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Provider: West London NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 2 June 2020

Our rating of the trust stayed the same. We rated it as good because:

  • We rated the trust as good for effective, responsive and well-led. Caring was rated as outstanding and safe as requires improvement. We rated three of the four core services we inspected this time as good and one as requires improvement. In rating the trust, we took into account the previous ratings for the core services not inspected this time.
  • We rated well-led for the trust overall as good.
  • The overall rating for West London NHS Trust remained as good overall and it was evident that many improvements had been made. Leaders had completely revitalised much of the trust infrastructure, such as information governance, repairs and maintenance, complaints investigations, data quality and performance monitoring, which underpinned the clinical work. This put their clinical leadership teams in a strong position to develop their services further and improve consistency in order to achieve their ambition to become an outstanding trust.
  • The trust had sustained and, in many areas, enhanced the core service improvements required following our last comprehensive inspection in 2018. In three of the four core services we inspected this time we found that all the requirements and recommendations from our previous inspections had been rigorously addressed with board level monitoring.
  • Where problems remained, they were linked to individual teams, rather than issues with the trust’s systems or processes.
  • The trust had particular strengths in the following areas; leadership at all levels, the positive culture of the organisation, the strong patient-focus, partnership working, pro-active engagement and co-production with patients, carers, staff and other stakeholders, creative recruitment and retention, training and development opportunities for staff and timely and effective completion of action plans and similar.
  • Patients and carers spoke well of staff.
  • Staff told us the trust had become a kinder place to work and they had confidence in their leaders who were very visible. The trust had implemented new practices to root out any accidental or deliberate unfairness to staff.
  • The new Broadmoor Hospital demonstrated a bespoke and well-designed clinical environment for patients and staff and patient transfers to the new building had been without fault.
  • There were several areas of outstanding practice which are detailed in this report.

However:

  • The trust still has a number of sites which are not fit for delivering modern health services.
  • The trust had not paid sufficient attention to its child and adolescent mental health ward (The Wells Unit) whilst it was waiting for a decision from commissioners and this had led to a drop in standards. The trust gave six months’ notice to NHS England to end the contract shortly after our site visit concluded.
  • Some specific safety issues had not been resolved within certain inpatient wards, although the trust was working to address them.
  • The trust had not yet fully implemented the accessible information standard.

Inspection areas

Safe

Requires improvement

Updated 2 June 2020

Our rating of safe stayed the same. We rated it as requires improvement because:

  • The ward environment at The Wells Unit was not fit for purpose.
  • Improvements were needed to ensure that all inpatients who received rapid tranquilisation had appropriate physical health checks completed afterwards.
  • Some specific safety issues associated with physical health checks and recording of and storage of medicines had not been resolved within certain inpatient wards, notably on Askew psychiatric intensive care unit (PICU). There was not always consistent recording of risk assessments, care plans and safeguarding information on The Wells Unit. The trust was working to address the issues.
  • Within a few teams there was some inconsistency with the storage of patient information in the electronic patient record system. This made it hard to find. There were also some difficulties in accessing uploaded documents in a timely way.

However:

  • Inpatient wards and clinic areas were safe, clean, well equipped, well furnished, well maintained and, for the most part, fit for purpose.
  • The core services inspected had enough nursing and medical staff, who knew the patients and received basic training to keep people safe from avoidable harm. The number of patients on the caseloads of staff in the community teams was manageable.
  • Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
  • Staff responded promptly to sudden deterioration in a patient’s health. Staff monitored patients on waiting lists to detect and respond to increases in level of risk.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff regularly reviewed the effects of medicines on each patient’s physical and mental health.
  • The service had a good track record on safety. The service managed patient safety incidents well. Staff recognised incidents and mostly reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

Effective

Good

Updated 2 June 2020

Our rating of effective stayed the same. We rated it as good because:

  • Staff assessed the physical and mental health of all patients on admission or at first contact. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected patients’ assessed needs, and were personalised, holistic and recovery-oriented
  • Staff provided a range of treatment and care for patients based on national guidance and best practice. They ensured that patients had good access to physical healthcare and supported them to live healthier lives.
  • Staff used recognised rating scales to assess and record severity and outcomes. They also participated in clinical audit, benchmarking and quality improvement initiatives.
  • The teams included or had access to the full range of specialists required to meet the needs of patients. Managers made sure they had staff with the range of skills needed to provide high quality care. They supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.
  • Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care. Each team had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice. Managers had made sure that staff could explain patients’ rights to them.
  • Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

However:

  • Staff supervision sessions were not being reliably recorded electronically, although staff told us they received supervision regularly.

Caring

Outstanding

Updated 2 June 2020

Our rating of caring stayed the same. We rated it as outstanding because:

  • The trust as a whole was very patient-centred. Staff at all levels wanted patients to experience the best possible outcomes and did their best to facilitate this.
  • There were many examples of staff and leaders going the extra mile to support patients, including those with protected characteristics. The trust stepped forward to provide support for one patient with complex needs who was not their responsibility, but who needed intensive skilled intervention to improve the quality of their life.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Patients had easy access to independent advocates.
  • Staff involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. Some patients were involved in the co-design of materials for training on prevention and management of violence and aggression; on a few wards patients were invited to participate in safety huddles. In perinatal services, staff always involved patients in pre-birth care planning and actively sought their feedback on the quality of care provided.
  • Co-production with patients and carers was increasingly well developed with opportunities for co-design and co-presentation in many areas, such as in the short film to introduce the trust’s community child and adolescent mental health services.
  • Patients at Broadmoor Hospital had played a significant role in the design of the new hospital and the artwork within it. Forensic patients had re-designed a staff training room.
  • Staff informed and involved families and carers appropriately. The trust had received its first Triangle of Care star for its work with carers.

Responsive

Good

Updated 2 June 2020

Our rating of responsive stayed the same. We rated it as good because:

  • Staff assessed and treated patients who required urgent care promptly. Staff followed up community patients who missed appointments.
  • Staff managed beds well. A bed was available when needed and patients were not moved between wards unless this was for their benefit. The trust had sustained this good practice for over two years at a time of immense pressure on beds across London. Discharge was rarely delayed for other than clinical reasons.
  • The service ensured that patients were supported to make a smooth transition to other services when this was required or in their best interests.
  • The design, layout, and furnishings of most wards supported patients’ treatment, privacy and dignity. Each patient had their own bedroom and they could keep their personal belongings safe. There were quiet areas for privacy.
  • The food was of a good quality and inpatients could access hot drinks and snacks at any time.
  • Staff supported inpatients with activities outside the service, such as work, education and family relationships.
  • The service met the needs of all patients – including those with a protected characteristic. Staff helped patients with communication, advocacy and cultural and spiritual support.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and wider service.

However:

  • Some young people and families waited a long time for an assessment or to start treatment. In Ealing, young people had to wait for up to three years to access a neurodevelopment assessment and this impacted on every aspect of their lives. The trust had worked to improve this and had raised it with commissioners of the service.
  • The accessible information standard had not been fully implemented.

Well-led

Good

Updated 2 June 2020

Our rating of well-led stayed the same. We rated it as good because:

  • The trust had been effective in addressing all the requirements and recommendations identified at previous inspections.
  • Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.
  • Staff knew and understood the trust’s vision and values and how they were applied in the work of their team.
  • Staff felt respected, supported and valued. They reported that the trust promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution.
  • Our findings from the other key questions demonstrated that governance processes operated effectively throughout the trust and that performance and risk were managed well.
  • Clinical teams had access to the information they needed to provide safe and effective care and used that information to good effect.
  • Staff engaged actively in local and national quality improvement activities, including audits and accreditation.

