the board.
• The trust has continued its commitment to promoting equality, diversity and inclusion. The board was more diverse. The networks had strengthened and actively contributed to decisions about the strategic direction of the trust. The leadership programme for Black, Asian and minority ethnic staff was supporting good career progression.
• The trust was fully embracing its work with external partners in systems and place. The trust was located across five integrated care systems. It also worked closely with provider collaboratives. The non-executive directors were aligned to geographical areas. The trust had appointed to new roles to increase capacity for this work including an executive director of partnerships. Operational staff working in the directorates were participating in a range of meetings, taking leadership roles where appropriate. This work was challenging as systems were at different stages in their development and so they were having to identify where their contribution would deliver the most.
• We saw increasing use of data in accessible formats to inform day to day care and management decisions. Staff displayed a range of ability in using this data and the trust knew that for some further support was needed to develop their confidence.
• We also found significant improvements in the mental health acute and crisis core service inspections. Many more patients in a mental health crisis received the right care at the right time. The trust had designed and implemented an innovative, bespoke integrated crisis assessment hub which was available to a wide range of people, including self-referrals or those signposted by emergency services. Premises were specially designed and staffed by a dedicated staff team. People in crisis could access timely support at the hub to assess their needs. Work had taken place to improve the standards of care and treatment on the acute inpatient mental health wards.

There were some areas where there was more work to do, but the trust was fully sighted on this and had plans in place. These areas included:

• Clinical leadership at a directorate level needed to embed further. The trust had established a triumvirate leadership structure with operations, nursing and medical input for each directorate. Other allied health professionals were also being aligned to this leadership team. The medical staff had two sessions (one day) available each week but a number said they were having difficulties covering their clinical work so they could focus on their leadership responsibilities. Other consultants said that whilst they were kept informed of changes, they were not always actively involved in decision making even where this directly impacted their area of work.
• Co-production work was developing with an involvement register linking up people with lived experience to paid and voluntary opportunities to support the work of the trust. The introduction of an advisor with lived experience to the board meetings was working well. In addition, people with lived experience or carers were participating in a number of key committees across the trust. There were also people with lived experience regularly participating as members of recruitment panels. The trust recognised that the COVID-19 pandemic had delayed the rollout of people participation committees in each geographical area. These groups were scheduled for implementation later in 2022.
• Quality improvement had slowed down during the pandemic with members of the team redeployed to frontline services. Large numbers of staff had been trained and a new QI lead was coming into post in September 2022. During our core service inspections, staff across the trust only occasionally referred to quality improvement and so further work was needed to embed this approach.
• Recruitment was an ongoing challenge, but a range of initiatives were in place including oversees recruitment, working with universities to attract professional graduates and extending apprentices. However, there were still pockets where recruitment was a particular challenge. One of these areas was medical staff recruitment for CAMHS in Kent. The trust recognised the need to improve medical staff recruitment but there was more to do.

How we carried out the inspection

During our inspection of the three core services, the inspection teams:

• reviewed records held by the CQC relating to each service
• visited seven wards at Sunflowers Court. We looked at the quality of the ward environment, management of the clinic rooms, and observed how staff were caring for patients
• spoke with seven ward managers and three matrons covering the wards we visited
• spoke with two assistant directors in the acute and rehabilitation directorate and one director for Kent community CAMHS
• visited four team hubs, in the Dartford, Canterbury, Maidstone and Medway localities; we looked at the quality of the environment for patients and staff, and management of the clinic rooms
• spoke with seven community CAMHS team managers
• visited three home treatment teams, the integrated crisis assessment hub and health-based place of safety and observed the environment and how staff were caring for patients
• spoke with the home treatment teams, the integrated crisis assessment hub and health-based place of safety managers
• spoke with 81 patients and carers
• reviewed 37 comment cards young people and carers
• spoke with 84 staff members, including, doctors, nurses, healthcare assistants, occupational therapists, psychologists, pharmacists, a physical health consultant, a ward administrator and a home treatment team liaison worker
• completed a review of medication management on four wards, three community CAMHS teams and the home treatment team clinic room
• observed a range of meetings and activities including safety huddles, ward round reviews, multidisciplinary handover meetings, occupational therapy groups, team meetings, handovers, an anxiety and depression session and community meetings
• reviewed 130 patient care and treatment records
• looked at a range of policies, procedures and other documents relating to the running of each 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

In the services we inspected, feedback from patients and carers was overwhelmingly positive. On the acute and PICU wards, patients told us that staff were empathetic, went out of their way, and kept on trying. In community CAMHS services we heard that staff were quick to respond in a crisis and that young people responded positively to the interventions delivered. Patients told us that home treatment teams involved them in their care and supported them through periods of crisis.

