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Provider: West London NHS Trust Good

Reports


Inspection carried out on 8th to 9th August, 17th September, 18th to 19th September, 18th to 20th September, 25th to 27th September, 15th October 2018

During a routine inspection

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.


CQC inspections of services

Service reports published 21 December 2018
Inspection carried out on 8th to 9th August, 17th September, 18th to 19th September, 18th to 20th September, 25th to 27th September, 15th October 2018 During an inspection of Child and adolescent mental health wards Download report PDF | 571.64 KB (opens in a new tab)Download report PDF | 1.85 MB (opens in a new tab)
Inspection carried out on 8th to 9th August, 17th September, 18th to 19th September, 18th to 20th September, 25th to 27th September, 15th October 2018 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 571.64 KB (opens in a new tab)Download report PDF | 1.85 MB (opens in a new tab)
Inspection carried out on 8th to 9th August, 17th September, 18th to 19th September, 18th to 20th September, 25th to 27th September, 15th October 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 571.64 KB (opens in a new tab)Download report PDF | 1.85 MB (opens in a new tab)
Inspection carried out on 8th to 9th August, 17th September, 18th to 19th September, 18th to 20th September, 25th to 27th September, 15th October 2018 During an inspection of Forensic inpatient or secure wards Download report PDF | 571.64 KB (opens in a new tab)Download report PDF | 1.85 MB (opens in a new tab)
Inspection carried out on 8th to 9th August, 17th September, 18th to 19th September, 18th to 20th September, 25th to 27th September, 15th October 2018 During an inspection of Community-based mental health services for adults of working age Download report PDF | 571.64 KB (opens in a new tab)Download report PDF | 1.85 MB (opens in a new tab)
Inspection carried out on 8th to 9th August, 17th September, 18th to 19th September, 18th to 20th September, 25th to 27th September, 15th October 2018 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 571.64 KB (opens in a new tab)Download report PDF | 1.85 MB (opens in a new tab)
See more service reports published 21 December 2018
Service reports published 3 August 2018
Inspection carried out on 4 June 2018 - 8 June 2018 During an inspection of High secure hospitals Download report PDF | 506.6 KB (opens in a new tab)
Service reports published 28 February 2018
Inspection carried out on 9-11 January 2018 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 306.64 KB (opens in a new tab)
Service reports published 22 September 2017
Inspection carried out on 26 and 27 July 2017 During an inspection of Other specialist services Download report PDF | 239.17 KB (opens in a new tab)
Service reports published 9 February 2017
Inspection carried out on 7 – 10 November 2016 During an inspection of Community-based mental health services for adults of working age Download report PDF | 366.91 KB (opens in a new tab)
Inspection carried out on 8 & 16 November 2016 During an inspection of Child and adolescent mental health wards Download report PDF | 314.39 KB (opens in a new tab)
Inspection carried out on 8 -10 November 2016 During an inspection of Community-based mental health services for older people Download report PDF | 316.12 KB (opens in a new tab)
Inspection carried out on 8 - 11 November and 17 and 18 November 2016 During an inspection of Other specialist services Download report PDF | 394.43 KB (opens in a new tab)
Inspection carried out on 7 - 10 November 2016 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 374.3 KB (opens in a new tab)
Inspection carried out on 7-11 November 2016 During an inspection of Specialist community mental health services for children and young people Download report PDF | 299.67 KB (opens in a new tab)
Inspection carried out on 7-11 November 2016 During an inspection of Forensic inpatient or secure wards Download report PDF | 493.86 KB (opens in a new tab)
Inspection carried out on 7-11 November 2016 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 455.96 KB (opens in a new tab)
Inspection carried out on 7 – 11 November 2016 During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 347.61 KB (opens in a new tab)
Inspection carried out on 8 – 10 November 2016 During an inspection of Wards for older people with mental health problems Download report PDF | 357.43 KB (opens in a new tab)
Inspection carried out on 7 November 2016 During an inspection of Community health inpatient services Download report PDF | 289.35 KB (opens in a new tab)
See more service reports published 9 February 2017
Service reports published 29 September 2016
Inspection carried out on 16th - 18th August 2016 During an inspection of Forensic inpatient or secure wards Download report PDF | 347.47 KB (opens in a new tab)
Service reports published 9 May 2016
Inspection carried out on 19 and 20 January 2016 During an inspection of Other specialist services Download report PDF | 273 KB (opens in a new tab)
Service reports published 16 September 2015
Inspection carried out on 8th – 11th June 2015 During an inspection of Forensic inpatient or secure wards Download report PDF | 536.7 KB (opens in a new tab)
Inspection carried out on 8-12 June 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 348.35 KB (opens in a new tab)
Inspection carried out on 8 - 12 July During an inspection of Long stay or rehabilitation mental health wards for working age adults Download report PDF | 299.44 KB (opens in a new tab)
Inspection carried out on 8 – 12 June 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 438.5 KB (opens in a new tab)
Inspection carried out on 9 June 2014 During an inspection of Child and adolescent mental health wards Download report PDF | 280.03 KB (opens in a new tab)
Inspection carried out on 09 -12 June 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF | 392.6 KB (opens in a new tab)
Inspection carried out on 8-12 June 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF | 265.58 KB (opens in a new tab)
Inspection carried out on 8 - 12 June 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 327.2 KB (opens in a new tab)
Inspection carried out on 9-12 June 2015 During an inspection of Community-based mental health services for older people Download report PDF | 297.54 KB (opens in a new tab)
See more service reports published 16 September 2015
Inspection carried out on 7 - 11 November 2016

