The Care Quality Commission (CQC) has published a report on acute wards for adults of working age and psychiatric intensive care units (PICU) run by South London and Maudsley NHS Foundation Trust, following a focused inspection in November.
This inspection was carried out to examine how well the trust investigated, learned from, and acted on self-harm related deaths and serious incidents to keep people safe in future.
This was a focused inspection of the safe and well-led key questions at only three of the trust’s acute wards and one PICU. Inspectors also interviewed ward managers at four further acute wards. As this inspection didn’t examine the whole service, no new ratings have been issued.
The service therefore remains rated good overall, as well as for effective, caring, responsive and well-led. The service remains requires improvement for safe.
South London and Maudsley NHS Foundation Trust remains rated good overall.
Jane Ray, CQC deputy director of operations in London, said:
“We were reassured to find the trust had responded to tragic incidents of self-harm with appropriate investigations, involving people in the service and their families to identify learning and make improvements to people’s safety.
“These included improvements to observations, ligature risks, and staff handovers. However, this didn’t always happen as quickly as possible, and the trust was acting on improving this.
“Most staff were skilled and understood people’s current needs, preferences, and risks, but we found some gaps in mandatory staff training, as well as some people’s care records. People’s risk assessments weren’t always good quality and we saw some people’s care plans didn’t include significant risks such as neglect and self-harm. This impacted people’s safety.
“We’ve shared our findings with the trust, so they know where they have good practice to build on and where improvements need to be made. We’ll continue to monitor this service, including through further inspections, to make sure people are receiving safe care.”
Inspectors also found:
- Although staffing remained a challenge, the trust had worked hard to improve levels and reduce the risks from low staffing since CQC’s last inspection of this service in 2021. Staffing is an issue across the NHS
- People were cared for in safe, clean ward environments
- Staff described an open culture, where leaders supported continuous improvements to people’s care.
However:
- Some staff described a high number of incidents in which people suffering from a mental health condition had become physically aggressive towards staff and other people on the wards, impacting everyone’s safety and morale. Inspectors found particular concerns at ES1, one of the trust’s PICU wards
- Staff were less knowledgeable about incidents which took place in directorates outside their own. This meant the learning from these incidents wasn’t always being shared as widely as possible.