There were however some areas for improvement identified by people who used the service. On the acute and PICU wards, some patients would like to be able to access one-to-ones with their named nurse more regularly. In community CAMHS, young people and their carers felt they waited too long to access some services. In the home treatment teams, patients would like to see the same staff during their time with the team.

Updated 9 January 2018

Overall rating for this core service: Good

North East London NHS Foundation Trust provides adult community health services across parts of London and Essex. This includes 45 distinct specialties or services including district nursing and integrated care teams. To come to our ratings we spoke with 20 patients, eight relatives and carers and 56 members of staff in a variety of roles. We observed 13 home visits and reviewed over 300 individual items of evidence.

We last inspected this service in April 2016 and rated it requires improvement. This reflected concerns about the documentation of medicines and risk assessments, a lack of consistency in staff appraisals and ineffective governance systems.

Overall we rated adult community health services as good because:

• There were a number of strategies and programmes in place to improve patient safety, which were led or supported by a dedicated harm free care team. This work had resulted in reduced falls and pressure ulcers and an improved early warning scores system.
• Staff recruitment remained a significant challenge for the trust. For additional shifts, 41% were filled by agency staff and 59% by bank staff. However, some teams had restructured to enable staff to better manage workloads, and strategies were in place to improve retention and make the recruitment process more efficient.
• There was significant evidence that care and treatment was based on best practice national and international guidance. Clinical teams used research, pilot projects and audits to benchmark their standards of care.
• There was consistent use of multidisciplinary working and coordinated care and treatment pathways for patients in all areas of the trust.
• Staff had access to specialist training and clinical competency development on a regular basis.
• During all of our observations and home visits we saw staff treated patients with care, compassion and kindness.
• There was a consistent focus on adapting services to meet the needs of local people. This included through service redesign and adaptation as well as ensuring care was delivered in line with equality and diversity priorities.
• The dementia crisis support team had developed and implemented an innovative model of care for patients that improved access to specialist services and reduced mortality and hospital admissions.
• Individual teams implemented projects to improve access, including restructuring and improving assessment methods.
• There was evidence of learning from complaints including the implementation of new policies and practices.
• Local clinical governance processes had been improved and a quality improvement and monitoring system had been established. As a result there were clearer links between locality teams and the trust board.
• The strategic patient experience partnership had a demonstrable role in quality improvement and took the lead in strategies and projects to improve patient experience.

However:

• Only one locality team met the trust’s target of 85% for completion of appraisals.
• Completion of mandatory training was variable between teams and localities.
• There was a lack of evidence that action plans from audits were consistently followed up or implemented.
• Although clinical governance processes had improved, some staff did not feel part of the trust. Results from the 2016 staff survey indicated a number of areas for improvement.

Updated 9 January 2018

Overall rating for this core service is good because:

• Following our last inspection in April 2016, we issued one requirement notice requiring the service to take action to remedy breaches to Regulation 17, in relation to good governance and issued 15 actions the provider should take to improve. During this inspection, we found that the service had dealt with or shown improvement for most of the previously reported concerns.
• Although the trust had addressed the previous inspection’s requirement notice through the implementation of electronic diaries, the leadership team recognised some staff were still using paper diaries whilst awaiting agile working equipment. The trust mitigated risks by completing data management audits of these diaries alongside supervision with line managers. However, the trust still had to ensure all staff had access to electronic diaries through the appropriate equipment.

• The trust had been addressing concerns around heavy caseloads through different methods. These included increasing staff skill mix, using a new caseload allocation tool and performance allocation tool, implementing managerial supervision to discuss caseloads, checking staff wellbeing and negotiated extra funding for staff from commissioners. However, the decommissioning of services, changes to service contracts, changing populations needs and recruitment challenges meant caseloads remained high for some services.

• The trust had implemented a transition policy in August 2017 but commissioning issues still affected the transition arrangements. Service leads acknowledged there were some gaps and recognised that receiving services had different criteria. Transition was recognised as a national commissioning issue. However, where transition arrangements were in place, the process was effective.

• The trust had recently developed a 10 year vision and strategy for the service. Senior leads told us the trust medical director engaged with staff and members of the public and patients to develop the strategy. However, the document was in its infancy and the trust acknowledged that not all staff would be aware of the document, and more time was required to embed it fully.

• The trust had demonstrated improvements in reducing staff vacancy rates in some services but recruitment of specialist therapy roles remained a challenge for the trust. However, the trust managed vacant staff posts effectively by using bank and agency staff as required.

• Although the trust had made improvements to waiting times for some services, further work was still required to be compliant with national guidance and maximum waiting times of 18 weeks. Staff recruitment and capacity issues affected wait times, but the trust had conducted data cleansing exercises to ensure only those clients who needed assessment and interventions remained on the waiting list.

• The trust had cleared the initial backlog of transferring scanned consent forms for immunisations by using additional administration staff. However, on this inspection, there was still a backlog due to lack of appropriate equipment such as scanners. The trust was addressing this at the time of the inspection and had developed an action plan to monitor progress.