During a routine inspection

We have rated West London Mental Health NHS Trust as requires improvement overall:

We have rated nine of the eleven core services that we inspected as requires improvement and the other two as good.

The trust requires improvement for the safe; effective; responsive and well led key questions. We have rated the trust as good for the caring key question.

The inspection took place at a time when the trust was going through considerable strategic change. They were in the process of transforming their adult inpatient services to reduce the number of people needing inpatient beds. This involved increasing services in the community. Since the previous inspection the trust had created a single point of access, enhanced assessment and treatment teams and a new primary care mental health service.

The trust was also working to improve existing care and the processes that support this. We were able to see many areas of improvement however, there was more to do and the changes needed to be embedded and sustained.

The main areas for ongoing improvement were as follows:

  • The trust continued to have a problem with staff recruitment and retention. Since the last inspection recruitment had improved but many new staff were leaving within a year. This was having an impact on the care received by patients. The most significant concern was in the high secure services where access to therapeutic activities and time with staff and other patients was restricted. This was an ongoing concern from the previous inspection and as a consequence a warning notice was served.

  • The trust had made improvements in the assessment, monitoring and treatment of patients’ physical health. This had been implemented well in some areas but in others still needed to improve. For patients cared for in the community, trust staff did not always establish effective working links with GPs and other professionals providing support with the person’s physical health care.

  • The trust was not always able to provide a bed on an acute ward for patients who had a clinical need for this service. This meant that at times, patients on the acute ward were being asked to sleep on a rehabilitation ward. This was disruptive for people’s care and potentially unsafe.
  • Some inpatient environments where patients received care were of a poor standard. Since the last inspection, the new Three Bridges medium secure unit had opened which had improved the care for patients. However, for other patients especially on the St Bernards site being accommodated in the Wolsey and Tony Hillis Wings, despite some building improvements, their privacy and dignity was impacted by the poor inpatient environments.
  • The trust had made changes to the governance processes but more was needed. This was to ensure that from board to ward the correct information was available in an appropriate format to support assurance processes and management. Where there were potential risks identified, clear actions needed to be in place and timescales for improvements to be made.

The trust had made progress in many areas since the previous inspection.

Four areas stood out as being very positive:

  • We found that staff morale was greatly improved. Staff talked about how the culture of the organisation had changed and most people felt this was now much more open. The area where this change was most notable was in the West London forensic services. There were still some pockets where further work was needed.

