Oxleas NHS Foundation Trust

Updated 26 May 2023

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

• We rated safe, effective, caring, responsive and well-led as good. We rated all the trust’s services as good. In rating the trust, we took into account the current ratings of the eight services not inspected this time, as well as the six we did inspect.
• We rated well-led for the trust overall as good.
• The trust had a committed leadership team with strong values and integrity and had delivered consistently high-quality patient care across the services we inspected. Leaders had a good understanding of services, and were visible and approachable. There were effective processes in place for cascading information between the trust board, senior leadership, clinicians and other staff.
• Leaders across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose. Staff described good morale within the teams. Staff felt well supported by managers and were confident in their leadership approach and direction. Most staff felt able to raise concerns and were confident they would be taken seriously.
• Services had enough staff with the right qualifications, skills, training and experience to keep patients safe and to provide the right care and treatment. Staff shortages were responded to promptly and recruitment campaigns were ongoing. The learning and development needs of staff were identified and prioritised through annual appraisals and regular clinical supervision. There were good opportunities for specialist training and development for staff. Lived experience practitioners had been recruited, trained and supported to work with patients from the perspective of someone who had used services in the past.
• Staff assessed and managed risks to patients well and followed best practice in anticipating and de-escalating volatile situations. There had been a reduction in incidents of violence and aggression across the inpatient wards. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The trust was committed to improving by learning from when things went well and when they went wrong. Staff learned from complaints, incidents and near misses and ensured that lessons learned led to improvements. Managers were aware of the key risks in their services and these were reflected in local risk registers. Risk registers were used effectively to escalate risks and ensure they were addressed.
• Staff took a person-centred, holistic approach to care and were recovery-oriented. Patients had good access to physical as well as mental healthcare and were supported to live healthier lives. Services took account of patients’ individual needs, including the needs of patients with protected characteristics. On the acute wards and psychiatric intensive care unit there was a high level of patient involvement in running and participating in community meetings.
• Staff had received training, understood their roles and implemented their responsibilities under the Mental Health Act 1983. The trust was at the forefront nationally of the introduction of non-medical approved clinicians.
• Services provided care and treatment that was based on national guidance and evidence of its effectiveness. Services monitored the effectiveness of care and treatment and used the findings to make improvements. Most people could access a service when they needed it. Services responded promptly to urgent referrals.
• The trust collaborated well with local organisations to plan new services and improve existing ones. Partnerships with other organisations across south London had a positive impact on the quality of care and treatment provided to patients including making sure they were cared for closer to home.
• Leaders understood the importance of sustainability and delivering services within budget. Staff at all levels were actively engaged in this work and always considered the potential impact of possible savings on the quality of patient care.
• The trust collected, analysed, managed and used information well to support all its activities. Managers had access to the information they needed to provide safe and effective care and used that information to good effect. The trust was making good use of digital technology. This was leading to the effective sharing of patient records with other health providers and simplified the transfer of information.
• The trust was striving for continuous improvement. The trust used a systematic approach to quality improvement. Over 300 staff had received training in quality improvement methodologies and there were over 40 active quality improvement initiatives across all directorates and trust wide.

However:

• Staff did not always follow best practice to ensure the safety of patients after they had received rapid tranquillisation. In the acute wards staff did not consistently carry out and record physical health checks on patients following the administration of rapid tranquilisation. Although staff assessed, monitored and maintained medical equipment to ensure it was fit for purpose on most wards, on one ward, despite carrying out regular checks, staff had not identified and replaced expired automated external defibrillator pads, syringes and emergency medicines.
• Although the trust had appropriate medicines management policies in place staff did not always follow these. Some managers in the community mental health teams for older people did not record the quantity or serial numbers of medicine prescription pads. There was a risk staff would not be aware of any prescription pads or single prescriptions that went missing. Some non-registered staff in the intensive home treatment team for older people administered medicines to patients but had not received training in medicines management and their competency to do so safely had not been checked.
• Documentation and record keeping was inconsistent across services in terms of the quality of recording and storage on the electronic patient record. This included patient care plans, information about risk and mental capacity assessments. Some records were not updated, did not contain a full risk history or lacked detail to support decisions about patients’ mental capacity. In several services, information was stored in different parts of the patient record by different staff, which could cause delays in finding information when needed.
• The trust needed to make environmental improvements on some wards to ensure the patient experience was positive and people’s individual needs were met. This included improving environments for patients with autism and people with cognitive impairments. The trust had plans to remove shared bedrooms from two acute wards to improve patients’ privacy and safety.
• Although most patients could access the services they needed in a timely way some patients in the health-based places of safety had long waits before they could access an in-patient bed. The waiting time for patients to be assessed by the Greenwich memory service had increased to 12 weeks.
• Whilst the trust had a diverse board that reflected the staff and local community, it did not have an overarching strategy to address equality, diversity and human rights. There were missed opportunities to link pieces of work together and share learning across the organisation. The trust had a strong BME network but other networks were still developing. The trust acknowledged they needed to continue to work to improve the experience of BME staff and staff with lived experience, and fully implement the accessible information standard.
• The trust board recognised that further work was needed to have a longer-term strategy, articulating the ambitions of the trust. There was a piecemeal approach to co-production work with service users and carers, with plenty of good practice, but little coordination to ensure this was fully embedded in all the trust’s work. Some key areas of work that needed to be signed off by the board had not been clearly presented and approved.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RPG/reports.