• The community health services for children, young people and families (CYP) service had systems for identifying, reporting, and managing safeguarding risks. The safeguarding team provided good support to staff across CYP services through supervision, training, monitoring of incidents and advice via the duty desk.

• Staff were encouraged to raise concerns and to report incidents and near misses. The CYP service effectively shared learning from incidents and good practice with staff through regular meetings, newsletters and across localities. Staff told us they valued working for the trust and that service leaders were supportive, accessible and approachable.

• The CYP service demonstrated effective internal and external multidisciplinary (MDT) working. Clinical practitioners worked with other staff as a team around the child. The co-location of services in health centres and partnership working with other service providers facilitated MDT working.

• The trust health centres and children centres we inspected were clean, tidy, and clutter free. Waiting rooms and clinic rooms were child friendly with toys, books and other resources appropriate for different ages.

• Staff supported the patients and families they worked with, and provided patient-centred support in clinics and in homes. The trust actively sought feedback from people using the service and engaged them to improve services.

• People using the trust’s community CYP services were treated with dignity and respect. People felt listened to by health professionals, well informed and involved in their treatment and plans of care.

• The service was responsive to the needs of people using it and had adapted to meet the diverse needs of the community it served. Staff, patients and families we spoke with told us they had good access to translation services.

• There was a robust governance framework and reporting structure. Staff had confidence in their immediate line managers and leadership at board level.

However:

• We saw inconsistent compliance with controls and standards for hand hygiene and infection prevention at some of the locations we visited and among staff.

• Compliance targets across localities were not consistent, with some localities performing significantly worse than others in the delivery of certain aspects of the health visiting service.

• The trust managed complaints appropriately, completing relevant investigations and responding within the time scales set in the trust policy. However, we found completion of the online recording system incomplete as risk assessments and lessons learnt sections were blank in some cases.

Updated 27 September 2016

• Overall we rated this service as good.
• This was because we found a good culture for the timely reporting of incidents and the trust were able to identify themes and trends among community inpatient services. Safeguarding processes had a level of profile that enabled the identification possible abuse and encouraged reporting. Processes for the safe administration of medication were in place and the overall standard of documentation was good. Wards were clean and staff were trained in infection prevention and control. Premises and equipment were largely well maintained and managed. However, we also found that equipment had not been serviced and space available for meaningful therapeutic activity compromised the service provided to patients.
• Community inpatient services were operating with a substantial nurse vacancy rate and on the whole we found this had been largely well managed. However, we found a number of examples where rehabilitation therapy staffing and facilities had led to a basic provision of rehabilitation service. Patients received timely pain relief and received adequate assistance to eat and drink. Staff were also able to access key skills training appropriate to their role. We found good examples of integrated and multidisciplinary working. Patient discharge was appropriately planned and managed.
• Staff understood their roles with consent and capacity. We also observed staff to be caring in their interactions. All patients we spoke with told us that staff were kind and treated them with respect. We did not come across any examples where this was not the case. Patients and relatives felt involved and included in care and treatment. Services were meeting the needs of vulnerable people. Assessments for wound management were completed and reviewed in accordance with the stated frequency. Community therapy assessments had taken place and case notes showed updates on preparation for discharge. Patients reported to us that their care and treatment needs were being met.
• Staff reported to us that they had confidence in their leadership, who they found responsive. There was a governance structure that enabled managers and senior managers to appropriately monitor and review the quality of the service.

Updated 9 January 2018

We rated end of life care (EOLC) good because:

