- NHS mental health service
St Bernard's Hospital
All Inspections
During an assessment under our new approach
We carried out a short notice announced assessment of all mental health wards for older adults delivered by West London NHS Trust. We inspected 3 wards across 3 sites between 7 -9 July 2026. We assessed 34 quality statements across Safe, Effective, Caring, Responsive and Well Led key questions.
During this assessment, the inspection team:
- visited 3 wards
- reviewed the environment on each ward and observed staff supporting patients
- spoke with a range of staff including ward managers, registered nurses, consultant psychiatrists, ward doctors, activity co-ordinators, psychologists, healthcare assistants, physiotherapists, discharge co-ordinators, safeguarding leads, pharmacist leads, matrons and occupational therapists.
- spoke with the Clinical Director, Deputy Director of Nursing, service directors,
- spoke with 9 patients and 9 carers
- reviewed the care and treatment records for 10 patients
- carried out a Mental Health Act monitoring visit
- reviewed medicine management on all three wards, including checking prescription charts, medication records and associated Mental Health Act documentation
- attended 3 safety huddle meetings and 1 ward round
- reviewed other documents, performance data and policies relating to the running of the service
The inspection team comprised of 2 CQC inspectors, 1 specialist advisor, 1 CQC Pharmacy Specialist and 1 Mental Health Act Reviewer.
The wards we visited were:
Meridian ward - 18 beds for male and female patients and is located on the ground floor of Hammersmith and Fulham Mental Health Unit. The ward offers an assessment and treatment inpatient service to older adults who have functional and organic mental health disorders.
Jubilee ward - 18 beds for male and female patients and is located on the ground floor of an old Victorian building at St Bernard’s Hospital. The ward offers an assessment and treatment inpatient service to patients with a mixture of functional and organic mental health disorders.
The Limes - 10 beds for male and female patients and is a ground floor stand-alone unit in Southall. This service provides a step down from the other 2 wards in the trust and provides a service for patients with functional and organic mental health disorders who require more time in an inpatient environment.
We carried out this comprehensive assessment due to the aged rating for this service. The service was last inspected in 2018. At that inspection safe was rated as requires improvement and effective, caring, responsive and well-led were rated as good. Our overall rating was good.
At our last inspection we found one breach of regulation on Meridian ward relating to the identification and recording of restraint incidents. At this inspection, we found that the service had made improvements and the service was no longer in breach of regulation in this area.
The scores from the quality statements covered during this inspection have been combined and calculated. These calculate the new key question ratings. At this inspection we rated this service as good in each domain, and good overall.
Patients were protected from avoidable harm. Staff recognised and managed risks well, including risks associated with falls, malnutrition, pressure care, deterioration and safeguarding. Care records supported safe practice, and systems for reporting, learning from and responding to incidents were well embedded.
Care and treatment was effective. Staff assessed people’s needs thoroughly and worked well together across teams and with partner organisations to deliver joined-up care. Staff developed holistic, recovery-orientated 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 audits to evaluate the quality of care they provided.
The multidisciplinary team included or had access to a range of specialists required to meet the needs of patients. Managers ensured that these staff received training, supervision and appraisal.
Staff mostly treated patients with care and kindness, respected their privacy and dignity, and understood their individual needs. Patients and carers were involved in care decisions where appropriate.
Services were responsive to people’s needs. Care was person-centred, and staff acted promptly when people’s condition changed. Staff had introduced improvements in response to feedback from patient’s and carers.
The service was well-led. Leaders were visible, approachable, and had a good understanding of the challenges facing the older people's wards. They were aware of areas requiring improvement and where additional support was needed, and they took appropriate action to provide this support. Governance processes mostly operated effectively, and performance and risk were managed well. Staff reported feeling valued and supported.
During this inspection we found 1 breach of the regulations in relation to safe care and treatment relating to medicines management.
Mental Health Act and Mental Capacity Act Compliance Summary
Mental Health Act
Over 92% of staff had received training in the Mental Health Act.
Staff were trained in and had a good understanding of the Mental Health Act, the Code of Practice and the guiding principles.
Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were.
Mental Capacity Act
Most staff had completed their training in the Mental Capacity Act. Over 94% 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.
Staff had a good understanding of the Mental Capacity Act.
Staff knew where to get advice from within the provider regarding the Mental Capacity Act.
Staff took all practical steps to enable patients to make their own decisions.
For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions.
When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.
14, 15 October 2013
During a routine inspection
During the inspection we spoke with a minimum of 37 people who use the service and a minimum of 56 staff from various disciplines.
The majority of feedback we received from people who use the service was positive and showed people valued the service they received. Comments we received from some people were: 'the service I have been receiving here has been excellent. Staff are friendly. It has done wonders for me', 'good help. They are very nice people', 'the staff are working miracles' and 'the service here is excellent.'
We found that people felt respected and involved in their care and treatment. Risks to people were identified and plans were in place to minimise risks to themselves and others. Similarly, staff knew how to respond to safeguarding issues that they came across as part of their work to protect people from abuse.
The provider took information about complaints seriously, though information of how to make a complaint was not always readily available to people.
3 October 2012
During a routine inspection
Part of our role is to monitor the rights of people who are detained under the Mental Health Act 1983 (and subsequent amendments to this). Our Mental Health Act (MHA) Commissioners have visited St Bernard's and Ealing Community Services a number of times in during 2011/2012. We looked at information from the MHA Commissioners recent visits. We also looked at information from advocates, Ealing Local Involvement Network (LINks) and written feedback from people who use Ealing community services.
We have also looked at the results of the Department of Health: Survey of NHS Staff 2011/2012 and the CQC Community Mental Health Survey 2012 (CMHS). Whilst the feedback for both of these was gained from across the trust and not at location level we have considered the findings as part of this inspection.
The majority of feedback we received from people who use the service was positive about their experience of being a patient and of being involved in their care. People who were detained under the Mental Health Act said they were informed of their rights and could generally take leave form the ward when they wanted to. Most people commented that their was enough activities to keep them occupied, though we found that these were lacking on the PICU (patient intensive care unit). We also found that privacy and dignity was not always respected in some areas we visited as part of this inspection.
We also found that, across the sites we visited of St Bernard's and Ealing Community Services, the majority of feedback from staff was that they did not feel approriately supported and listened to, which they felt had an impact on the care people received, and could put people who use the service at risk.
1 August 2011
During a routine inspection
Patients said they were usually involved in making decisions about their treatment and care and had opportunities to give feedback on their experiences. The majority said they had seen and agreed their care plan and some said they had signed the plan and had been given a copy of it. Patients told us there were activities on offer in the hospital such as using the gym, arts and crafts and watching TV. They said they felt safe in the wards and would talk to staff, advocates or relatives if they had a concern.
Patients told us there were usually sufficient numbers of staff on duty to meet their needs. However, they also told us they did not get their escorted leave as there wasn't always a member of staff available. One ward was described as 'chaotic at times' by patients due to staffing issues. They said 'staff do their best, there isn't enough of them' and 'there is an over reliance on bank and agency staff'.
Patient comments across the services included 'the nurses and doctors are really very good', 'staff are generally lovely' and 'the nurses are ok'.