Updated 13 September 2016

We judged that Community Adult Services were good. This was because:

• We found that there were arrangements to ensure that patients were safe, and there were systems to report, investigate and learn from safety incidents.
• We found that care and treatment was based on current guidance and best practice.
• Patients told us that they were treated with kindness and empathy and that their dignity was upheld.
• Services were arranged to respond to patients’ individual needs and could be accessed when they were required.
• We found that services were well-led; with a positive learning culture which staff were engaged in and identified with.
• Governance systems were in place to monitor safety and service quality and there was an emphasis on on-going quality improvement.
• Staff felt supported by their line managers who encouraged staff to innovate and develop their practice.

Updated 2 May 2017

We rated service for children, young people and families as good overall because:

• Following the inspection in April 2016, we rated the service as good for effective, caring and responsive.
• During the current inspection we found that the service had addressed the issues that had caused us to rate safe and well-led as requires improvement following the April 2016 inspection. The service was now also rated good for safe and well-led.

Updated 26 March 2019

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

• Feedback from patients and people who are close to them was consistently positive. Those we spoke with felt that staff often went the extra mile and the care they received exceeded their expectations.
• There was a strong and visible person-centred approach to care. Staff and leaders valued and promoted caring and supportive relationships between staff, patients, and those close to them.
• Patients’ individual needs were highly respected by staff and embedded in their care and treatment.
• Staff had a good understanding of managing individual patient needs and helping patients living with dementia.
• Governance arrangements were proactively reviewed and reflected best practice.
• Leaders had an inspiring and shared purpose. There were comprehensive leadership strategies in place to develop the desired culture.
• There was a positive culture amongst staff across all wards and departments. Staff and managers appeared receptive of our review of services. Any concerns we identified during our inspection were recorded, shared with relevant staff, and acted upon immediately.
• Staff were patient-focussed, proud of the work that they carried out and shared responsibility to achieve positive outcome for the patients.
• There was clear accountability and reporting from ward to board.
• There was an improved culture of shared learning across the organisation following incidents and near misses.
• There were effective systems for infection prevention and control and the management of sepsis.
• Staffing levels were planned and reviewed to keep people safe, with any staff shortages responded to quickly. Staff had the skills and competence to carry out their roles effectively and in line with best practice.
• Dementia screening and training had improved.
• Collaborative multi-disciplinary working enabled patients’ independence and supported evidence-based care.

However:

• Staff working at the Greenwich Intermediate Care Unit did not always understand the nuances of seeking informed consent from patients.
• Opportunities for shared learning between the two community inpatient services could be enhanced.
• The monitoring of the performance of the services by the trust could be developed further.

Updated 13 September 2016

Overall we rated community end of life care services at Oxleas NHS Foundation Trust good.

This was because:

• We found staff provided focused care for dying and deceased patients and their relatives.

• Do not attempt cardio-pulmonary resuscitation (DNACPR) forms were generally completed in accordance with national guidance.

• Community health services had policies, guidelines and training in place to ensure that all staff delivered suitable care and treatment for a patient in the last year of their life.

• Community health services provided end of life care training for staff which was mandatory for community nursing staff.

• Community health services fulfilled the World Health Organisation definition of end of life care and met the National Institute of Health and Care Excellence’s (NICE) guidance.

Updated 13 September 2016

We rated the service as good because:

• Patients told us they generally felt safe in the service. Staff effectively mitigated individual clinical risks.
• Staff were positive about working for the trust. Mandatory training rates were high; staff felt supported and accessed regular supervision. The teams consisted of enthusiastic people with patient care as their priority. Services included a range of staff able to deliver psychological therapies recommended by NICE.
• Parents, carers and young people felt services were welcoming, clean and comfortable and gave very positive feedback about how staff treated them. The trust employed a participation worker who supported engagement with young people and families to support their involvement in service development.
• Staff regularly assessed and discussed elevated risks. This meant that young people and parents/carers had crisis plans in place if needed.
• Service waiting times were within the trust maximum target of 13 weeks. Services could offer rapid response in an emergency between 9am and 5pm. Bromley CAMHS was a pilot site for an out-of-hours service and was able to offer an emergency response between 9am and 9pm on weekdays and 8am and 10pm on weekends.
• Services had developed several helpful resources, such as a physical healthcare clinic and a self-help and referral website called ‘headscape’. This was created with the input of young people and provided information about mental health issues and self-help.