• There had been a restructure in EOLC in the trust. This meant most specialist palliative care was outsourced and provided by hospice staff. District nurses worked in integrated community teams and were responsible for providing treatment and support to palliative and EOLC patients in the community.
• Staff understood their responsibilities to raise concerns and to record safety incidents.
• There was an open culture in reporting incidents and there were systems in place to learn from incidents and reduce the chances of them happening again.
• There was identification of patients at risk of deterioration and we saw evidence of the use of emergency health care plans in ensuring that all patients had a plan in place should their condition deteriorate.
• There was appropriate equipment available in patients’ homes and use of anticipatory prescribing of medicines at the end of life.
• Mandatory training levels were good, with all specialist palliative care team staff.
• An integrated electronic records system was in use across specialist palliative care staff community. Although, in Essex, patients electronic records could be viewed by acute hospital staff and GP practices; and in London, trust staff had access to patients’ electronic records, but did not have access to other community providers’ records.
• The trust had implemented the ‘individual care plan’ which was being used as a guide for the delivery of end of life care. We saw that treatment escalation, emergency healthcare plans and advance care plans were in place to support patients and those close to them in making decisions at the end of life.
• There was a commitment to working collaboratively to deliver joined-up care through multidisciplinary working. This was demonstrated through the trust’s community services collaborating with hospice staff and staff from local NHS acute trust. There were established links with GPs and local nursing homes.
• The trust were rolling out ‘essential to role’ EOLC training to all relevant staff.
• Consent practices were embedded across teams providing EOLC.
• Staff demonstrated compassionate care to patients and their families. We observed a commitment to providing care that was focused on meeting the emotional, spiritual and psychological needs of patients as well as their physical needs.
• There was a visible person-centered culture. Staff were highly motivated to offer care that was kind and promoted people’s dignity. Relationships between people who used the service, those close to them and staff were caring and supportive. These relationships were valued by people and their families.
• The trust were developing pathways of care to provide care that met people’s individual needs.
• There was an open approach to handling complaints.
• There was a vision and strategy that focused on the early identification of patients at the end of life, patients being cared for in their preferred place of care and the use of partnership working to develop services.
• There was end of life care representation and leadership at trust board level.
• There was comprehensive leadership within the palliative care service with clearly defined leadership roles. The director of nursing was passionate about the service and encouraged staff to deliver high quality EOLC. Local managers were proactive and demonstrated an understanding of the issues facing EOLC services.

However, we also found:

• Incident reporting rates for palliative and EOLC were low in integrated community teams teams when compared to specialist palliative care teams.
• Staff were not aware of whether the trust had audited anticipatory medicines.
• Staffing levels had improved in the previous 12 months, but retaining staff was an issue across integrated community teams.
• Waltham Forest had the worst results in England in the national care for the dying audit 2016, for patients achieving their preferred place of care at the end of their life.
• Some staff we spoke with told us they were not aware of any audit proposals in 2017, even though there had been an audit of ‘do not attempt cardiopulmonary resuscitation’(DNACPR) decisions in 2017.
• Staff at Mayfield inpatient unit had piloted the provision of EOLC in a rehabilitation focused inpatient unit. However, staff felt they had not been fully prepared for the palliative care remit.
• Staff told us they didn’t feel connected to other teams across boroughs and there were very few opportunities for staff to meet with colleagues from other directorates across Essex and London to share learning.
• The trust had introduced a new EOLC strategy which aimed to meet patients’ needs through direct care, advice, information and education, enabling patients to die in their place of choice. However, across community services staff told us the EOLC strategy was relatively new and teams needed time to embed it.
• Some local managers we spoke with were unaware that there was a specific risk register for EOLC.

Information about the service

North East London NHS Foundation Trust (NELFT) provides integrated community and mental healthcare services to a diverse population of over 2.5 million people in the London boroughs of Barking and Dagenham, Havering, Redbridge and Waltham Forest. NELFT also provides services in the Essex boroughs of Basildon, Brentwood and Thurrock. The trust employs approximately 6,000 staff. End of life care (EOLC) services are provided by individual directorates based upon London and Essex boroughs. However, there was a NELFT organisational structure to support the individual directorates.

In Essex boroughs NELFT are commissioned to provide community EOLC services through St Luke’s Hospice. The community EOLC service provides specialist palliative care to adults in their own homes. Day care services are provided by St Luke’s and St Francis Hospices. Patients are also supported by community nursing and district nursing services working in integrated community teams (ICT)) to work with patients in nursing and residential care home settings, as well as working with patients who live in their own homes.

Mayfield inpatient unit provides two specialist palliative care inpatient beds.

St Luke’s and Saint Francis Hospices provide a 24 hour advice line, specialist nursing services and out of hours palliative care nursing services. The multidisciplinary team includes physiotherapy, occupational therapy, chaplaincy, clinical pharmacist, complementary therapists and access to medical social workers.

The Redbridge specialist palliative care team is a multi-disciplinary team, which provides expertise in holistic assessment, management of difficult symptoms and patients with co-morbidities.

We visited the specialist palliative care team in Redbridge. We visited district nursing services based in ICT in: Waltham Forest, Barking and Dagenham, Thurrock, Basildon, Redbridge, and Havering. We visited Mayfield inpatient unit in Thurrock. We visited Waltham Forest children’s community services. We also visited EOLC facilitators in Basildon and Havering.

Updated 14 November 2017

We rated children and adolescent mental health wards as outstanding overall because:

• There was strong and inspirational leadership at a trust and service level that had transformed this service and over an 18 month period the ratings moved from inadequate to outstanding.

• During this most recent inspection, both staff teams were fully committed to ensuring that they provided quality services and continued to improve through innovation. Staff from both teams were involved in a number of quality improvement projects and accreditation. Young people receiving care were encouraged to become actively involved in these quality improvement projects and their input was valued.

• Staff treated young people and their families as partners in their care. They understood the importance of being kind and respectful. There was genuine empathy and understanding of individual needs and wishes, which was reflected in the work undertaken with young people and their families. There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Staff morale was high and commented that this had steadily improved since the ward had re-opened in September 2016.

