The Care Quality Commission (CQC) has published a report on East London NHS Foundation Trust’s acute wards for adults of working age and psychiatric intensive care units, following an inspection in February.
This inspection was undertaken after the trust informed CQC that they’d put improvements in place following a number of incidents of people self-harming.
This inspection didn’t re-rate the service, which remains outstanding overall and for caring, responsive and well-led. It remains rated good for safe and effective.
Jane Ray, CQC deputy director of operations in London, said:
“Where tragic incidents had occurred in the service, we were pleased to see leaders had taken quick and thorough action to learn from them and improve people’s safety in future.
“For example, we saw leaders had identified repeating problems with staff observation of people whose distress could pose risks to themselves or others. In response, they sought the views of staff and people using the service to find innovative solutions. They also worked with experts at City University to understand current research and good practice in this area.
“We’ve shared our findings with the trust so they know where there’s good practice to build on and where improvements can be made. We’ll continue to monitor the trust, including through future inspections, to support it to deliver the best possible care.”
Inspectors also found:
- People using the service said staff were friendly, competent, and helped them to understand their care
- People were supported to share their views of the service and leaders encouraged an open culture
- To improve staff observations and keep people safe, the service introduced high-visibility jackets for staff doing observations, so that colleagues knew not to distract them
- Leaders also introduced a folder relay system which made sure the observation folder was never allowed to be put down and could only be handed to another colleague. This was a way to ensure a member of staff always had responsibility for observations
- The trust created online training to teach staff about learning from serious incidents that could protect people in future
- Leaders introduced a new process to give people’s loved ones immediate support if an unexpected death did occur.
However:
- Leaders didn’t always support staff to improve their practice through supervision and not all staff had completed mandatory training such as restrictive practice and basic first aid
- Leaders didn’t always keep action plans updated, meaning learning about what did or didn’t work to improve people’s safety wasn’t always shared.