However:

• Staff did not carry out regular environmental ligature risk assessments. There were several areas where ligature risks were present. For example, in bathrooms where staff were unable to fully mitigate risks.
• There were several vacancies across teams so there was pressure to meet the demands on the service. A large number of vacant posts had been recruited to and staff were waiting to start. In the interim, agency staff filled a large amount of the vacant posts.
• Leaflets that were available, for example about the complaints procedure, were only available in English. Information about advocacy services was not displayed clearly across all services.
• The trust had designated a CAMHS inpatient bed on an adult acute ward for use when an inpatient CAMHS bed was not available. There was a protocol on the use of this bed, which was a shared responsibility between this team and the acute ward concerned; however, we found several examples where CAMHS and other trust staff had not followed procedures appropriately. CAMHS staff had not worked together with other trust staff to ensure that the environment on this ward was appropriate and safe for a young person.
• We found evidence that feedback and learning from incidents was effective within a borough, but not as effective across services in the three different boroughs.

Updated 13 September 2016

We rated Oxleas NHS Foundation Trust community mental health service for people with learning disabilities or autism as good because:

Staff worked in innovative and creative ways to provide people, their families and carers with support, care and treatment that made a positive difference to people’s lives. Staff assessed in detail the personal needs of individuals and provided them with care and treatment plans that were holistic and addressed their needs. As well as a wide range of psychosocial and psychological interventions the service also provided innovative support to people living with anxiety and depression.

People who use servcies, their families and carers consistently told us that the standard of care they received was very high and that it had made a positive difference to the lives of all those who used the service.

The service empowered people to contribute to the development of services giving them the opportunity to formally review staff practices, materials, premises and to actively participate in the recruitment of staff to ensure the service met people’s needs.

Systems were in place to ensure that staff continuously delivered services according to best practice and staff liaised and worked with external agencies to share knowledge of best practice methods and ideas.

We observed that staff treated people with care and respect in every aspect of their work and demonstrated patience and concern about all aspects of their mental and physical health.

Staff ensured that they continuously obtained the feedback of people, their families and carers, providing numerous opportunities for them to give their comments and concerns.

The service was well led with a clear commitment from senior management to ensure that staff were well supported, their ideas encouraged and opportunities provided for their professional development. As a consequence staff morale was high and staff were committed to mutually supporting each other to maintain high standards of care.

Updated 26 March 2019

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

The services provided a comprehensive range of treatments including medicines, clinical psychology and occupational therapy. Treatments reflected patients complex needs in relation to the ways in which physical health can have an impact on patients’ mental health. Services offered treatment, group therapies and activities for patients with anxieties associated with depression.

• Staff cared about patients. Patients spoke positively about the support they received, describing staff as caring and supportive. Patients said they could contact their care co-ordinator whenever they needed to and that staff always listened to them.
• The services managed risks effectively. Staff completed a risk assessment for all patients and frequently updated this. Risks were reviewed in multidisciplinary team meeting. If a patient’s risks increased, staff responded promptly by increasing the frequency of visits, reviewing medication or referring the patient to a more intensive support service.
• Feedback from staff was positive. Staff felt respected and valued, and found their managers to be supportive. Staff said that teams worked well together and that colleagues were always available to provide support.
• Each service had good links with each other and with other agencies. The intensive home treatment team worked closely with the inpatient services to arrange admissions to hospital and provide support to patients being discharged. In each borough, services worked closely with voluntary organisations that supported older people. Care co-ordinators worked closely with care homes to ensure that residents who may require the service were seen promptly.
• Most of the services responded promptly to new referrals. Most services saw patients within the target times.
• Teams took steps to ensure that all people, including those with protected characteristics, could access the services. The Greenwich Memory Service had done work to increase referrals for people from Black African communities, who were under-represented. Information displayed in waiting rooms stated that homophobia was unacceptable, an issue that the trust took seriously. Services made adjustments for patients with physical disabilities so that they could attend appointments.

However:

• In Bexley, staff did not record the serial numbers of prescription pads. This meant that staff would not be aware of any prescription pads or single prescriptions that went missing. Some non-registered staff supporting patients with their medicines had not yet received formal training or a check of their competence to do so safely.
• In Greenwich, two safeguarding concerns had not been investigated in a timely manner.
• Services did not take a consistent approach to recording and storing patients’ care plans, risk assessments and mental capacity assessments. Some patient information was difficult to find on healthcare records.
• In Greenwich Memory Clinic there were delays to assessments of patients referred to the service, following a reduction in funding to the service. The waiting time for an assessment in this service was 12 weeks rather than the target of six weeks.

Updated 26 March 2019

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

• Staff assessed and managed patient risk well. Staff demonstrated a sound understanding of patients’ risk and kept them under continuous review at twice daily team meetings. Staff completed full risk assessments, physical health assessments and crisis plans where appropriate, and completed them to a good standard.