• The leadership, governance and culture of the service drove improvement and underpinned the delivery of high quality person-centred care. Staff were accountable for delivering change. Leaders had an inspiring shared purpose and motivated staff to succeed. There were high levels of staff satisfaction and staff were proud of the organisation as a place to work and spoke highly of the culture. Staff at all levels were actively encouraged to raise concerns. Managers made themselves available and were actively involved in ward based activities.

• There were robust and effective governance procedures. Managers and senior members of the multi-disciplinary team met regularly to discuss issues relating to the running of both services. There was a good flow of information from these meetings to the trust leadership team and back to the frontline staff. The trust’s development and implementation of the YPHTT demonstrated a clear proactive approach to seeking out and embedding new and more sustainable models of care. The service was seeking accreditation and beginning the process of identifying a research model to formally evaluate outcomes for patients accessing the YPHTT.

• Young people said that they received excellent care, staff were amazing and that they felt safe on the ward.

• Although the ward had staffing vacancies, the managers had planned for this and ensured that there were sufficient staff on duty. Existing staff members or a small group of regular bank and agency staff filled vacant shifts. The trust monitored safe staffing levels against admission numbers. The Young Peoples’ Home Treatment team was adequately staffed and staff turnover was low.

• The building was modern and there were various outside spaces, which all young people could access. Families could stay in a family suite on site if needed. The building was visibly clean and well furnished. Young people could personalise their bedrooms. The environment was well maintained and potential ligature anchor points were appropriately managed.

• Staff had a good understanding of risk. Both teams had regular risk meetings, which were attended by a broad range of disciplines. All staff had the opportunity to contribute to the risk identification and formulation of risk management plans. Risk assessments were frequently updated. Both teams had clear time frames to assess new referrals and formulate the young person’s care plan, which meant that there was no delay to care and treatment commencing. Both teams liaised with the trust’s safeguarding team and other external organisations appropriately and in a timely manner when risks were identified. There were clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was evident in these services. Teams considered the review of incidents to be an opportunity for learning.

• Planning and delivery of care was holistic, personalised and recovery focussed. Planning and delivery of care placed children and young people at its centre and staff ensured that patients, their families and carers had appropriate information so they could make informed decisions. Staff from both teams ensured that they monitored all aspects of the young person’s well-being including their physical health. There were mechanisms to identify when a young person’s physical health was deteriorating. Where young people had additional physical health needs, staff escorted them to their hospital appointments. Since the previous inspection in October 2016, there had been improvements in how patients’ physical health checks were recorded.

However:

• We identified a number of minor procedural lapses in governance systems. A fire evacuation drill was overdue. Staff arranged for this to take place shortly after the inspection. Fire alarm checks and staff radio checks were not completed as frequently as required by the trust.

• Whilst the majority of equipment used to monitor patients’ physical health was maintained, a blood glucose monitoring machine had not been calibrated. This was escalated and addressed by ward staff during the inspection.

• The majority of frontline staff were not aware of the name of the trust’s Freedom to Speak up Guardian and their role. However, all of these staff stated that they could get these details from the trust’s intranet.

• At a previous inspection in October 2016, we found that some meal choices were not available in sufficient quantities. During this inspection this had improved, however, patients said that the quality of food was poor. Managers and staff were actively working to address this and had organised meeting with the catering provider.

Updated 6 September 2019

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

• In some teams the number of staff in post, including the use of bank and agency, did not match the providers staffing plan. The vacancy rate in the core service (27%) was significantly higher than the trust average (17%). The vacancy rate for medical staff in Kent was 50%. There was a risk that Kent services may be disrupted by the lack of consistent medical input and leadership. In Kent, some clinicians had high caseloads which could prevent them from giving individual patients the time they needed.
• Governance processes needed strengthening to ensure that performance and risk were managed well. Systems to ensure consistency from learning from incidents or to share good practice across the geography were not embedded. Systems were not always in place to ensure equipment was clean and safe to use. Systems were not in place to enable management oversight of supervision within teams or services although this was being implemented. Some performance data was not accurate. In Kent there were operational variations between teams in how young people on waiting lists were monitored with no effective assurance process in place to ensure each was safe and effective.
• There were significant waiting lists for both initial assessment and treatment in Kent. The trust had introduced systems to detect and respond to increases in risk whilst young people waited. However, we saw examples in Kent where these systems had not been effective in identifying changes in risk or ensuring an appropriate response. Across Kent, there were 4143 young people at the end of May who had been waiting over 16 weeks for treatment following referral. Of these, 3372 were waiting for treatment through the neurodevelopmental and learning disability pathway and 771 were waiting for treatment through the other pathways available. We were told by family members that they were not consistently given information about the length of time they would be waiting for services to start.
• Equipment used to monitor physical health or to treat young people in an emergency was not always calibrated or checked. Less than 75% of staff had completed mandatory immediate life support training.
• Improvements were needed in how staff assessed and managed risk in Waltham Forest. Thirty percent of the care and treatment records we looked at in this team did not include an assessment of risk or management plan. In other teams across the geography there were inconsistencies in where risk information was included in patients records.
• The operation of the Kent single point of access was on the directorate risk register. Not all referrals in Kent were screened in a timely fashion and prioritised for follow up by the correct team.
• Whilst incidents were appropriately investigated, learning from these was not consistently shared across the whole geography. Where learning from incidents was to be shared in a specific learning forum, these were not always convened in a timely fashion.
• Some patients and carers in Kent were not clear what treatment and support they should be receiving from the team.

