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Provider: West London NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 21 December 2018

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

  • We inspected five key questions for seven core services; a total of 35 key questions. The rating improved for 21 key questions and for two questions it went up by two ratings. Two ratings decreased from good to requires improvement, but the overall picture was of a trust that had made significant improvements.
  • At this inspection we rated one service as outstanding, four services as good and two services as requires improvement. The two largest inpatient services provided by the trust, forensic and high secure, were outstanding and good. Forensic services had improved from inadequate to outstanding within a three year period.
  • When these ratings were combined with the other existing ratings from previous inspections, there was one outstanding service, five good services and four services requiring improvement.
  • We carried out a focused inspection of acute wards for adults of working age and psychiatric intensive care unit, one of the services requiring improvement, in January 2018. This service was not re-rated as we only looked at specific issues, but we found that it had made significant improvements in key areas. At a time of high pressure on acute mental health beds in London, the trust was able to provide patients with access to a bed when needed. Bed occupancy on the acute wards was at 87% and patients were no longer being placed in beds outside the trust unless they required a specialist service not provided by the trust. This was a major improvement since our inspection in 2017 when acute patients had to sleep in the trust’s rehabilitation wards, and the improvement had been sustained throughout 2018. This is not evident from the current rating for acute services which pre-dates the improvement.
  • We rated well-led for the trust overall as good.
  • The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to make the necessary changes to provide high quality care to their local communities.
  • The trust had a strong, cohesive senior leadership team which had succeeded in changing the culture of the organisation for the better and which was well regarded by trust staff and external organisations. The chief executive officer was recognised as an inspiring leader.
  • The board had good oversight of all operational issues. The system of committees and sub-committees ensured that both achievements and concerns were escalated appropriately. There were comprehensive clinical governance arrangements in place which were inclusive of staff and patients. We found senior leaders already had plans in place to address all but one of the concerns we identified.
  • The trust had a strong grip on its finances. In 2017-18 the trust fully delivered on its £9.4m cost improvement plans (CIPs). It had reduced its agency spend and was working to drive it down further.
  • The trust was fully committed to working in partnership with patients and, increasingly, carers. There were many examples of coproduction. For example, the design and delivery of training and staff induction. Patients were involved in the development of their care and treatment plans, as well as ward matters and clinical governance. The trust engaged effectively with inpatients, outpatients and the local community.
  • Patients were actively encouraged, through paid and other opportunities, to get involved in service development. Patient representatives were supported to participate in a range of meetings and events and de-briefed afterwards. There were similar opportunities for carers. Senior leaders led by example and worked closely with patients and carers at meetings and on projects.
  • Staff engagement (as shown by the staff survey) had improved. The experience of doctors in training was now positive (as shown by the General Medical Council survey). Leaders were very visible within the trust. The trust prompted staff to raise concerns with support from the Freedom to Speak Up Guardian. There was low take up to date, but local champions had been recruited to start raising awareness. Staff told us they had lots of different opportunities to raise issues with management.
  • The trust was committed to improving the safety of staff, patients and the wider community and there were a number of initiatives and programmes in place to try to achieve this. The arrangements for lone-working in the community had improved and good relational security was now well established in forensic services.
  • The trust was actively participating very effectively in local care systems and with NHS partners and academic institutions to drive progress and develop new models of care, such as community mental health rehabilitation services. The trust’s participation in the North London partnership for forensic services meant that an increasing number of patients were receiving their care closer to home.
  • The trust had succeeded in becoming a learning organisation; staff learned from success and also when things went wrong. This was achieved through mortality review meetings, clinical improvement meetings, team meetings, supervision, newsletters and emails. A trust-wide learning from experience event was scheduled to take place soon after our inspection.
  • Staff at all levels were supported to enhance their skills and knowledge through a wide variety of training, mentoring and coaching opportunities. Courses ranged from popular two-hour sessions to professional qualifications.
  • The trust had invested in the development of leadership skills. It offered all staff employed at band 3 or above the opportunity to develop them. In order to address the under-representation of black and minority ethnic (BME) staff in leadership roles, specific training was available for this group of staff. Graduates from the programme attended a BME forum and were consulted about issues relating to BME under-representation. The trust ensured a person with a BME background was present on all interview panels for staff at band 8 or above.
  • The trust was recognised as a Stonewall champion and had an active lesbian, bisexual, gay, transgender (LGBT+) network and made a point of being inclusive of all sexual orientations. The chief executive was included in the Financial Times 2017 OUTstanding Global Leading Public Sector LGBT+ executives list. Rainbow lanyards were in use to let patients know who they could approach if they wanted to discuss their sexuality or gender identity. We heard how the trust was working on some guidance about meeting the needs of individuals who identified as transgender.
  • The trust maintained a high level of compliance with mandatory training. It made it compulsory for all mandatory training to be up-to-date before specialist training could be accessed.
  • The trust worked to improve the quality of patients’ lives in hospital and in the community. Patients were supported to understand their condition and to acquire vocational skills and academic qualifications. The recovery college operated from a central base In west London and convenient satellite sites and Broadmoor had its own recovery college.
  • Staff and patient successes were celebrated. Teams and staff who had ‘gone the extra mile’ for patients were recognised by senior leaders and colleagues. There were regular awards and events for both patients and staff and they told us they felt valued as a result.
  • The trust had a range of measures in place to support staff returning to work from long-term sick leave and was particularly mindful of the needs of staff who had been injured at work. Affected staff told us they could not fault the support they received.
  • The trust supported staff, patients and carers to develop the skills and knowledge required to carry out quality improvement work. Many projects were underway and the trust was making progress with coordination and monitoring outcomes.
  • Clinicians were fully involved in digital developments to make sure they were fit for clinical use. We saw how the electronic patient information system was regularly adjusted to better capture important information, such as physical health checks. The trust had just introduced a new dashboard which showed managers how their ward or team was performing. A manager who was an early-implementer showed us its potential, but training was still being rolled out so its impact could not be fully assessed.