However:

  • The trust had let standards slip in The Wells Unit whilst waiting for an external decision about refurbishment.
Checks on specific services

Forensic inpatient or secure wards

Outstanding

Updated 21 December 2018

Our rating of this service improved. We rated it as outstanding because:

  • Leadership within the service was highly effective. Leaders at all levels were supportive of staff and visible within the service. They supported each other to deliver the best possible service for all patients. Staff were supported to develop their leadership skills through a range of creative training, coaching and mentoring opportunities. This service had greatly improved since its inadequate rating at our first comprehensive inspection in 2015 and this confirmed that leaders had good skills and knowledge.
  • There was a strong ethos around patient involvement and it was integral to the way the service was provided. Patients were at the heart of any decision making about the way the service was delivered and in respect of their own care and treatment. We heard examples of changes that had taken place as a direct result of patient feedback.
  • Patients were inspired to have hope in their recovery by staff members and recovery and involvement (HOPE) workers. The service was focused on rehabilitation, with patients offered extensive opportunities for vocational training, education and personal development. Staff were committed to this approach. Patients told us that this was important to them and helped them progress through towards discharge.
  • The service provided individual care which reflected the holistic needs of patients. This meant that as well as needs relating to physical and mental health being assessed, monitored and reviewed, the patients’ social, cultural and spiritual needs were well met.
  • Staff had an excellent understanding of patients’ needs and this enabled them to take positive risks to aid patients’ recovery. For example, one ward escorted all its patients to a leaving party for one patient in the hospital café. The patients concerned said they appreciated the trust put in them and it encouraged them in their recovery.
  • The service had safely reduced the use of restrictive practices. De-escalation techniques were used well; rapid tranquillisation of patients had only been required on eight occasions in one year. There were fewer blanket restrictions in place and both patients and staff were better informed about those that were in place and the reasons for them. For example, previously, in the Tony Hillis wing, there had been a ‘one-size fits all’ approach to searches on return from unescorted leave, even though the wing accommodated both medium and low secure wards. Now patients on the low secure wards received searches in keeping with that level of security.
  • Patients had access to a full range of physical healthcare professionals at the on-site primary healthcare centre, which included a fully equipped dental surgery. Patients could be seen on the ward if they could not visit the centre so no one was disadvantaged. Patients were supported to make healthy lifestyle choices, such as using the gym facilities and selecting healthy snacks.
  • Plans were well underway to move some wards in the least suitable building to a newly refurbished building and to make sure those wards that remained behind also had improved facilities. Repairs and maintenance had not been put on hold in the interim period and were taking place throughout our inspection.

However:

  • Although all shifts were covered and recruitment and retention had improved, there were insufficient permanent nursing staff to ensure proper continuity of care for all patients.
  • Some records of seclusion were not comprehensive and did not record all the observations which had taken place to show staff were following the Mental Health Act Code of Practice.
  • A few patients in the women’s service may not have had all their physical healthcare needs met as on one ward diabetes care plans were not in place for four patients with the condition.

Acute wards for adults of working age and psychiatric intensive care units

Good

Updated 2 June 2020

Our rating of this service improved. We rated it as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and usually followed good practice with respect to safeguarding.

• Staff developed holistic, recovery-oriented 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.

• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

• The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Improvements were needed to ensure that patients who received rapid tranquilisation had appropriate physical health checks completed afterwards.

• Whilst the service had systems and processes in place to safely prescribe, administer, record and store medicines, further work was needed to ensure staff always followed these.

• Some staff on Askew Ward were not using personal alarms. A few staff on this ward told us they did not feel safe on the ward and managers were investigating their concerns.

• Further work was needed to fully embed the training in safeguarding staff had received into practice.

• Improvements were needed in how staff on Kingfisher Ward reported incidents where the patient had been restrained.

• The current audit programme had not identified issues with medicines, administration of rapid tranquilisation, reporting of restraint and Mental Health Act documentation that we found during the inspection.