  • Blanket restrictions had been reviewed, involving staff and patients. This had looked at ‘rules’ that had been in place and whether they were needed for everyone in the service or just based on individual patient need. This had led to a large number of restrictions being reviewed and where appropriate reduced.
  • More incidents were being reported and the trust had promoted a culture where staff understood the importance of doing this. A new online reporting system had been introduced. The trust had also carried out its own review of patient deaths following the Mazars report and had an ongoing process for reviewing all deaths.
  • Work with other agencies and partners had progressed. The trust was working closely with commissioners. The new single point of access was working with GPs and hospital doctors, the police and paramedics, prison staff and members of the public as well as others.

There had been a number of changes in the leadership of the trust. The new chief executive was received positively across the trust. The senior leadership team at the time of the inspection was capable and had the potential to make the necessary improvements, although there was a great deal to be done.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

Inspection carried out on 8-12 June 2015

During a routine inspection

We have given an overall rating to West London Mental Health NHS Trust of requires improvement.

We have rated one of the nine core services that we inspected as inadequate, three as requires improvement and the other five as good. The services that were inadequate are the forensic and high secure services. The services that require improvement are the acute admission wards for adults, the community based mental health services (mainly the community recovery teams) and the crisis services. The latter include the home treatment teams and health based places of safety.

The forensic core service report covers both the high secure services at Broadmoor and the West London forensic services. We were most concerned about the West London forensic services.

At the start of the inspection, the chief executive of the trust gave a presentation about the areas they were proud of and the challenges faced by the trust. Our inspection findings reflect the priorities identified by the trust. This demonstrates that the senior trust managers had identified many of the problems that they needed to address. However, we believe that our inspection identified that the scale and speed of change that was needed was very significant. They must address these as a matter of urgency.

The three main areas for improvement were as follows:

  • The trust had a substantial problem with staff recruitment and retention. There were too few staff to consistently guarantee safety and quality in the forensic services, high secure services and community based mental health teams (mainly the community recovery teams). There were staffing problems in some other areas but these are not as severe.
  • The trust had a problem with low morale and poor engagement with front-line staff in some of its services. This particularly affected those in working in the forensic services. Poor morale can adversely affect the quality of care and make staff reluctant to show openness, transparency and honesty that are essential to safe care.
  • The trust must improve its practices in relation to restrictive interventions such as the use of restraint and seclusion. They have started to tackle this problem but there is much more to be done. The problem is most serious in the forensic, high secure, adult admission and older peoples’ wards. The trust must ensure that its seclusion rooms meet the required standards, that staff use restraint only as a last resort, that they minimise the use of restraint in the prone position, that they accurately document and record the use of restrictive interventions and that they make the necessary physical health observations after a patient has been given an injection to manage disturbed or distressed behaviour

Despite these problems there was much for the trust to be proud of. The problem of low morale was not endemic. In many services that we visited, staff were very positive about the work of the trust and in most places care was delivered by hard working, caring and compassionate staff. This was particularly noted at Broadmoor where staff showed a real concern for patients on an individual basis and a desire to see them progress towards recovery.

Three other areas stood out as being very positive.

  • The trust actively encouraged the personal development of its staff. It supported them in this and enabled them to access training and other development opportunities. We heard of many examples where staff had been able to extend their skills and develop their career within the trust and as a result provide better care to patients.
  • The trust was making real strides with user and carer engagement. An example of this was the support it offered to the West London Collaborative. We also found many examples across the services where staff involved people in their care and in the wider service.
  • The trust worked closely with statutory and voluntary sector partners to improve mental healthcare in the wider community. For example it had worked with the police to better support people in a crisis. This had resulted in the police not having to take a single person detained under section 136 to a police cell for over a year.

The trust was developing a strong leadership team which had good insight into the challenges they faced and were working to create a more open and positive culture within the organisation. The management restructure into two clinical services units was leading to clearer accountability. The trust was improving the quality of its integrated performance report which it used to monitor the quality and safety of its services. The recent introduction of clinical improvement groups for each ward and team was leading to better sharing of information.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Organisation Review of Compliance


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.


Other types of report

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.