South London and Maudsley NHS Foundation Trust

Ratings - Acute wards for adults of working age and psychiatric intensive care units

• Overall

  Requires improvement

• Safe

  Requires improvement

• Effective

  Good

• Caring

  Requires improvement

• Responsive

  Good

• Well-led

  Requires improvement

Our view of the service

Overall Summary / Our view of this service

We carried out a comprehensive assessment of the acute mental health wards for adults of working age and psychiatric intensive care units (PICU) delivered by South London and Maudsley NHS Foundation Trust.

We decided to inspect this service as we wanted to follow up on the requirements and recommendations from the previous inspection in November 2023. There had been a total of 2 self-harm-related deaths in the acute and PICU wards in the 2 years prior to the inspection and we wanted to ensure that learning from these deaths had been implemented to improve care and treatment and maintain patient safety. Areas we followed up included therapeutic observations, carrying out emergency resuscitation, the use of restrictive practices (restraint, seclusion, rapid tranquillisation), and environmental safety, especially ligature points and visibility on the wards.

The trust has 18 acute mental health wards and four psychiatric intensive care units located on four sites – the Bethlem Royal Hospital, Lewisham Hospital, Lambeth Hospital and the Maudsley Hospital. All the wards are single sex. We inspected 14 wards across each of these locations.

The wards we visited were:

Three wards at Croydon - Bethlem Royal Hospital

• Tyson West- 17-bed acute – male
• Croydon PICU - 10 bed – male
• Gresham 1 – 20-bed female acute admission ward

Six wards at Ladywell- Lewisham Hospital

• Virginia Woolf- 16-bed acute - female
• Clare Ward- 17-bed acute – male
• Wharton Ward- 18 bed acute female
• Powell Ward- 18-bed acute male ward
• Evans Ward – 15 bed acute male
• Johnson Ward - 10 bed acute male ward

Two wards at Lambeth – Lambeth Hospital

• Luther King Ward- 18-bed acute male
• Rosa Parks Ward - 18 bed acute male

Three Wards at Maudsley- Maudsley Hospital

• Jim Birley Unit - 19 bed acute – female
• Eileen Skillern 1 10 bed PICU – female
• Lucas Ward- 11-bed female acute ward (newly opened in 2024)

The Acute wards and PICUs were last inspected on 7 and 8 November 2023. At that inspection we identified two breaches of regulation. These related to staff training, risk assessments and risk management plans.

At this assessment we identified breaches of regulation: 10 Dignity and respect, 12 Safe Care and Treatment, 14 Meeting nutritional and hydration needs, 17 Good governance and 18 Staffing.

We rated the service as Requires improvement. We found that improvements were needed in the completion of accurate records following incidents of restraint; completion and recording of therapeutic observations; offering debriefs to patients after incidents; training compliance for safeguarding adults and children; consistent identification and management of safeguarding; completion of nursing and medical seclusion reviews; recording of reasons to administer ‘as required’ (PRN) medicines; recording physical health observations using National Early Warning Score (NEWS) charts so that deteriorations and the persons health can be identified; ensuring staff engagement is consistent across wards and shifts; ensuring all patients had suitable access to drinks and snacks; ensuring staff are supported to be engaged in changes in service delivery; enabling staff to feel they are able to speak up and their concerns will be addressed; and having effective systems of assurance in place.

We have asked the provider for an action plan in response to the concerns found at this assessment.

At this assessment, we also identified areas of good practice. These included significant improvement in risk assessment and care planning; staff teams working well together; an embedded quality improvement approach with several ongoing projects; and positive patient involvement in care.

During this assessment, the inspection team:

• Visited 14 wards across the 4 hospital sites
• Carried out an environmental tour of each of the wards and observed staff supporting and interacting with patients
• Spoke with 57 patients
• Spoke with 16 carers
• Spoke with 76 members of staff. This included ward managers and deputies, deputy head of nursing, community link workers, physical health specialist nurse, safeguarding leads, dual diagnosis practitioners, activity coordinator/leads, head of therapies, student nurses, matrons, registered nurses, support Workers, nurse associates, clinical psychologists, consultants psychiatrists, clinical pharmacists and technicians, mental health law team leaders, carers lead, occupational therapists, peer support workers, volunteers.
• We attended handover meetings, daily clinical care meetings, safety hurdles, ward rounds, community meetings, and activities.
• Looked at policies and procedures related to the running of the service.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

Most staff undertook training in the Mental Health Act 1983 and demonstrated an understanding of its principles and application. This knowledge supported safe practice, ensuring patients’ rights were protected and that care was delivered in line with statutory requirements. Overall, 93.1% of staff had received training in the Mental Health Act. However, compliance in this training varied across wards. For example, 100 % of staff on Tyson West 1, Croydon PICU, Virginia Woolf, and Lucas had completed this training, compared to 75% on Gresham 1 Ward, which was below the trust’s target rate of 85%.

Staff knew who their Mental Health Act administrators were and how to contact them and had access to the Maze book.

Staff could access The Maze book, which was a guide to the Mental Health Act. It could assist staff at all levels to understand the Act.

Mental Capacity Act

Most staff had completed their training in the Mental Capacity Act. Overall, 91.6% of staff had completed this training. Staff appropriately assessed and documented patients’ capacity to consent on a decision-specific basis; we saw clear evidence of these in patients’ care records.

Overall Ratings Grid

Overall – Requires Improvement

Safe

Effective

Caring

Responsive

Well-Led

Acute wards for adults of working age and PICU

Requires improvement

Good

Requires improvement

Good

Requires improvement

People's experience of this service

People’s experience

We spoke with 57 patients across the trust.

Feedback from patients about most staff was that they were kind and caring. Many patients expressed confidence in the quality of care and treatment they received. Patients described positive experiences with staff. Some highlighted this particularly related to staff delivering therapy and patients on Tyson West 1 spoke very positively about the dual diagnosis sessions.

However, there was mixed feedback about feeling safe across the wards. Several patients spoke of safety concerns related to other patients and management of their behaviour. Three patients told us they have had personal belongings stolen from their rooms. Three said they had been involved in fights to protect themselves and eight said they had been assaulted by other patients.

Patients across wards described some variation in engagement and attitude from staff.

We spoke with 16 carers across the trust. Feedback from most carers we spoke with was positive about their experiences with staff; they expressed confidence in the quality of care provided. Eleven of 16 carers said the staff were supportive, caring and committed. Carers told us they were happy with the treatment their relatives received and felt it had a positive impact on their relatives’ health. However, five carers raised concerns about patients’ access to illicit drugs while in hospital. They highlighted poor communication between themselves and ward staff.