• Improvements were needed to ensure that all staff discharged their responsibilities under the Mental Health Act well. For example, staff did not always update records to show that patients had been explained their rights in a timely manner.

Perinatal services

Good

Updated 2 June 2020

We rated this service as good because:

The leaders of the service had the vision, capability and drive to ensure that care pathways for women with perinatal mental health continually improved.

•Patients and partner organisations reported that staff were skilled, caring and motivated.

•Partnership work with other agencies was well-developed at both the strategic and operational level. The service led on work with other organisations to improve the care pathway. There were clear operational policies and referral systems and working relationships were positive.

•Staff organised pre-birth planning conferences which were very effective in ensuring that patients with severe and enduring mental health problems and their infants received holistic care and support.

•Staff were fully aware of the diverse cultural background of patients. They worked sensitively with patients and their support network to provide effective support. Patients said their views were always respected.

•The service had a proven track-record of successful and creative work in partnership with experts-by-experience to develop the service.

•The service responded promptly to crisis situations and managed risks effectively. Staff ensured that any safeguarding concerns were acted on.

•Staff reported an open and supportive team culture with many opportunities to learn and develop their skills.

Specialist community mental health services for children and young people

Good

Updated 2 June 2020

Our rating of this service improved. We rated it as good because:

• The service had made the required improvements since our last inspection in November 2016. This included ensuring environments met young people’s and visitors’ needs, ensuring medical equipment worked, ensuring staff learnt from incidents and improved staff engagement across the children and adolescent mental health service.

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.

• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.

• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.

• Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.

• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

• The criteria for referral to the service did not exclude children and young people who would have benefitted from care.

• The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

• Some pathways within the service were not always easy to access. Some young people and families waited a long time for an assessment or to start treatment. In Ealing, the wait for 55 young people and their families to access a neurodevelopment assessment had been in excess of three years.

• Staff could not always access electronic records easily. We noted during the week of the inspection that there was a delay in staff being able to access documents that had been uploaded. Staff, particularly in Hounslow, commented on how the delays caused disruption to their work.

• Across the teams we visited, staff were recording children and young people’s care and treatment plans and risk information in different parts of the trust electronic system. This meant there could be delays in accessing key information across teams.

• Staff identified as having responsibilities to develop user involvement felt they did not have enough protected time to complete this work.

• Some line managers were not confident in using the electronic system to upload supervision records and continued to maintain paper supervision records. This meant that data regarding the frequency and overall compliance with supervision was not accurate.

Child and adolescent mental health wards

Requires improvement

Updated 2 June 2020

Our rating of this service went down. We rated it as requires improvement because:

• The ward environment was not fit for purpose. The ward did not provide a therapeutic environment. There were some poor lines of sight and measures to manage and mitigate the risks from these were not always followed. The seclusion room was inappropriately located. The building was waiting for refurbishment, but commissioners had not confirmed this could proceed. There were also some outstanding repairs, which were completed by the end of the inspection.

• Risk assessments and risk management plans needed further work to make sure they all joined up and there was no discrepancy between risk assessments and the plans to manage the risks. The service audited this immediately we told them there was a problem and acted on their findings.

• Further specialist training was needed to ensure that staff from diverse forensic and CAMHS backgrounds had the right skills and experience to meet the needs of patients.

• Whilst governance systems were in place, these were not operating effectively at ward level to ensure that performance and risk were managed well.

• Aspects of the service, such as repairs and maintenance, were not being attended to as promptly as they should have been. Some staff felt the ward had been left behind and they told us the refurbishment delays were frustrating and demoralising.

• It was not always easy to access historical records that related to patient care and treatment. Staff did not always maintain complete safeguarding records. Improvements were needed to ensure that learning from lower level incidents was always shared and the identified actions were implemented.

However:

• The wards had enough nurses and doctors. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

• Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.

• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider promoted equality and diversity in its day-to-day work. Staff felt able to raise concerns without fear of retribution.

• The trust has a strong track record in responding to inspection requirements and recommendations in a timely way. They addressed our concerns during the inspection period.