However:

• Clinical premises where patients were seen were safe and clean. Staff followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments 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 understood the principles underpinning mental capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients.
• Staff assessed and treated patients in crisis promptly.
• The criteria for referral to the service did not exclude children and young people who would have benefitted from care.

Updated 6 September 2019

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

• The service provided safe care. Clinical 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.
• 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 understood the principles underpinning capacity, competence and consent and managed and recorded decisions relating to these well.
• 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. Feedback from people who use the service, their families and carers was continually positive about the way staff treated them.
• The service was easy to access and staff and managers managed waiting lists and caseloads well.
• The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly.
• The service was well led and the governance processes ensured that procedures relating to the work of the service ran smoothly. The requirement notice made at a previous inspection in relation to monitoring waiting times from referral to treatment had been met.

However:

• A small number of patients (12) had waited more than 18 weeks to start their treatment at the time of our inspection.
• Across the three teams, there were vacancies for speech and language and occupational therapists. Challenges in recruiting to the posts permanently and in the interim, meant there was a risk that individual teams may not always include, or have access to speech and language therapists or occupational therapists.

Updated 27 September 2016

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

• Arrangements for safeguarding were clear with good systems in place to monitor and follow up concerns. Patient areas at Barking and Dagenham and Waltham Forest were clean and well-maintained. Staff had manageable caseloads and managers ensured that workloads were evenly distributed across the teams.

• Staff provided an effective service and the majority of care plans were personalised, up to date and reflected patient’s views. Staff followed best practice by using National Institute and Care Excellence (NICE) guidance and participated in clinical audit. Patients had access to psychological therapies such as cognitive stimulation therapy and took part in post diagnosis groups. Staff were considerate of patients physical needs and used a variety of assessment tools when assessing for cognitive impairment. Teams had experienced staff who had access to good specialist training and managers appraised and supervised them on a regular basis. Teams worked well with other internal services and external agencies, such as GPs, the voluntary sector and local authorities.

• Staff were caring and interacted well with patients and carers. Patients and families were involved with their treatment and staff had addressed patient’s individual needs. Staff encouraged patients to give feedback on services.

• The services were accessible and responded promptly to referrals. Staff engaged creatively with people who experienced more difficulty accessing services and had worked with the local community to make them aware of services. Teams had a wide range of information available for patients and environments at Barking and Dagenham and Waltham Forest were welcoming.

• Teams were well led and had the right meetings, policies and procedures in place. Staff felt senior managers were visible and that managers supported them. Memory services were accredited with the Royal College of Psychiatrists.

However:

• The environment at Havering was not fit for purpose and unwelcoming. Interview rooms at Havering and Barking and Waltham Forest did not have alarms which could compromise staff and patients safety. The environment at Barking and Dagenham did not have a dementia friendly environment.

• Risk assessments at Barking and Dagenham contained little detail in regards to risk management andfour out of the six the care plans we reviewed were either missing or out of date.

• Managers had difficulties in accessing information to monitor the quality of their services which were sourced from a large number of different systems. Records of supervision at Barking and Dagenham and Havering were unavailable for this reason.