• Bexley and Bromley home treatment teams used a comprehensive spreadsheet that collated key information about each patient on the team caseload at a glance. This included the current risk profile, physical and mental health, medicines, as well as social needs. This information was updated at every handover so the team always had the most recent information available to them.

• The service had good working relationships with other teams both within the trust and externally, to meet the needs of patients in crisis. This included community mental health teams (CMHT), inpatient wards, day treatment teams, child and adolescent mental health services, police, local authorities, and accident and emergency departments. Home treatment teams had regular face to face meetings with CMHTs and inpatient wards to help ensure smooth transition of care between teams.

• Safeguarding was integral to the teams’ daily practice. Care records demonstrated that staff clearly recorded safeguarding decisions and made appropriate safeguarding referrals where necessary. Staff were aware of the team and trust safeguarding lead.

• Provider premises were visibly clean and staff had access to well-equipped clinic rooms to carry out necessary physical health examinations. Staff ensured patients’ physical healthcare needs were met. Staff ran weekly physical health clinics and provided psychoeducation on improving health and lifestyle factors.

• Staff were competent and skilled to deliver care. Staff had received mandatory training in key skills. One hundred percent of staff had received an appraisal and regular supervision. Managers ensured staff had access to regular team meetings.

• Patients’ care plans were personalised, holistic and recovery-oriented. Staff considered goals and interventions with patients, reflecting their employment, education, housing, relationships and financial needs.

• Staff cared for patients with compassion and had a good understanding of their individual needs. Staff demonstrated examples where they went the extra mile in the care they delivered. For one patient, staff arranged a voluntary driver to transport them to provider premises due to their fear of public transport.

• Teams signposted patients to other appropriate facilities to support their care and treatment. For example, in Bexley home treatment team, staff signposted patients to the Bexley crisis café, where mental health professionals provided support to people in distress during the evenings.

• Managers had the right skills, knowledge and experience to lead the teams. Managers had access to information to support them with their management role and promoted a positive team culture. Staff said they enjoyed working for the teams, and described good team morale. There were low staff vacancies and turnover across the teams.

• Lived experience practitioners were part of the teams. They were staff members with lived experience of mental health illness.

• The home treatment teams were responsive to referrals for assessment. Teams met the 24-hour target time to assess referrals received from primary care plus (PCP). PCP was the single point of access for referrals from GPs. The teams tried to engage with people who found it difficult or reluctant to engage with the service to ensure their safety.

• Staff were proactive in improving services. Staff were involved in quality improvement projects in Bromley and Greenwich home treatment teams, and were looking at ways to reduce paperwork and increase patient contact time in one project, and improving clinicians access to medical doctors during home visits via the use of technology in another. Bromley and Greenwich home treatment teams had received Home Treatment Team Accreditation from the Royal College of Psychiatrists.

However:

• In Bexley home treatment team meetings did not follow a clear framework to ensure learning from incidents, complaints, and safeguarding concerns were shared and discussed between the team. Since the home treatment teams changed to operating as a borough-based model, staff reported that there was a lack of sharing key information between the teams.
• The emergency alarm system at Greenwich health-based place of safety had a fault. When it was activated, staff were wrongly alerted to an incident at the PICU ward in the building, presenting a risk that staff may not respond to emergencies as quickly as possible.
• Staff at the health-based place of safety did not always clearly record when patients refused their physical health observations following receipt of medication by rapid tranquilisation.
• Not all staff in the Greenwich home treatment felt confident in being able to provide support to patients from the lesbian, bisexual, gay and transgender (LGBT+) community.
• Four per cent of patients detained under Section 136 since January 2018 had been detained unlawfully. This was due to their Section 136 expiring often due to staff not being able to find an appropriate bed in a timely manner. Some patients had long waits before they could access a bed. Between January and October 2018, 31 patients waited longer than the 24-hour limit for a Mental Health Act assessment because staff could not identify a suitable bed for the patient to move on to.
• Although monitoring information relating to the use of Section 136 and timeliness of assessments was collected, staff did not routinely complete clinical audits to assess the completeness and quality of clinical records. This included timeliness and quality of risk assessments and management plans.

Updated 26 March 2019

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses, doctors and other professionals. 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 could be challenging.
• 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 cared for in a ward for people with a learning disability and autism and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included, or had access to, the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisals. The ward staff worked well together as a multi-disciplinary team and with external organisations that had a role in providing aftercare.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff planned and managed discharge well. As a result, discharge was rarely delayed for other than a clinical reason and readmission numbers were low.
• The service was well-led and the governance processes ensured that ward procedures ran smoothly.