Community-based mental health services for adults of working age

Requires improvement

Updated 21 December 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Services needed to improve access and waiting times. The recovery teams did not assess all referrals promptly. They did not meet the 28-day trust target to see the patient for their initial assessment from the day of their referral. Some patients had to wait for a long time for transfers between teams. Ealing West Recovery Team needed to have a better system for monitoring the safety of patients on their waiting list.
  • Some teams had staffing challenges due to high vacancies and high staff turnover. This meant that many staff in the teams affected had more patients on their caseload than recommended by national guidance. In Ealing Early Intervention Service there were not enough care coordinators for all the patients within the service.
  • Staff did not always manage medicines safely. At Ealing West Recovery Team, we found out-of-date medicine kept with in-date medicines. This increased the possibility that a patient may be given an out of date medicine.
  • Some teams did not assess and plan how to manage patients’ risks robustly. Patients’ risk assessments and care plans were not reliably updated following changes in circumstances or incidents. These documents were not regularly audited to check they were person-centred, accurate and up-to-date. Staff in the Ealing West Recovery Team also did not fully address risk in their ‘zoning meeting’.

However:

  • Senior and team managers across the teams had a good understanding of their teams and the challenges they faced. Senior managers had already implemented support and intervention plans for the two teams where we found the most concerns during our inspection. This demonstrated managers understood the risks associated with their teams and had acted to eliminate them or reduce them.
  • Despite the pressures faced by the teams, managers and staff worked well together to ensure patients received good care and treatment. There was an open culture and morale was generally good. The provider regularly recognised staff success within the service.
  • Staff had the necessary training to ensure they could deliver their role safely and effectively. Staff followed good lone working practice, which enhanced their safety when meeting patients. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff recognised incidents and reported them appropriately.
  • Staff demonstrated excellent working relationships with other teams, both internal and external to the trust, which ensured seamless and holistic care for patients. Staff offered interventions aimed at improving patients’ social networks, education and employment.
  • Staff used technology to support patients effectively and avoid missed appointments, such as by sending text appointment reminders.
  • Staff demonstrated good practice when using the Mental Health Act and the Mental Capacity Act.
  • Staff involved patients and, when appropriate, carers in decisions about care. They had implemented a way of working collaboratively with patients and carers. Teams supported patients, families and carers to understand their mental health and to develop strategies for dealing with its impact.
  • Patients told us that they could contact the service easily if they felt unwell or had any questions about their treatment.
  • Staff planned for patients discharge from services well. Teams had been involved in quality improvement projects, which aimed to improve the patient discharge pathway.
  • Patients knew how to complain or raise concerns. Information about how to complain was on display in the patient waiting room in the service we visited.
  • Managers had better access to data to help them monitor the performance of their teams. A new ‘dashboard’ had just been made available and the trust was rolling out training to support managers to get the best from it.
  • The teams had made good progress with addressing the recommendations made in the November 2016 inspection. This included access to psychological therapies, and staff receiving regular appraisals and supervision.
  • Improvements had also been made in the delivery of physical healthcare, but teams still needed to do more work to embed physical healthcare in their day-to-day practice.

Mental health crisis services and health-based places of safety

Good

Updated 21 December 2018

Our rating of this service improved. We rated it as good because:

  • Care professionals in the trusts single point of access worked closely with the health based places of safety and crisis assessment and treatment teams to ensure patients had access to services in a timely manner. For example, the health-based places of safety were open to young people under the age of 18, as well as adults and they did not turn away people who presented as intoxicated. Also the CATTs were now operating 24 hours a day.
  • The crisis services worked closely with other stakeholders including the police, local authority AMHP leads and psychiatric liaison teams to review services and address challenges in joint working.
  • Staff monitored patients’ physical health needs and ensured that any issues identified were addressed appropriately. Each CATT had specific physical health clinics to ensure that basic checks could be carried out and this information was recorded. In the health-based places of safety, each patient had a physical health check on admission and their physical health was monitored while they were awaiting an assessment. This was an improvement since our last inspection.
  • Staff in the CATTs offered a range of brief interventions and support groups which enabled them to provide care and treatment to a wide range of people. This was in line with recommendations in national guidance.
  • Staff teams were highly motivated and morale was strong in the teams we visited. Staff were positive about the support they received from managers and felt they were supported to develop, personally and professionally by the trust.