However:

  • Whilst we found significant improvements in most of the teams and wards we inspected, in most core services there was at least one team or ward which was not up to the standard of the rest. This lack of consistency impacted on the ratings we could award. The trust were aware that these wards and teams needed to improve and additional support was being provided.
  • Recruitment and retention of staff remained an issue for the trust; matters were improving and the trust was finding some creative solutions, but there was still a negative impact on the workload of some teams and the continuity of patient care.
  • The Tony Hillis wing at St Bernard’s hospital, which was the site for several inpatient services and other facilities, was not a suitable place to provide modern healthcare. It presented risks to the health and well-being of patients due to antiquated electrical, plumbing and heating systems which required constant repair and the number of ligature anchor points that had to be monitored. Parts of the current Broadmoor Hospital were also not fit for purpose, although a new hospital was being built next door.
  • The trust did not have good oversight of the performance of its health-based places of safety. In part, this was because activity within the three suites was mainly reported via the wards from which staff were drawn to work in them. This meant most of the data gathered was absorbed into the ward data and was not easily identifiable as data related to the health-based places of safety.
  • The trust needed to make sure there was more consistency in the storing of patient records, both paper and electronic. Staff kept records, but not always in the same place as their colleagues which made them hard to find, especially in an emergency situation.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RKL/reports.

Inspection areas

Safe

Requires improvement

Updated 21 December 2018

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

  • At this inspection we rated safe as requires improvement in six of the services and good in the one service. When these ratings were combined with the other existing ratings from previous inspections, eight of the trust services were rated requires improvement and two were rated good. In part, this reflected the lack of consistency across many of the services. We found plenty of good practice amongst most teams, but poor practice by a few weaker teams meant that we could not award a higher rating.
  • Staff recruitment and retention had improved, but there was still an impact on the workload of some teams and professions and the quality and continuity of patient care. Some caseloads, for example in the Ealing Early Intervention Service, were almost twice as large as the recommended size.
  • The Tony Hillis wing at St Bernard’s and parts of Broadmoor hospital were not fit for the delivery of modern healthcare. There were plans to replace or refurbish both, but in the meantime patients and staff were having to cope with buildings that only increased risk.
  • Seclusion, when used, was not always reviewed in line with the Mental Health Act Code of Practice and it was not always clear why.
  • Risk assessments and risk management plans were not always updated following incidents, for example, in the trust’s crisis services. This was necessary for teams working on a shift system supporting people during a mental health crisis. All staff needed to be able to see the latest information at a glance.
  • Records, both electronic and paper were not always stored consistently. Staff in the same team stored similar records in different places, making it hard to find, especially in an emergency.
  • There were some recording issues in relation to the length of time patients were spending in the health-based places of safety. Staff were not accurately recording the detention start time. It was not clear whether multidisciplinary reviews were always taking place during episodes of seclusion.
  • The pharmacy staffing levels were not always sufficient to make sure all aspects of medicines safety were covered, particularly in teams based in the community.
  • Some teams were not operating safely. For example, Ealing West Recovery Team had been identified as in need of support and plans were in place to strengthen the team. In the meantime, the waiting list was not being closely monitored and caseloads were unmanageable.

