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Provider: Central and North West London NHS Foundation Trust Good

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Good

Updated 4 June 2019

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

  • On this occasion, we inspected five key questions for three core services; a total of fifteen key questions. The rating improved for three key questions and worsened for one - from good to requires improvement. This meant that the overall pattern of ratings for the whole trust remained broadly the same. When these ratings were combined with the previous ratings from services not inspected this time, 15 core services are rated as good and two as outstanding.

  • We rated the trust as good for well-led. The trust had a highly experienced, skilled and respected executive leadership team. They were inspiring, committed and continuously challenged themselves to improve services to meet the needs of patients.

  • The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to provide high quality care to their local communities and those in receipt of specialist services.

  • The trust had a strong, cohesive senior leadership team which had instilled a positive ‘can-do’ culture within the organisation. Senior leaders expected high standards of themselves and their colleagues, but most staff regarded them as kind and supportive when teams and individuals were facing challenges. The depth of knowledge held by senior leaders about each service and the people running them was phenomenal given the size of the trust.

  • The divisional structure and borough-based working for local services were fully embedded and there was evidence of strong partnership working, with good foundations to increase this much further. The trust was participating effectively in local care systems and with NHS partners to drive progress and develop new models of care, such as integrated community health services in Hillingdon.

  • The board had good oversight of operational issues across all divisions. The governance processes were robust and ensured that both achievements and concerns were escalated appropriately. Problem areas had largely been identified before we brought them up and work was, for the most part, underway to resolve matters. The trust was very responsive and took steps to increase the pace of improvement and the support available following our feedback.

  • The trust had a strong grip on its finances. It was on target to achieve its control target for 2018 -19. Its spending on agency staff had significantly reduced and it was working to drive it down further.
  • The trust was fully committed to working in partnership with patients and, increasingly, carers. There were many excellent examples of patient and carer involvement at many levels within the organisation, including well established peer support workers.

  • 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. For example, the roll out of the safer leave project for both detained and informal patients on the mental health wards. The trust was just short of its target of 95% compliance with statutory and mandatory training, averaging 93% which was high for a trust of this size.

  • The trust had worked creatively to meet emerging needs. A large-scale example was their response to the Grenfell tragedy where they, alongside many partners, were seeking to try to meet mental health needs that had been triggered, or exacerbated, by the trauma. On a smaller scale, the Campbell Centre at Milton Keynes had developed a social recovery team to focus on resolving practical issues for patients which delayed discharge.

  • The trust was making good progress with their quality improvement (QI) work, and despite this approach only being used in practice for about 18 months, it was becoming established across the trust. The trust had received an award from the South of England QI collaborative for building capability and capacity. During the inspection many of the staff we met spoke about their involvement in QI projects. At the time of the well-led review there were 276 active projects and 32 completed projects. The trust had a QI microsite which was accessible on the trusts website. This live site enabled staff to access resources, sign up for training events and record progress with their own project. This enabled services to identify similar projects and learn from each other. The trust was working with patients and carers and they were actively involved in 26% of the projects.

  • All staff we spoke with acknowledged they were provided with good learning and development opportunities and, through the trust’s recovery and wellbeing college, patients who used mental health services and their carers benefited from access to a wide range of courses. Trust mental health staff and staff working in partnership with them could also access these courses. The trust had invested in the development of leadership skills and we noted the competency and confidence of most leaders at all levels of the organisation.

  • The trust was making good progress with promoting equality diversity and human rights throughout the organisation. They had stated a commitment to becoming one of the most inclusive employers in the NHS by 2020. The trust had three well-established staff networks in place to support staff and to promote equality and diversity; the Black, Asian and minority ethnic staff network, the disability equality network and the lesbian, gay, bisexual and transgender staff network. Stonewall ranked the trust equal 28th in its list of top employers for 2019 (only five healthcare employers were in the top 100).

