• Community
  • Community healthcare service

Trust Headquarters, 350 Euston Road

350 Euston Road, Regent's Place, London, NW1 3AX (020) 3214 5700

Provided and run by:
Central and North West London NHS Foundation Trust

Important: This service was previously registered at a different address - see old profile

All Inspections

Other CQC inspections of services

Community & mental health inspection reports for Trust Headquarters, 350 Euston Road can be found at Central and North West London NHS Foundation Trust. Each report covers findings for one service across multiple locations

23,24, 28 February and 01 March 2023

During an inspection looking at part of the service

We carried out an announced focused inspection of healthcare services at HMP Aylesbury provided by Central and North West London NHS Foundation Trust, remotely on 23 and 24 February 2023 and onsite on 28 February and 01 March 2023. The prison can hold up to 402 male adult prisoners. On 1 October 2022, the prison had been re-designated a category C training establishment.

Following our last joint inspection with His Majesty’s Inspectorate of Prisons (HMIP) in December 2022, we found that the quality of healthcare provided by Central and North West London NHS Foundation Trust required improvement. We issued a Warning Notice in relation to Regulation 12, Safe Care and Treatment and Regulation 17, Governance and 18 Staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The purpose of this focused inspection was to determine if the healthcare services provided were meeting the legal requirements of the Warning Notices that we issued in December 2022 and to find out if patients were receiving safe care and treatment. At this inspection we found that improvements had been made and the warning notice no longer applies.

We do not currently rate services provided in prisons.

At this inspection we found:

  • The service had a high vacancy rate for nursing staff, shifts were covered by regular temporary staff to ensure services provided to patients were safe. Staff working for the service completed training and were provided with supervision. Staff cared for patients safely and ensured that monitoring was undertaken for patients where indicated and any deterioration in a patient’s wellbeing was escalated as required.
  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the provider learned from them and improved their processes.
  • Systems and processes to administer medicines for patients were safe, however, we found that equipment used to monitor blood glucose levels was not always maintained in accordance with manufacturer’s instructions and when fridge temperatures were out of range this was not always escalated.
  • Identified risks were documented and the risk register reviewed and updated, and performance data was reviewed and checked for accuracy.
  • The complaints process and guidance was inconsistent and meant that patients did not always receive a response in line with policy.

The areas where the provider should make improvements are:

  • Review the management of equipment for monitoring blood glucose levels.
  • Review the storage of insulin in current use to ensure that it is being stored in line with the manufacturer’s guidance.
  • Review the management of medicines when the fridge temperature readings are outside of the recommended range.
  • The provider should ensure that the complaints guidance is clear and consistent.

16 March 2023

During an inspection looking at part of the service

We carried out an announced desktop, follow-up inspection of healthcare services provided by Central and North West London NHS Foundation Trust (CNWL) at HMP Coldingley on 17 March 2023. This was in response to a joint inspection carried out by His Majesty’s Inspection of Prisons (HMIP) in January 2022 (report published April 2022) when we found the quality of care needed improvement. We issued a Requirement Notice in relation to Regulation 9: Person Centred Care. Systems and processes did not always ensure the maintenance and quality of care. There were gaps in psychological therapy provision which resulted in unmet patient need. The purpose of this follow-up inspection was to determine if the healthcare services provided by CNWL were now meeting the legal requirements of the above regulation, under Section 60 of the Health and Social Care Act 2008.

At this inspection we found that required improvements had been made and the provider was meeting the regulations and were no longer in breach. The Requirement Notice was lifted.

We do not currently rate services provided in prisons. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

At this inspection we found:

  • Systems were effective in ensuring the management of patients waiting for assessment or treatment for psychological therapy.
  • The number of patients waiting for their treatment to start had reduced since the previous inspection.
  • Improved monitoring of patients with complex needs meant most patients (83%) were seen within the 18-week NHS target.
  • The number of patients waiting for an assessment for psychological therapy was similar to the last inspection; however, clear plans were in place to see each patient within a short timeframe.
  • The staffing model had been reviewed in line with patient demand, and increased counselling and psychological assistant hours were available.
  • Most vacancies were filled and regular bank staff covered vacant shifts.

07 December 2022

During an inspection looking at part of the service

We carried out an announced follow up inspection of healthcare services provided by Central and North West London NHS Foundation Trust (CNWL) at HMP Downview on 7 December 2022. This was in response to a His Majesty’s Inspectorate of Prison’s (HMIP) joint inspection carried out in July 2021 when we found the quality of care needed improvement. We issued a Requirement Notice in relation to Regulation 17: Good governance. There were no systems or processes that enabled the registered person to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk. In particular: Patient applications to see a healthcare professional were not triaged by clinically qualified staff. There was no oversight of patients who were waiting to see the GP. There was insufficient oversight of the electronic task system with over 450 tasks open at the start of the inspection.

The purpose of this focused inspection was to determine if the healthcare services provided by CNWL were now meeting the legal requirements of the above regulation, under Section 60 of the Health and Social Care Act 2008.

At this inspection we found the required improvements had been made and the provider was meeting the regulations. The requirement notice was lifted.