However:

  • The trust was working creatively to increase recruitment and retention. For example, it had commissioned an external organisation to conduct exit interviews to find out the real reasons for staff leaving and had made changes as a result. A workforce plan was closely monitored through a sub-committee of the board.
  • In services where restrictive interventions took place, the trust was working hard to reduce them. Many blanket restrictions had been lifted and, where they remained, staff and patients recognised them and understood why they were needed.
  • The trust achieved a high uptake of mandatory training. Staff could not access specialist training until they had completed all mandatory courses. Wards and teams with the highest rate of compliance were entered into a prize draw.
  • Lone-working procedures had been strengthened and new trackers had been introduced for staff working in the community and this improved staff safety.
  • The facilities for delivering primary healthcare services to forensic patients were excellent. The primary healthcare centre was fully equipped and included a dental surgery.

Effective

Good

Updated 21 December 2018

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

  • At this inspection we rated effective as outstanding in two of the services, good in four services and requires improvement in one service. When these ratings were combined with the other existing ratings from previous inspections, two of the trust services were rated outstanding, six were rated good and two required improvement.
  • Patients’ mental and physical health was assessed on or soon after admission or first appointment and care plans reflected the needs identified.
  • The trust made sure care and treatment was in line with national guidance and best practice. Patients had timely access to psychological therapies and other recommended therapeutic interventions.
  • The trust had made substantial progress in relation to screening and monitoring patients’ physical health. For example, they had introduced physical health clinics in their community-based mental health services for patients who found it difficult to engage with their GP services.
  • The trust worked hard to encourage patients to make healthy lifestyle choices. For example, a range of age-appropriate challenges and rewards were in place on the child and adolescent mental health unit.
  • The trust ensured that staff received an annual appraisal of their performance.
  • The trust made sure staff in the majority of services received regular supervision and many staff also participated in reflective practice sessions. In contrast, staff working on the rehabilitation wards and one of the older people’s wards did not receive supervision at the frequency outlined in the trust’s own policy.
  • The trust had electronic records systems in place which enabled relevant staff to access patient notes. Inpatient services could see what care and treatment patients had received from other trust teams prior to admission and community teams could access notes from inpatient stays.
  • The trust had strong multidisciplinary teams and members worked well together for the benefit of patients. There was evidence of close working with GPs and other agencies and information was shared appropriately.
  • Trust staff were, on the whole, very well informed about both the Mental Health Act and the Mental Capacity Act and, in relevant services, about issues of consent for children and young people. Good practice was underpinned by advice, support and training from experienced staff in the Mental Health Act office.

However:

  • There were inconsistencies between the two rehabilitation wards which meant patients on one ward received more educational and vocational opportunities and more focused recovery plans than patients on the other ward.

Caring

Outstanding

Updated 21 December 2018

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

  • At this inspection we rated caring as outstanding in two of the services and good in five services. When these ratings were combined with the other existing ratings from previous inspections, three of the trust services were rated outstanding and seven were rated good.
  • The trust promoted patient involvement at every opportunity. Patients were supported to get involved in service development and in decision-making about their own care and treatment. Staff at all levels worked in partnership with patients and, increasingly, carers. Patients were involved in staff recruitment.
  • Trust staff helped both patients and carers to understand mental health conditions and their treatment, through informal discussions, meetings and courses at the trust’s recovery college.
  • The trust paid peer support workers and service user consultants to assist them with quality improvement projects, to co-produce and co-deliver training and to become involved in many other projects. Patients told us this was inspirational and gave them hope for their own recovery.
  • The trust worked very effectively with an external organisation to get patient feedback on their services and to coproduce a range of events, publications and internal documents. They successfully engaged with both inpatients and patients in the community.
  • Trust staff treated patients with kindness, compassion and respect. There were many opportunities for patients to make their views known. For example, senior managers attended the monthly patients’ forum at Broadmoor and action plans were in place to address issues raised.
  • The trust held various carers meetings and, with patients’ consent, worked in partnership with carers to support recovery using a model called ‘triangle of care’. Both patients and carers were involved in a crisis care forum where they were encouraged to provide honest feedback on the support they had received during a mental health crisis.