  • The trust had developed robust and innovative ways of managing its estate of 150 sites in ways that were just starting to benefit staff, patients and its finances. With the exception of one site, where there were ongoing negotiations with commissioners, the trust had plans in place to eliminate all its dormitory bedroom accommodation.

  • The trust transferred most of its services to a new electronic patient record system during our inspection; possibly the biggest migration of its kind in the UK. Technically, it went well, although staff were still in the process of getting used to it and some areas needed more time and support than originally envisaged. The new system will enhance joined up work with primary care services.

  • Trust staff had access to a full range of accurate and clearly displayed data relevant to their work which could be viewed at numerous levels from trust-wide to individual team or ward. Clinicians were involved in digital developments to ensure they complemented clinical work.

  • The trust’s communications strategy was working extremely well and staff commented favourably about the high quality of communications and the relative ease of finding information, when needed, on the trust’s intranet site.

  • The trust’s public website had been developed with the needs of people with communication difficulties in mind with links to a growing library of easy-read information on every page. The intranet and microsites were developed to make it as easy as possible for staff to adjust the information to their needs in terms of colour and font.

However:

  • Our inspection did identify wards and teams where improvements were needed. The trust was already aware of where services were facing challenges and was providing additional leadership and support.

  • The inspection did find that some of the improvements recommended at the previous inspection had not taken place. This included ensuring patients on the wards for older people had access to specialist staff such as a dietician when needed, or that information was put into accessible formats for patients with dementia or other cognitive impairments.

  • Recruitment and retention of staff remained challenging for the trust; and they were working creatively to address this within the context of national shortages. Despite the use of temporary staff where needed, some teams were struggling to deliver consistently high-quality care.

  • Some staff were not receiving supervision at the frequency required by the trust’s own policy and neither this, nor the quality, was monitored in a systematic way by managers, unless individuals had set up their own systems. This had also been identified as an area for improvement at the previous inspection. During the inspection the trust was piloting an online system to address this, but this would need to be embedded.

 

Inspection areas

Safe

Good

Updated 4 June 2019

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

  • At this inspection we rated safe as good in two of the services and requires improvement in one. When these ratings were combined with the other existing ratings from previous inspections, 15 of the trust services were rated good and two rated requires improvement.

  • The trust was working creatively to improve staff recruitment and retention. Offender care and learning disabilities services were particularly challenged by vacancies and there was targeted work to recruit to these posts. The trust was working with ten universities to support clinical training, including placements within the trust, in an effort to attract newly qualified staff. Schemes, such as Capital Nurse and preceptorships were in place. Retention and engagement events were held for existing staff and an internal transfer system had been established to make it easier for staff to move between different roles in the trust. In February 2019, the trust vacancy rate average for the calendar year was 13.91% against a target of 12%. Turnover rate average for the calendar year was 16.2% against a target of 15%.

  • The trust was committed to improving its premises to enhance patient safety. This involved eliminating dormitories and creating ensuite bathrooms. To facilitate this programme, the trust had already commenced a reduction of beds to improve safety.

  • The trust had well established workstreams set up to improve the sexual safety of patients and staff on mental health inpatient wards and had participated in CQC’s review of this topic. They were revising how sexual safety incidents were reported including the grading of harm; developing a training package; using a sexual safety leaflet commended nationally; continuing to work to improve the safety of the environment; ensuring sexual safety incidents affecting staff are reported to HR.

  • The trust was committed to reducing restrictive interventions. It had adopted a ‘zero tolerance’ approach to prone restraint in January 2018 and by September 2018 it had achieved a 50% reduction. When prone restraint was used, 94% of incidents lasted less than four minutes. Previously the trust was an outlier for the use of prone restraint, but recent data showed it was now within the middle 50%. All restraints were monitored by the trust’s restrictive interventions group and trends were recorded and benchmarked within the trust and against national data. Data analysis showed that the trust’s use of restraint for adult acute wards, psychiatric intensive care units and older adults’ wards was approaching the best 25% nationally. Restraint and de-escalation training was co-produced and co-delivered. Two full-time peer support workers were working within the team that provided training in the therapeutic management of violence and aggression.