Updated 27 April 2023

We carried out this unannounced, comprehensive inspection because we had not inspected these services since April 2017

Oxleas NHS Foundation Trust provides forensic services across eight wards, based on two sites. Joydens Ward provides care and treatment for female patients. All the other wards provide care and treatment for male patients. During this inspection, we visited Danson Ward, Crofton Ward, Heath Ward, Joydens Ward and Birchwood Ward. All these wards are at the Bracton Centre. We also visited Greenwood and Hazelwood wards at Memorial Hospital. Whilst our inspection activities focused on these wards, most of the data we reviewed covered all eight wards within this core service.

The previous comprehensive inspection of this core service was in April 2017. At that inspection, we rated the service as good. We rated the service as ‘good’ for the domains of safe, effective, caring and well-led. We rated the service as ‘outstanding’ for responsive.

Oxleas NHS Foundation Trust is registered to provide the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury.

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

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. The service took a proactive approach to anticipating and managing risks to patients. This was embedded and is recognised as the responsibility of all staff. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding. All staff were open and transparent, and fully committed to reporting incidents and near misses.
• The service took a holistic approach to assessing, planning and delivering care and treatment to all people who use services. This included addressing, where relevant, their nutrition, hydration and physical health needs. 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. All staff were actively engaged in activities to monitor and improve quality and outcomes
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• People who were detained under the Mental Health Act 1983 (MHA) understood and were empowered to exercise their rights under the Act. The service supported staff to understand and meet the standards in the MHA Code of Practice. Staff worked effectively with others to promote the best outcomes with a focus on recovery for people subject to the MHA.
• 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. Patients valued their relationships with the staff team and felt that they often go ‘the extra mile’ for them when providing care and support.
• There is a holistic approach to planning people’s discharge, transfer or transition to other services, which is done at the earliest possible stage. As a result, discharge was rarely delayed for other than a clinical reason. There were innovative approaches to providing integrated person-centred pathways of care that involve other service providers.
• Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. Leaders had an inspiring shared purpose. They strived to deliver and motivate staff to succeed. Governance arrangements are proactively reviewed and reflect best practice. A systematic approach is taken to working with other organisations to improve care outcomes.

However,

• The service did not inform patients routinely that body worn cameras were being used by staff.

How we carried out the inspection

During this inspection, the inspection team:

• visited seven wards
• conducted a review of the environment on each ward and observed staff supporting patients
• spoke with 7 ward managers
• spoke with 27 staff including registered nurses, support workers and activity co-ordinators
• spoke with the director of forensic services and the head of mental health legislation
• spoke with 6 doctors
• spoke with 20 patients
• reviewed the records for 14 patients
• reviewed the medication charts for 25 patients
• attended handover meetings, a safety huddle, a staff meeting, multidisciplinary team meetings and a community meeting
• reviewed other documents, performance data and policies relating 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.

What people who use the service say

During this inspection, we spoke with 20 patients. Overall, feedback from patients was positive.

Patients felt safe and said there were always enough staff on the wards. Patients spoke positively about staff. They said that staff were caring and supportive. Patients said that they engaged in activities. They told us about activities such as playing table tennis, visiting the library and using the computers. Patients said they met with their psychiatrist and multidisciplinary team every two weeks and felt involved in decisions about their care. They said they found medication, groups and individual therapies helpful in their recovery. Patients who were allowed leave said they valued this. They told us they were able to visit their families, attend activities in the community and go shopping in areas they were familiar with. Patients said that if they did have any concerns, they would talk to staff about this.

A small number of patients were unhappy about being in hospital. There concerns focused on the nature of their detention under the Mental Health Act and the restrictions this placed upon them.

Updated 13 September 2016

We rated Oxleas Healthcare NHS Foundation Trust's long stay and rehabilitation wards as good because:

• Cleanliness was good across all wards. Infection audits showed good levels of controls across the rehabilitation and long stay wards.

• Staff used evidence-based tools and assessments to measure needs and risk. Clinicians took part in audits to monitor and improve the quality of care. Staff had access to additional training for their role to improve clinical effectiveness.

• Staffing levels across most of the wards was good except Somerset Villa that operated with lower number. The number of nursing staff each shift on Somerset Villa meant that staff could not do restraints and on nights, there could be one nurse on the ward at any time.

• Staff treated patients and carers with dignity and respect. Staff were enthusiastic, positive and had understood the needs of patients and how to meet them. All patients and carers we spoke with were positive about the care and treatment they had received.

• Staff felt well supported and supervised, staff appraisal rates were good. Mandatory training rates met trust requirements.

• Wards were committed to quality improvement and innovation.

Updated 18 June 2021

Oxleas NHS Foundation Trust provides wards for older people with mental health problems across four locations. These are Shepherdleas Ward, based at Oxleas House and Oaktree Lodge, based at Memorial Hospital, both in Greenwich. Scadbury Ward is based at Green Parks House in Bromley and Holbrook Ward based at the Woodlands Unit in Bexley.

Shepherdleas Ward is a 19 bedded ward providing care to people over the age of 65 who have mental health needs.