Responsive

Good

Updated 21 December 2018

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

  • At this inspection we rated responsive as good in six of the services and requires improvement in one service. When these ratings were combined with the other existing ratings from previous inspections, seven of the trust services were rated good, two were rated requires improvement and one was rated inadequate.
  • In January 2018 we carried out a focused inspection of the acute wards and psychiatric intensive care unit that were inadequate for the responsive key question to see if they had improved. We did not re-rate the service as we only looked at specific issues, but we found that there had been significant improvements to the experience of patients using these services. Patients now had access to a bed when needed and most were being discharged in a timely manner. Patients who were admitted for acute care were no longer sleeping on non-acute wards. Bed occupancy on the acute wards was at 87% and patients were not placed in beds outside the trust unless they needed a specialist service not provided by the trust.
  • The trust had systems and resources in place to support good discharge planning. For example, discharge planning started at the point of referral in many of the services and the trust worked effectively in partnership with other organisations to make sure there were robust community options.
  • The trust had made it easy for people to contact the trust for help and support through the single point of access. Patients told us they could get help by phone when needed. The crisis assessment and treatment teams (CATTs) had recently extended their working hours and now provided a 24/7 service in response to patient need.
  • The trust provided patients with opportunities for education and vocational training tailored to their needs. The West London recovery college had moved to a new base in the community, but also operated a number of satellite sites and there was a recovery college at Broadmoor too. Many courses were co-designed and co-delivered with patients or carers.
  • The trust had an inclusive approach. For example, patients could identify staff who could be approached if they wanted to discuss issues related to sexuality and gender identity because they wore rainbow coloured lanyards. Patients in high secure services who wanted to support their peers in this way had piloted the use of rainbow wristbands. Following this successful initiative, the wristbands were due to be made available to other patients in February 2019.
  • The trust’s complaints procedure was widely publicised and complaints were responded to in line with the standards laid out in the trust’s policy. Any lessons learned were shared with the relevant team and, when appropriate, trust-wide.

However:

  • The recovery teams were not meeting the trust’s 28 day target to see the patient for their initial assessment from the day of their referral.

Well-led

Good

Updated 21 December 2018

Our rating of well-led improved. We rated it as good because:

  • There had been a sustained improvement in staff engagement and morale. Staff felt respected, valued and proud to work for the trust. Staff were willing to go the extra mile to meet the needs of patients and this work was being recognised and celebrated. This was reflected in the improved engagement scores for the previous two years in the staff survey and in the General Medical Council (GMC) survey where medical trainees were very positive about the support they received from the trust.
  • The chief executive was recognised as being an inspirational leader who had championed many of the improvements taking place. People internal and external to the trust said how much they respected the work she had led and the collaborative manner in which this had been done. Clinicians were now engaged in the work of the trust, for example, clinicians were leading on the development of trust strategies and in the development of information systems.
  • The culture of the trust had improved and was more open and transparent. Staff felt able to raise concerns without fear of retribution and had access to the Freedom to Speak Up Guardian where needed, although the numbers of staff accessing this support were quite low. The trust did not have a blame culture and positively supported staff to learn from when things went wrong.
  • Senior leaders were visible and approachable and recognised the importance of visiting services and speaking to people who use those services, their carers and staff. This was now central to the role of the leadership team. Other engagement took place including listening events, leadership blogs and an improved website and intranet.
  • The trust had a clear vision that was recognised and put into practice by staff throughout the organisation. Whilst work on the trust strategy was not yet complete, there was a clear sense of direction with a desire to provide integrated physical and mental health care services within their current geographical areas. This was reflected in the recent change to the name of the trust to make it clear that it was not just providing mental health services.
  • The trust was actively engaged in collaborative work with external partners, such as involvement with sustainability and transformation plans. The trust was working well with other stakeholders including regulators, commissioners, other providers and third sector organisations to improve services for people with physical and mental healthcare needs within the geography served by the trust.
  • Collaborative work with people who use services was integral to the operation of the trust. This led to a range of co-produced initiatives to enable patients to be actively involved in improving the delivery of care and promoting opportunities to enable people to develop skills and become more independent. For example, in the high secure, forensic and one rehabilitation ward people were accessing a wide range of educational and employment opportunities.
  • The trust was very clear about the risks they were facing and had management plans showing how these were being managed. These plans identified who had responsibility for the necessary actions and the assurance processes in place.
  • The trust was working to improve career progression and address discrimination for black minority ethnic (BME) staff. This included an award winning BME leadership development programme. The trust also had a visible and active LGBT+ network. It was recognised that there was more to do and that further networks, such as for staff with lived experience, were just getting started.
  • Staff had good access to a range of learning and development opportunities. For example, any staff in band 3 roles or above who aspired to or were already in leadership or management roles were supported to extend their skills and knowledge. The trust took full advantage of established schemes, such as Capital Nurse, to enhance opportunities for new or existing staff, as well as local initiatives, such as their ‘two hours to learn’ sessions.
  • The trust was making progress with their quality improvement programme and had set ambitious targets going forward. Staff across the trust felt engaged in this work.
  • The trust had invested in systems to manage information, particularly relating to patient care to provide staff at different levels of the organisation with the data they needed to deliver services and gain assurance. Further work was needed to develop the system and support staff to understand and make good use of the data.
  • The trust had a strong grip on its finances. An example of a sustained improvement had been the reduced use of paying for inpatient beds in the independent sector. This was because of the hard work undertaken to manage the flow of patients accessing services for acute mental health needs. This had also improved the quality of care for patients as they received their treatment locally and did not need to move between services.

However:

  • There were several areas where work had started but further improvements were needed. This included ensuring all staff had regular supervision; implementing staff networks especially for people with lived experience, completing the implementation work on the accessible information standards, improving the systems to manage serious incidents so they are addressed in a timely manner, ensuring service lines were effectively providing assurance, delivering high quality training for Mental Health Act hospital managers, ensuring maintenance and IT issues are addressed in a timely manner and staff were kept informed of progress. In all these cases the trust was aware of the issue and was actively working to make the necessary improvements.
Checks on specific services

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.

Child and adolescent mental health wards

Good

Updated 21 December 2018

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

  • The care and treatment provided was in line with national guidance for children and young people. The unit had adopted a therapeutic model of care, the “wellness and recovery action plan” (WRAP), and staff had received training to deliver it. A range of therapy and was available for all patients.
  • Staff were skilled in helping distressed patients to calm down and there had been few incidents of restraint. When restraint did occur, the standard of recording had improved. Any incidents were analysed and learning from them was shared with the staff team.
  • The premises were safe, secure, clean and well-maintained. The environment was regularly checked.
  • Risks for individual patients and the environment were discussed, documented and managed. Staff were aware of them.
  • Most staff had attended most mandatory training sessions, including training on the Mental Capacity Act and consent for under 18s. This was an improvement since our last inspection.
  • Medicines were managed in line with best practice.
  • Patients’ mental and physical health was assessed and monitored. Staff knew how to identify improvement and deterioration using appropriate tools.
  • Patients were encouraged and supported to make healthy lifestyle choices using challenges and reward schemes. Patients had access to equipment that encouraged activity, such as an outdoor sports pitch, gym and table tennis table.
  • Staff were supported in their roles through supervision meetings, annual appraisals, regular reflective practice discussions and training and development opportunities. Staff told us their morale was good.
  • Patients said staff treated them well and they and their families or carers were routinely involved in meetings to discuss their care plans. They also had opportunities to give their feedback about the unit and carers could attend the trust’s quarterly carers meetings.
  • A buddy system was in place so existing patients supported new patients to get used to the unit.
  • Admissions and discharges were well planned and discharge planning started immediately to minimise the risk of delay.
  • Staff were responsive to individuals’ needs and care plans took account of patients’ cultural, religious and social needs. Staff knew how to access interpreters and materials in a range of languages if needed. When appropriate patients were supported to attend activities in the community.
  • There had been two formal complaints about the service and information about how to complain was on display and staff knew what to do on receipt of a complaint.
  • Senior managers were visible and supported quality improvements. The unit regularly audited some aspects of its work and was participating in a national quality scheme.