  • The use of seclusion was also monitored. Between 39-63 episodes of seclusion per month had been recorded within the trust over the period April 2018 to January 2019. Child and adolescent mental health inpatient services do not contain seclusion rooms, but the external door could be locked to maintain safety. When this happened, it was recorded as seclusion and in January 2019 six seclusions took place in this service.

  • The trust learnt from serious incidents. Following an increase in deaths on the rail line in Milton Keynes, the trust worked as part of a multiagency ‘gold group’ lead by the British Transport Police and Network Rail. This included work to train all platform staff in suicide prevention. Improved information sharing about ‘near misses’ has benefitted patient care and there have been fewer incidents at the station.

  • The trust incident reporting system was designed to automatically feedback progress to incident reporters. This complemented local arrangements to support and de-brief staff when an incident occurred. Staff were well-informed about incidents within their own services and significant incidents elsewhere in the trust. However, there was still scope to improve the sharing of good practice and learning from incidents between similar teams across different geographical areas.

  • The trust had made good progress in ensuring staff received statutory and mandatory training, averaging a 93% completion rate.

  • Medicines optimisation within the trust was good, and effectively integrated into trust governance arrangements. The chief pharmacist post was filled on an interim basis with a plan to fill the substantive post by August 2019. The pharmacy team provided leadership for medicine optimisation and included a medicine safety officer (MSO) post who reviewed all medicine related incidents. However, electronic prescribing and medicines administration (EPMA) was only available within offender care and addictions services. Planned changes to the trust’s digital infrastructure made it more feasible to implement it more widely. A business case had been developed for extending EPMA to inpatient settings and the trust intended to submit its bid before November 2019 for funding in 2020/21.

However:

  • While most wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose, a few were not. Bedrooms on two wards at the Gordon Hospital were too small for safe use by patients in distress. Also at the Gordon Hospital, rooms designed to offer flexible accommodation for male or female patients were breaching guidance to eliminate mixed gender accommodation. Pond Ward at Park Royal was not clean. By the end of the inspection the trust had addressed all these matters and where needed taken rooms out of use.

  • Whilst the trust was working to recruit and retain staff and most wards had safe staffing levels, a few wards were struggling to maintain safe staffing. Some wards did not have enough medical cover and some nursing staff told us they felt unsafe at night, especially when they had to attend to patient admissions as well as those already on the ward. We also heard from staff who said that patient leave was sometimes cancelled or that they could not leave the ward to attend training.

  • With the exception of the Campbell Centre where there were call bells, patients did not have access to a means of calling for urgent assistance from staff.

  • Whilst systems were in place to support staff to be safe while working on their own, some staff in community teams were not yet using these systems.

Effective

Good

Updated 4 June 2019

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

  • At this inspection we rated effective as good in two of the 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, 14 were rated good and one requires improvement.
  • In the core services inspected, assessment and monitoring of patients’ physical health, including after rapid tranquillisation, had improved and robust processes were in place to make sure patients’ mental and physical health needs were met. The new electronic patient record system matched the one used by GPs in some boroughs so this would make blood test results and similar more accessible to relevant trust staff. In addition, the new system included a physical health tab that, if used correctly by staff, will make the trust better able to produce reports on this topic and monitor performance. Patients were supported to make healthy lifestyle choices.
  • The trust offered patients care and treatment in line with national guidance and best practice. Managers and senior clinicians were fully aware of the guidance applicable to their area and senior leaders were often involved in developing it at national level so were exceptionally well informed. Staff told us they could rely on getting up-to-date information from the trust to guide their practice.
  • The trust enabled staff to develop their skills and experience to undertake their roles. Staff could access continuing professional development and all staff focus groups commented positively on this. Staff could apply for courses and training linked to their personal development plan. The trust monitored the percentage of staff with an in-date appraisal and this had averaged at 91% across the year. This information was available for teams.
  • We found examples of effective multidisciplinary teams in many of the services we visited. There was a strong focus on discharge planning in conjunction with community colleagues; the Campbell Centre at Milton Keynes was particularly strong in both regards.
  • Relevant staff had easy access to patient records and this was set to improve with the new electronic patient records system, as, in some boroughs, GPs used the same system. This meant, for example, it was easy to check patients’ prescribed medicines on admission.
  • Staff met their legal responsibilities in relation to the Mental Health Act 1983 and Mental Capacity Act 2005. However, some areas for improvement were identified in a few services.