However:

  • In the health based places of safety, staff had not ensured that key information relating to the operation of the service was effectively captured and that other systems were working well. For example, data was not being collected accurately, such as the time the patient arrived (and therefore their length of stay) or when the service was closed due to staff shortages. Other essential records such as physical health observations and a record of patients being told their rights were not stored consistently in each service. Environmental audits and ligature risk assessments had not been completed and this was not identified until the inspection visit although this was addressed immediately. Incidents had been reported but were assigned to wards rather than the health based places of safety themselves which hindered oversight by managers and potentially, learning.
  • In the crisis assessment and treatment teams (CATTs) staff did not always keep appropriate records of patients’ care and treatment. Risk assessment documentation in Hounslow and Hammersmith and Fulham CATTs did not reflect the current patient risk. Some care planning documentation in all the CATTs had not been completed comprehensively to reflect the care that was being provided to patients.
  • Medication in the CATTs was not consistently reconciled which meant that medical and nursing staff in the teams did not always liaise with GPs and inpatient wards to ensure that the prescriptions and the medicines received by patients were consistent. As a result there were errors on a few prescription charts.

Long stay or rehabilitation mental health wards for working age adults

Requires improvement

Updated 21 December 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Whilst improvements had been made and embedded on Mott Ward, further work was still required on Glyn Ward. On Glyn Ward there had been changes in the leadership team and this had impacted on the operation of the ward and communication with staff. At the time of the inspection a new manager had been appointed. On Mott Ward there was some outstanding practice, but the ratings for this ward had been brought down by the performance of Glyn Ward. Senior leaders in the trust were aware of the challenges on Glyn Ward.
  • Last time we inspected the service patients did not have access to educational and vocational opportunities to support their recovery. This time they had good access at Mott House, but on Glyn Ward only basic educational and pre-vocational sessions were available to patients.
  • While patients at Mott House received structured rehabilitation with identified recovery goals to support the work towards discharge, for patients on Glyn Ward this was less well developed.
  • Staff were not regularly receiving supervision on either ward, so staff could not rely on having time with their supervisor to discuss their practice or learning or to raise any issues.
  • While the service had made some improvements in ensuring the privacy and dignity of patients since our last inspection, we observed patients receiving routine medical checks in full view of others in the lounge at Glyn Ward, which compromised their privacy.
  • Regular team meetings were not happening on Glyn Ward which meant that staff did not have sufficient opportunities to discuss the day-to-day running of the ward.
  • Repairs and maintenance were not provided promptly to Glyn Ward. The organisation and cleanliness of the clinic room on Glyn Ward was not up to the standard required and some first aid equipment was past its expiry date.
  • The service’s inability to recruit and retain sufficient numbers of nursing staff affected the continuity and consistency of the nursing team. It impacted on patients receiving one-to-one time with their named nurse on Glyn Ward.
  • Staff on Glyn Ward did not routinely update patients’ records when needs or risks changed. There was little evidence of updates between care programme approach meetings, which were six monthly, or following incidents.