Scadbury Ward is a 22 bedded ward providing care for people over the age of 65 with functional mental health problems such as depression.

Holbrook Ward is a 22 bedded dementia intensive care unit for people who have complex needs and behaviours related to their dementia.

Oaktree Lodge is a 17 bedded continuing care unit providing care for people over the age of 55, with long term mental health rehabilitation needs.

The regulated activities provided are treatment of disease, disorder or injury and assessment or medical treatment for persons detained under the Mental Health Act 1983.

We carried out this unannounced focused inspection to check whether the trust had made improvements and complied with a Warning Notice served under Section 29A of the Health and Social Care Act (HSCA) 2008 in 2020. The Warning Notice was issued due to concerns about the assessment and management of ligature risks to patients and the governance arrangements, which had led to a failure to implement key safety recommendations from a serious incident investigation. The date for compliance with the Warning Notice was 8 February 2021.

At the previous inspection we identified breaches of Regulation 12 HSCA (RA) Regulations 2014 safe care and treatment and Regulation 17 HSCA (RA) Regulations 2014 good governance. The overall rating for this core service following this inspection in October 2020 went down and was limited to Inadequate for the safe and well led key questions, due to the enforcement action we took. The core service was rated as Inadequate overall.

The current inspection was a focused inspection looking at Safe and Well Led, to review improvements that had been made in all four older adult wards. We inspected all four wards for older people with mental health problems. We inspected the Safe and Well-led key questions in full to enable a re-rating of these areas.

As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent in the service to prevent cross infection. Whilst on site we wore the appropriate personal protective equipment and followed local infection control procedures. This included staff interviews over the telephone and via video and analysis of evidence and documents. Our final video call interview was completed on 15 April 2021.

During the inspection visit, the inspection team:

• spoke with two patients who used the service and four carers;
• visited all four wards and observed the safety of the ward environment;
• spoke with the ward managers for each of the wards;
• spoke with one healthcare cleaning manager;
• spoke with one director of estates and facilities and two estates senior facilities managers;
• spoke with four matrons;
• spoke with fourteen staff members; including healthcare cleaners, health care cleaning supervisor, consultant psychiatrist, occupational therapists, physiotherapist, registered nurses and healthcare assistants and a pharmacy technician;
• used the Short Observational Framework for Inspection (SOFI2) to conduct periods of observation on two wards, Holbrook Ward and Oaktree Lodge. SOFI2 is a way of observing care to help us understand the experience of people who cannot talk with us; and
• looked at a range of policies, procedures and other documents relating to the running of the service.

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

• The trust had complied with the Warning Notice. The service had made significant improvements in the safety of the wards. The management of environmental ligature risk assessments had improved. All four wards had an updated live environmental ligature risk assessment that staff could access. Refurbishment work, including the removal of ligature risks had been carried out on all wards. Staff were aware of the remaining ligature risks on the wards and there were clear plans in place to manage these. All environmental ligature risks had been updated following a serious incident. Remaining works to remove ligature risks on the wards were due to be completed by the end of the July 2021.
• The overall governance of the service had improved. Governance operated effectively from directorate to ward level, particularly in relation to the implementation and monitoring of serious incident action plans on the wards. The trust senior management had introduced a matron with responsibility for and oversight of ligature risks on the wards and the implementation of improvements.
• All wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose. Staff maintained good practice in terms of infection prevention and control.
• The wards had enough nurses, doctors and therapists to keep patients safe. The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received appropriate training, supervision and appraisal.
• Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing distressed behaviour. Staff minimised the use of restrictive practices.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service through meetings, posters in staff offices, serious incident ‘flash alerts’, individual supervision and directorate meetings. Since our last inspection improvements had been made to ensure staff were aware of and learned from incidents across the services.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• 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 mental and physical health. Staff followed trust policies when administering covert medicines.
• Staff ensured clear and full documentation of the decisions, reasons, and the discussions that informed do not attempt cardiopulmonary resuscitation (DNACPR) decisions.
• Staff participated in clinical audits and quality improvement initiatives to monitor the effectiveness of services provided and continuously improve the service provided.
• Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service and approachable for patients and staff.
• Staff knew and understood the provider’s vision and values and how they applied to the work of their team. The trust was reviewing their overall strategy and staff had been involved. Staff felt respected, supported and valued. They said the trust promoted equality and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.

However:

• We found some excess, out of date and used equipment that needed to be removed or disposed of from two clinic rooms in two wards. There was no thermometer to measure room temperature in two clinic rooms meaning the temperature was not monitored or recorded. Two wards had an out of date British National Formulary.

How we carried out the inspection

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

What people who use the service say

We spoke to two patients who felt safe on the ward, staff were supportive and met their needs.

