- NHS mental health service
St Bernard's Hospital
Assessment report published 17 September 2026
Contents
Ratings
Our view of the service
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.
People's experience of this service
During this inspection we spoke with 9 patients and 9 relatives/carers of patients across all 3 wards. Patient feedback overall was positive. They told us that staff treated them well and they felt safe. We observed activities taking place on Meridian and The Limes. Patients were observed to be positive and happy with the activity provided. Patients at The Limes were overwhelmingly positive about their care experience. Two patients on Jubilee ward reported that they wanted to be more involved in their care.
Carer feedback was mixed across the wards visited. Three carers told us that communication between them and the ward staff could be improved. They did not always feel involved in their relative’s care. Two carers commented that the culture on Jubilee ward needed to improve. Other carers told us they were involved and had attended care programme approach meetings.
On Meridian ward a carer told us that they ‘would be happy and confident in their relative returning to the ward in the future’. Another carer told us ward staff were “really nice people” and that they were “kind and helpful”. At the Limes a carer commented “It is like heaven here. The manager is particularly good, and staff are willing and helpful. They are so friendly and support me.”
Throughout the inspection we mostly saw positive interactions between staff and patients. We observed staff communicate in a way that was suitable for the person’s communication needs.