However:

  • The trust had successfully implemented a range of measures to make sure patients who were admitted for acute care no longer had to sleep on the rehabilitation wards due to the shortage of acute beds. These improvements had been sustained throughout 2018 so there was no longer any impact on the rehabilitation wards.
  • There were sufficient therapy staff to support each patient’s rehabilitation. Doctors, nurses and other healthcare professionals supported each other to provide care.
  • Staff appraisals were being carried out and this was an improvement since our last inspection.
  • Doctors’ prescribing practice was very thoughtful; minimum effective doses were prescribed and potential side-effects were always taken into account.
  • Staff were good at supporting people to calm down when they were distressed so there was little need for physical interventions. There was evidence of positive risk taking.
  • Physical healthcare was exemplary, with patients with complex needs receiving specialist care from acute hospitals.
  • Patients spoke positively about staff and regular staff knew them well and understood their needs.
  • Patients were now much more involved in developing their care plans and understanding their medicines. They were supported to voice their opinions by a peer support worker and in a regular independently run forum. There was evidence that staff made changes in response to patient views.

Wards for older people with mental health problems

Good

Updated 21 December 2018

Our rating of this service improved. We rated it as good because:

  • There were significant improvements in the culture of the service and the responsiveness of leaders which had had a positive impact on staff morale and the quality of the service.
  • Staff took account of patients’ individual needs and preferences and treated patients kindly. They took care to make sure patients understood their care and treatment and brought in independent advocates if they had doubts about the patient’s ability to make a decision for themselves.
  • The wards were bright and cheerful and, although the ward layouts were not ideal, action had been taken to make the most of the environment and to improve safety.
  • Patients received a thorough assessment of their mental and physical health and were monitored for any deterioration. Care plans and risk assessments were in place for all patients.
  • Medicines were prescribed appropriately and at the lowest therapeutic dose and prescribers took full account of possible medicine interactions.
  • Staff were up-to-date with their mandatory training and were able to access other training opportunities too. They were aware of their responsibilities in relation to the Mental Health Act, the Mental Capacity Act and safeguarding children and adults.
  • A range of therapeutic activities was available across the service.
  • Families and carers were well-supported by staff and, when appropriate, fully involved in meetings to discuss the patient’s care and treatment.
  • Patient information was kept securely, but it was accessible to relevant staff members.
  • Ward managers could access timely information about the performance of their ward so they could attend to any emerging issues.
  • All the staff we spoke with were committed to ongoing improvement of the quality of the services they provided.

However:

  • Episodes of restraint were not always recorded, so managers could not effectively monitor its use.
  • The service found it hard to recruit registered nurses so there were a significant number of vacancies being covered by bank or agency staff.
  • There was not equal access to therapeutic activities across all the wards.

High secure hospitals

Good

Updated 3 August 2018

We rated the High Secure Hospital managed by West London Mental Health NHS Trust as good because:

  • The trust had made significant improvements within the hospital since our last comprehensive inspection in November 2016.
  • Patients were very positive about the staff and we observed staff interactions with patients which were respectful and kind. Staff spoke about patients with hope and knew the patients they worked with very well. We heard many positive examples of staff going the extra mile to provide a caring service which made patients’ needs central.
  • Staff took into account patients’ culture, religion and social interests when planning and delivering care and treatment. Staff had an excellent understanding of the individual needs of the patients they worked with and they demonstrated patient-focused and patient-centred practice which put patients’ needs at the heart of the work they did.
  • The hospital and staff were committed to ensuring that the patient voice was embedded in the governance processes and in decisions about the strategic development of the hospital’s clinical model. Patients were actively involved in a range of forums, groups and surveys, so they could raise issues and also identify areas for improvement. They had been engaged in the development work of the new hospital environment and the decisions made by the patient group had led to changes.
  • While there were still staff vacancies, the hospital had focused on ensuring that the patient experience was affected as little as possible in terms of activities being cancelled.
  • The hospital had undertaken significant work to reduce the use of long term segregation. This involved specific projects on several wards; including staff supporting patients to spend as much time out of their rooms as possible.
  • Staff could articulate learning from incidents and how they had changed practice because of incidents, complaints and feedback.
  • Staff morale had improved further since the last inspection. Arrangements were in place to keep staff informed and enable them to escalate issues they wanted addressed.
  • The trust had a strong ethos of research and developing best practice and innovative solutions including using technology to improve the outcomes for patients in their care.