Updated 26 March 2019

• Staff completed comprehensive mental and physical health assessments when patients were admitted to the wards. Patients received support from staff of a wide range of relevant mental health disciplines working together as a team. Staff teams provided a wide range of personalised interventions, which included medicines, psychological therapy and a wide range of therapeutic and rehabilitation activities. Patients on some wards had access to psycho-education, a hearing voices group, and talking therapy groups.
• Staff learned from incidents that had occurred across the service, and ensured that learning from lessons was put in place across the wards, for example, in implementing more frequent searches, and implementing protected time for staff to interact with patients.
• The trust had effective safeguarding procedures and staff understood how to protect patients from abuse, working 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.
• Staff were kind and compassionate. We observed positive, caring and supportive interactions between staff and patients throughout the inspection. There was a high level of staff and patient involvement in community meetings across the service, with systems in place to ensure that patients had opportunities to contribute, and received all relevant information.
• 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.
• Lived experience practitioners had been recruited, trained and supported to work with patients on the wards, supporting them from the perspective of someone who has used services in the past.
• Occupational therapists and the staff teams focused on ensuring patients had meaningful activities, which improved their life skills. Patients had access to a range of therapeutic activities. These included tai-chi, baking, current affairs, drumming, personal grooming, fitness, meditation, music and art.

• The trust had ensured that environmental risks relating to ligature anchor points, and blind spots were included in environmental risk assessments and that staff were aware of these risks and how to mitigate them.

• The trust had implemented the Safewards model to improve safety for patients and staff. Interventions had reduced incidents of violence and aggression. They had plans in place to reduce patient restraint, and prone restraint in particular.

• The trust provided training and support to staff to ensure they had the necessary skills to support patients effectively. Managers held regular supervision meetings with staff to provide support and monitor the effectiveness of their work. Ward managers received support and tools to manage their wards appropriately including dashboards with accurate information including data on staffing, complaints, physical health checks, and incidents.

• The trust had implemented an ongoing recruitment drive to fill staff vacancies at the service. This was proving effective, although further work was needed to ensure retention of new staff.

• Staff supported patients to live healthier lives. The trust provided support for patients who wanted to stop smoking. Staff provided appropriate support to patients with physical health needs, and some wards held weekly health and well-being clinics. Staff used a recognised tool to record patients’ physical health observations. Staff prescribed, administered, recorded and stored medicines appropriately.

• Wards were implementing some quality improvement approaches to care delivery. Projects included the introduction of physical health and well-being clinics, standardised templates to note the actions agreed at ward rounds, support for patients to have time with their named-nurse in a more relaxed environment off the ward, and the use of the Broset Violence Checklist to monitor and address state of agitation before violent incidents occur.

However:

• 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 trust retained a blanket restriction at Oxleas House of removing all patients’ shoelaces, and cords from hooded tops on admission, instead of conducting prompt individualised risk assessments on admission.

• Work was required to remove shared bedrooms from Lesney and Millbrook wards, ensure that all the windows at Oxleas House were made safe, and all patients had access to vision panels that they could adjust, and alarm bells in their bedrooms.

• Staff, particularly on Betts and Norman wards, did not always record a full history of patients’ risk incidents, changes to patients’ risk status, or new relevant incidents on their risk assessments, to ensure that new staff working on the wards, could access this information without delay. Care plans were variable across the wards, in terms of patient input, addressing all areas of need identified, and regular review.

• Details of all staff involved in patient restraints were not always recorded. Records of mental capacity assessments were not easily available, and did not always include evidence on which the judgements were based.

Updated 28 November 2022

We carried out this short notice announced inspection because at our last inspection we rated this service overall as requires improvement.

Oxleas NHS Foundation Trust provides a range of community-based mental health services for adults of working age. Community mental health teams support patients who have complex mental health and social care needs. They provide medium to longer term support to patients. The pathway of care includes:

• Hubs (previously known as primary care plus (PCP)) directly linked with primary and secondary care services. The hubs provide a single point of access to trust mental health services. Staff focus on telephone triage of patients, providing advice and support to GPs and directing patients to the pathway that meets their needs.
• The ADAPT pathway provides focused, therapeutic interventions to patients needing treatment for anxiety, depression, affective disorder, personality disorder and trauma.
• The intensive case management for psychosis (ICMP) pathway provides care and treatment for patients diagnosed with schizophrenia and bipolar disorder.
• The early intervention pathway (EIP) for patients aged between 18-65 experiencing psychosis for the first time, or at risk of developing psychosis.

We inspected the following services:

Bexley ICMP

Bexley ADAPT

Bexley hub (PCP)

Bexley EIS

Greenwich West ICMP

Greenwich West ADAPT

Greenwich East ICMP

Greenwich EIP

Greenwich hub (PCP)

Bromley West ICMP

Bromley hub (PCP)

In addition, we collected feedback and information about some of the trust’s other services, including the attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorders (ASD) teams, commissioned to provide assessments.