However:

  • The seclusion room did not fully protect patients’ privacy and dignity.
  • Meals were not always served at the recommended temperatures.
  • Patients were not enthusiastic about the main meals provided.

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.

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.

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.

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.

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

Updated 28 February 2018

We did not re-rate this service.

While good progress had been made in some key areas, we found the following areas that the service needs to improve:

  • Some maintenance work in the wards had not been carried out in a timely fashion and some faulty equipment had not been reviewed. There was no system in place at the Hammersmith and Fulham site to identify recurring faults so they could be properly addressed.

  • The trust had started environmental work across the wards to address ligature risks and blind spots. However, there was further work outstanding to mitigate a few remaining blind spots and the ligature action plans, while comprehensive, were not always clear about the timescales for this work.

  • There were high vacancy rates for nurses at the St Bernard’s site.

  • While some wards had been reconfigured to reduce the incidence of female patients being secluded on male wards, this work needed to continue. The trust was not able to provide us with accurate data relating to numbers of incidents of seclusion.

  • There were gaps in the data supplied to ward managers to help them monitor their ward. In particular, there was a risk that the information they received about incidents of seclusion was not comprehensive. This potentially limited their ability to identify any themes and could prevent them from responding appropriately.

  • Some incidents, which should have been reported through the trust reporting system, had not been reported which meant that data provided about the quality of service was sometimes incomplete.

  • There was no evidence in the service’s risk registers or the minutes of clinical governance meetings that the data accuracy or the lack of incident reporting had been identified or was in the process of being addressed.

  • While most staff had a good understanding of safeguarding and their responsibilities to patients at risk on the ward, some staff did not follow the trust’s safeguarding policy which required them to record the reason behind any decision to not refer concerns about a patient to the local authority.

However, we found the following areas of good practice:

  • The trust had undertaken considerable work to better manage patient flow. This had resolved the issue of patients receiving care on one ward while sleeping on another ward because no beds were available where they were receiving treatment.

  • Permanent and contracted agency members of staff were receiving supervision regularly. Staff across the service told us that they felt supported by their managers and that they were able to raise concerns.

  • Patients had up to date risk assessments and care plans.

  • Records showed physical health screening was carried out regularly with follow up intervention when required.

  • The service had started to undertake some quality improvement projects. Members of staff were positive about this.

  • The divisional management and local service managers had a good understanding of the acute and PICU services and knew about key risk areas in the services they managed. While work on some areas of risk or concern was not complete, most of the issues we found had been identified internally and work was planned.

  • Although there were gaps, ward managers had access to improved information about the ward to support them to manage the service.

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.

Specialist community mental health services for children and young people

Requires improvement

Updated 9 February 2017

We rated specialist community mental health services for children and young people as requires improvement because:

  • The staff working in the teams were not all having the opportunity to hear about and learn from incidents which had occurred across the service.
  • Some clinical equipment was not being regularly checked to ensure it was working accurately.
  • Some of the clinic environments were not meeting the needs of young people and staff, for example they did not have sufficient rooms for appointments or provide reliable disabled access. Sessions were disturbed by alarms ringing and lights going on and off.
  • Whilst many staff said they had good morale a smaller number did not feel so positive and further work was needed to improve staff engagement.
  • Team managers did not have access to timely and accurate management information to support their role.
  • There were several different paper and electronic patient records and information was not always stored consistently.
  • There were long waiting times for the neurodevelopmental service although it was acknowledged that this was linked to how the service was commissioned.
  • Young people sometimes experienced long waits for accessing specific psychological therapies.

However:

  • Staff could access advice from psychiatrists and see urgent referrals quickly. They assessed risks regularly, used effective crisis plans, knew how to make safeguarding referrals and managed medicines appropriately.
  • Staff planned and provided personalised and holistic care. Young people could access a range of evidence-based therapies and fed back about their experiences positively.
  • Staff reported good working links with external services.
  • At the last inspection we recommended that staff ensure rooms were soundproofed. The trust had completed this work.

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.