Updated 26 August 2022

Updated 6 September 2019

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

• Feedback from patients and those who are close to them was continually positive. Staff went the extra mile and their care and support exceeded expectations. Patients and those close to them were active partners in their care and staff were fully committed to this partnership approach. Patients’ individual preferences and needs were always reflected in how care was delivered. Between April 2018 to March 2019, the ward received 58 compliments, which accounted for 1% of all compliments received by the trust as a whole.
• There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promotes people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring, respectful and supportive. These relationships were highly valued by staff and promoted by leaders.
• Staff encouraged patients to have a voice and be actively involved in decisions about their care. The consultant psychiatrist encouraged patients to take a central role in their ward round, listened to their views and took these into account when reviewing changes in care and treatment. Patients could submit a written document completed with the help of staff or a relative prior to the ward round outlining what they wanted to discuss.
• Patients were able to give feedback about the ward at community meetings. For example, patients discussed issues such as the ward being too hot, limited mealtime options and activities to do in the summer. Staff were proactive in providing possible solutions such as speaking to maintenance department about the heating, the catering company about the food and suggesting activities for the summer to include gardening and a summer sports day. Minutes were available to patients in easy read format.
• There were high levels of satisfaction across all staff. There was strong collaboration and team-working and a common focus on improving the quality and sustainability of care and people’s experiences. Some staff had lived experience that added real value. Quality improvement methodology was embedded on the ward. Staff were empowered to lead and deliver change. Quality improvement projects involved patients and carers.
• Governance arrangements were robust, and incidents and risks were reported, analysed and shared. Leaders had high quality management information, which showed trends and risks in the service. They were able to use this information to manage risks and improve the service. We were given examples of learning from incidents that had led to changes to improve the service.
• The service provided safe care. The ward environment was safe and clean. The ward had enough nurses and doctors. Managers ensured that staffing levels were adjusted to reflect the fluctuating needs of patients and the risk levels present at that time. Any potential impact of staffing vacancies was mitigated by the use of bank and agency staff familiar with the ward and its patients. Staff assessed and managed risk well, managed medicines safely, followed good practice with respect to safeguarding and minimised the use of restrictive practices. Staff had the skills required to develop and implement good positive behaviour support plans to enable them to work with patients who displayed behaviour that staff found challenging.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment; they also engaged carers in the planning and reviewing process. They provided a range of treatments suitable to the needs of the patients cared for in a ward for people with a learning disability and autism and engaged in clinical audits to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the ward. Managers ensured that these staff received training, supervision and appraisal. The ward manager had actively recruited learning disability nurses. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. The ward proactively referred all patients to speech and language therapists from community teams.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

However:

• Two patients and two carers felt that there did not have much choice at mealtimes and food was unappetising when it was served.

Updated 6 September 2019

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

• Patients’ individual needs and preferences were central to the delivery of tailored services. Patients led their own ward review meetings. The services were flexible, provided informed choice and ensured continuity of care.
• Feedback from patients and those who are close to them was continually positive. Staff went the extra mile and their care and support exceeded expectations. Patients and those close to them were active partners in their care and staff were fully committed to this partnership approach. The service had listened to patient feedback regarding food. Innovative plans to develop a kitchen in the ward, so that food could be prepared on-site were planned and a capital bid made.
• There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring, respectful and supportive. These relationships were highly valued by staff and promoted by leaders. The ward had an elected patient representative who attended staff team meetings. Improvements had been made to the service as a result of feedback. Patients and carers were confident in raising concerns and no complaints had been received. Two percent of all the compliments received by the trust related to Morris Ward.
• The ward continued to maintain excellent links with the community and engaged patients in a range of activities seven days a week. Since the last inspection the ward had developed one of its gardens to provide an innovative programme where patients looked after a range of small livestock, including chickens and rabbits. This therapeutic activity supported patient’s recovery.
• The service provided safe care. The ward had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward team included the full range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Whilst a need for call alarms in patient bedrooms had been identified, no dates for these works had been set. Staff did not describe how they were managing this risk until the alarms were installed.
• The ward manager had identified that staff would benefit from further training to ensure that incidents where patients were administered rapid tranquilisation were accurately identified and reported. Further work was needed to ensure that physical health checks post rapid tranquilisation was consistently recorded, including when a patient declined these.

Updated 27 September 2016

We rated long stay/rehabilitation mental health wards for working age adults as good because:

• There was evidence of good medicine management and patients medicine records were clear and accurate. The pharmacy team reviewed medicine charts including antipsychotic medication. Staff recorded patients allergy status on the prescription charts. Staff recorded where patients self administered medicines.
• Comprehensive and holistic care plans demonstrated patient involvement. Patients and carers were involved in care planning and care plans were written in a person centred way.
• Patients’ physical health was assessed and regularly monitored by staff. Patients’ physical health was discussed and reviewed during ward rounds.
• We saw kind and caring interactions between staff and patients. Patients told us that staff were polite and respectful. Staff were knowledgeable about patient needs. There was evidence of family and carer involvement in care planning.
• There was evidence of discharge planning in patient records. Staff discussed discharge planning with patients, familes, carers and community services.
• Staff received regular supervision and appraisals. Staff received monthly supervision which could be increased if appropriate or requested. We saw evidence that all staff had completed their annual appraisal within the preceding 12 months.

However:

• We saw high use of bank staff, although regular bank staff was used where possible.
• There was no dedicated psychology input on the ward. However, staff could refer patients for psychological interventions. Staff told us there was a long waiting list and referrals were not based on wards although patients were fast tracked where possible.
• Patients were unable to make a drink or snack as required.
• Staff and patients expressed anxiety regarding the planned ward closure.