Our rating of services stayed the same. We rated community-based mental health teams for adults of working age as requires improvement because:

• Patients gave some mixed feedback about the care and support received from the teams, particularly when they were in crisis. They reported some difficulty being accepted by some teams and getting through to some services by phone.
• Risk management or crisis plans were not always updated as patients’ risks changed, although we found some improvement in staff recording patient risks, as required in the last inspection report published in August 2020. We also found some patients at risk of being missed due to gaps in the electronic waiting lists which had recently been introduced.
• Teams used a zoning system to monitor patients' level of risk, and inform caseload management for staff, but records did not always make clear why patients were allocated to or had changed risk zoning levels and what extra support was needed.
• Patients were still waiting too long for neurodevelopmental assessments and some psychological therapies. The trust had taken a wide range of actions to address long waits as required at the previous inspection. However, as demand had increased for these services, there were still excessive waiting times for assessment and treatment.
• There was insufficient oversight of medicines management across the community mental health teams, including some errors in the management of prescription charts for patients.
• The trust was not monitoring delays in Mental Health Act assessments and Community Treatment Order recalls for patients in the community mental health teams.
• Staff had improved their systems for collecting feedback from patients, but there was insufficient feedback collected from carers. There was also insufficient communication from the service, about improvements made as a result of patient or carer feedback.
• Staff were not sufficiently recording the needs of patients with a protected characteristics and how they met these.
• Some staff including some managers had very high caseload sizes including complex cases on their caseload due to ongoing issues with staff recruitment and retention.
• Staff were not always clear about the new protocols for recording care plans, particularly staff in the hubs using the new care planning tool for assessments.
• The teams had taken significant steps to improve monitoring of the physical health needs of patients and make sure that patients who needed an electrocardiogram received them regularly as required at the previous inspection. However, further work was needed to ensure that this continued, particularly when staffing levels were low.

However:

• Most staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Patient feedback was particularly positive for the early intervention services, with patients particularly appreciating access to family therapy.
• Staff provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients.
• Teams had improved monitoring of patients on waiting lists to detect and respond to increases in their level of risk. They had also provided and were developing more groups for patients waiting for psychology services.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Staff followed good personal safety protocols.
• The teams included or had access to the full range of specialists including peer support workers who met the needs of the patients. The trust employed lived experience practitioners who were able to work with patients from a position of personal experience.
• There was effective joint working with voluntary sector provision, and staff were embedding roles in GP practices, and a move to a ‘no wrong door’ approach to the services.
• Staff were strongly motivated, working very hard to meet demand, and felt well supported by their immediate managers. New roles had been created, such as band 4 nursing associates with career pathways, to address gaps in staffing.
• Leaders had the skills, knowledge and experience to perform their roles and had a good understanding of the services they managed. Staff described strengthened management within the last year with improved processes, and systems and support. Staff reported that the trust promoted equality and diversity in its day-to-day work and in providing opportunities for career progression.
• Teams were undertaking a wide range of quality improvement projects including projects to improve patients’ physical health, increase patient feedback, working to reduce appointments which patients did not attend, looking at barriers to discharge, and a project led by patients looking at their experience of coming off medicines without discussions with healthcare professionals.

How we carried out the inspection

Before the inspection visit, we reviewed information that we held about these services and information requested from the trust. During the inspection visit, the inspection team:

• visited 11 services and looked at the quality of the environment

• spoke with 29 patients and 9 relatives/carers

• spoke with 63 staff including team managers, consultant psychiatrists, registered mental health nurses, psychologists, occupational therapists, social workers and lived experience practitioners

• attended and observed 9 meetings, including zoning, bed management, referral screening, and cases of concern meetings

• reviewed 50 care and treatment records

• reviewed medicines management including over 60 prescription charts

• looked at a range of policies, procedures and other documents relating to the running of the service

• met with 6 senior managers within the service by video conference

• contacted 6 local GP practices, and 3 advocacy services, to request feedback, but we did not receive any feedback from them

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 staff treated them well and behaved kindly. Although some patients and relatives expressed concerns about waiting times, almost all spoke positively about the individual staff supporting them. Patients described staff as reliable, respectful, caring, and listening to them. Some patients spoke positively about regular contact with staff, offering emotional support and advice when they needed it, helping them to manage stress, and supporting them with practical tasks such as benefit claims, and housing issues. Most patients said staff were compassionate. A small number of patients did not always feel respected and listened to by staff working with them.

Patients valued therapeutic groups and other activities arranged by staff such as walking groups, and a picnic. Patients were very aware of staff shortages in the teams, and some felt this had impacted on the frequency at which they were seen, and the amount of time staff had to speak with them on each occasion. Several patients said that it was hard to get accepted by the teams on referral. Some patients noted that it could be hard to get through on the phone to the Heights office base.

Patients’ feedback was mixed about the service overall, with suggestions for improvement in waiting times, responses from the crisis team, more frequent reassessment, and improving transition from children to adult services.

Patients told us that it was not always clear how their feedback was used to improve services.