However:

  • The hospital continued to have high vacancy levels for nurses and this had an impact on the delivery of care. Some activities were cancelled due to staff shortages.
  • Some medication was not stored at the recommended temperature and staff were not seeking advice or reporting incidents consistently when this was the case.
  • Some emergency medication was not immediately available to all staff. It was not clear that the potential impact of this had been considered and mitigated.
  • Some emergency equipment had been checked but had expired.
  • Staff did not assess and record patients’ capacity to treatment consistently. Staff had not recorded some seclusion reviews correctly and some patient records did not clarify why patients were subject to long term segregation.

Community-based mental health services for older people

Good

Updated 9 February 2017

We rated community-based mental health services for older people as good because:

  • At our last inspection in June 2015, we found that nurse caseloads in Ealing and Hounslow were higher than the target of 60 set by the trust. At this inspection, we found that the trust had taken action, in partnership with other agencies, to develop the service. At this inspection, caseloads in Ealing and Hounslow had started to reduce due to the fact that cases were being transferred to five new link workers in Hounslow and seven new link workers in Ealing.
  • All the CIDS teams operated from safe and suitable premises. The trust had improved the waiting area for patients and carers at Ealing east since our June 2015 inspection.

  • Patients and carers were able to access information and leaflets in languages other than English. This had improved since our June 2015 inspection.

  • CIDS teams were well staffed, with agency staff covering vacant posts. Permanent and agency staff were skilled and experienced. Managers ensured staff received one to one support and training to carry out their work role. Staff were positive about their work and the support received from their managers.

  • Patients and carers were fully involved in assessments of need and care and treatment processes. Carers and patients gave us very positive feedback about the sensitivity and professionalism of staff. Carers spoke very highly about the support staff gave them. They said staff treated them and patients with dignity and respect. Care and treatment plans complied with best practice guidance. The CIDS offered a range of psychosocial interventions to patients and carers. The service supported care homes in relation to managing behaviour which challenged staff.

  • Staff knew how to recognise abuse and neglect. They raised safeguarding alerts when necessary. Staff understood and put into practice the key principles of the Mental Capacity Act.

  • The Ealing and Hounslow teams were accredited by the Royal College of Psychiatrists in January 2016. The CIDS included a clinical trials unit. This helped to promote a learning culture within the service and enabled patients to participate in research if they wished.

However:

  • Although nurse caseloads in Hounslow and Ealing CIDS had started to reduce, in some instances caseloads were still high, for example at 90 in one instance.

  • The site used by the CIDS team at Hammersmith and Fulham was leased by the trust from another organisation. The trust had identified issues with the safety and suitability of the premises and was in communication with the owner of the property. However, at the time of the inspection there was not an agreed action plan in place to resolve these issues.

Community health inpatient services

Good

Updated 9 February 2017

We rated community health inpatient services as good because:

  • Magnolia ward provided support to patients so they could avoid an acute hospital admission, be supported with their rehabilitation and ideally regain enough independence to return home.

  • Staff were very caring and provided support in a sensitive manner that met the needs of each patient and their carers.

  • Magnolia ward was a safe and clean environment that was well maintained.

  • Magnolia ward had a skilled multi-disciplinary team that considered the needs of each patient and provided appropriate care and treatment. Medicines were managed well on the ward.

  • Staff were mindful of potential risks for patients, such as the risk of falls and worked to mitigate these as far as possible.

  • Staff on the wards worked well with other professionals such as GPs and social services to ensure patients needs were fully met.

  • Staff on the ward were skilled and had opportunities for learning and development.

However:

  • Staff needed access to regular individual supervision that was recorded. They also needed to attend regular team meetings.

  • More work was needed on staff engagement, especially while the service was going through ongoing review and change.

  • Managers needed to have clear performance information, well presented to facilitate their management of the service.

Patient records needed to be reviewed to move away from using paper records.