Updated 3 November 2017

Our overall rating of wards for older people improved. We rated it as good because:

• The trust had made improvements since the previous inspection in April 2016. At our previous inspection of wards for older people in April 2016, we found that the trust was in breach of Health and Social Care regulations. These breaches were in relation to safety, dignity and respect and staffing. At this inspection, we found that the trust had taken appropriate action to improve the service.

• There was now a robust system in place to reduce the risk of falls. Patients were now able to access their bedrooms at any time as they wished. The trust had improved ward premises. The wards had been redecorated, there was new furniture and the risk to patients from ligature points had been reduced. Patients on all wards now had easily accessible call bells to alert staff if they needed support. Staff understood the legal requirements of the Mental Health Act. Patient privacy and dignity was promoted.

• Staff thoroughly assessed patients in relation to their physical and mental health when they were admitted to the ward. Staff screened patients for risks in relation to falls, skin care, continence and nutrition. Staff worked in partnership with the patient and their carer to develop care plans which reflected the patient’s choices. Staff liaised with a geriatrician and other clinical specialists to ensure care and treatment was effective.

• Staff checked the physical health of patients each day and took action to address any deterioration in the patient’s health. Multidisciplinary team work was effective and care plans addressed patients social and rehabilitation needs. Staff were experienced and well-trained.

• Patients were encouraged to be as independent as possible. There was a range of activities available on the ward. Discharge planning was effective for almost all patients. The trust worked with other agencies to manage delayed transfers of care.

• Staff were kind and caring. They were able to communicate well with older frail people. Staff welcomed carers onto the wards. Staff gave carers appropriate support and advice.

However:

• Patients on some wards were accommodated in shared bedroom areas which compromised their privacy and dignity.

• Some ward layouts did not allow staff to readily observe all areas and whilst the risks associated with this were mitigated through observations, the trust had not considered the use of aids such as convex mirrors to improve visibility.

• Whilst the take up of mandatory training averaged over 80% in most areas, there were two exceptions. Ward managers were taking action to ensure staff attended any courses they had not yet completed. We did not see that lower compliance levels with these mandatory training courses had impacted upon the quality and safety of care and treatment being provided.

• Whilst learning from incidents was taking place in team meetings, the template to record team meetings did not allow for the recording of these discussions. This meant that staff who could not attend the team meeting could not readily access this information in one place.

Updated 26 August 2022

Updated 6 September 2019

• Governance systems required strengthening to ensure they were consistent and that a high quality and safe service was delivered from all locations. We identified isolated pockets of poor practice relating to caseload numbers, lone working practice, medicines transportation, recording of allergy information, identification of patients prescribed high dose anti-psychotics, provision and monitoring of clinical supervision; efficacy of audits and recording of risk information across the geography.
• Some teams did not have effective systems and processes to safely prescribe, administer and record medicines. Staff in the Redbridge community recovery team did not have a process to identify and regularly review the effects of high dose anti-psychotic medications on each patient’s physical health. At Waltham Forest community recovery team, the room used to store medicines experienced high temperatures which could impact the efficacy of medicines stored there. In the same team, staff had not been equipped with lockable bags to transport medicines. Allergy information was not always recorded on patient’s medicines charts.
• Staff in Waltham Forest community recovery team did not follow trust protocols for lone working which could put them at risk.
• The numbers of patients on the caseload of teams and of individual members of staff was in some cases high. In early intervention teams these were above the numbers recommended by best practice guidance. Staff in some teams with a high turnover of staff reported feeling ‘burnt out’.
• Learning from incidents was not always consistently implemented across all teams. When incidents of unexpected death were investigated and underlying physical health issues were found to be the cause, learning from these incidents was not routinely shared with staff, which could mean that opportunities to learn and develop practise were missed.
• Whilst the majority of teams received regular supervision, staff in the Barking and Dagenham community recovery team did not. Managers across all directorates reported that the introduction of a new system to record and monitor supervision had been problematic as it was difficult to use and extract management data from.
• Locality teams were working in partnership to improve their relations with the acute crisis assessment team. Locality teams were frustrated that their multidisciplinary referrals were being rejected without appropriate feedback.
• Not all staff felt respected, supported and valued. A small number of staff felt there was a culture of blame in the team when incidents occurred. They also commented that there was a lack of meaningful consultation when changes were made to the teams and that they did not feel heard, or feared retribution when they raised concerns.
• There were some long waits to access individual psychology in Barking and Dagenham access, assessment and brief intervention team. New referrals were triaged and prioritised and patients were offered groups whilst they waited. The team were actively recruiting psychologists to increase their psychology offer.

However:

• Clinical premises where patients were seen were safe and clean. 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.
• 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. Staff worked well together as a multidisciplinary team.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff assessed and treated patients who required urgent care promptly and those 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.