However:

  • The trust had not been monitoring whether staff received regular supervision. The inspection found that whilst most staff were satisfied with the quality of the supervision they received, there were teams where regular supervision was not delivered. The trust addressed this immediately and purchased a system to pilot supervisions being completed recorded on-line.
  • Not all wards for older people with mental health needs had timely access to specialists. For example, on Kershaw and Redwood wards staff had not had access to a dietician since November 2018. Arrangements were put into place by the trust immediately after the inspection. Some wards experienced delays of several weeks when referring patient for input from a physiotherapist or speech and language therapist.
  • On the wards for older people with mental health problems not all staff had received training in dementia. Many of the patients had dementia or a cognitive impairment. Following our inspection, the trust arranged for relevant staff to complete dementia care e-learning by 29 March 2019.
  • The trust had some good practice in falls prevention such as non-slip socks, access to falls mats and adjustable bed heights. On the wards for older people with mental health problems there had only been one serious incident reported in a year attributable to a fall. However, a few patients across a number of wards did not have a completed falls risk assessment on admission, which was not in line with the trust’s policy for prevention and management of falls. For one patient, staff only filled out a falls risk assessment following a fall on the ward.

Caring

Outstanding

Updated 4 June 2019

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

  • At this inspection we rated caring as good in all three of the services. When these ratings were combined with the other existing ratings from previous inspections, three of the trust services were rated outstanding and 14 were rated good.
  • In quarter three of the financial year, 92% of people completing the Friends and Family Test said that they would be likely or extremely likely to recommend CNWL services. This was the same proportion as in quarters one and two. The overall satisfaction rate across year to date was 95% for community services and 88% for mental health. This is broadly in line with the national average for similar trusts.
  • The trust had an active patient involvement forum and carers’ council. Both groups were involved in developing the trust-wide patient and carer involvement strategy and action plan. There were many opportunities for patients and carers to make their views known at every level of the service. The trust and divisional boards discussed all formal feedback received, as well as any informal feedback from patients and carers gleaned during board visits to services.
  • The trust’s wellbeing and recovery college offered a wide range of courses and workshops which are co-designed and co-delivered by peer recovery trainers (people with lived experience of mental health issues) and mental health practitioners. Patients of mental health services and their carers, as well as staff, had access to these sessions, which covered topics such as understanding self-harm, a good night’s sleep and exploring what works for me.
  • The trust could provide many examples of working in an inclusive way with patients. For example, offender care had recruited thirteen patient experience leads to enhance patient involvement with a group that could be hard to engage. Patients, carers and staff had worked together to co-produce more dementia-friendly environments on wards for older people. Carers had been involved in putting on a carers conference together with the trust.
  • We saw many examples of kindness, compassion and respect in action during the inspection. The desire of the trust and divisional boards to do their best for patients was evident at every meeting we attended. When talking about any aspect of the work of the trust senior leaders, as well as the majority of staff, never lost sight of the individual patient experience; it was what motivated them.

However:

  • The annual national community mental health survey saw a slight decrease in the performance of the trust and this was the case for many trusts. The trust had put together an action plan in response with a focus on overall experience of care, patient contact time, dignity and respect, more help with physical health, financial and employment needs.
  • Sometimes, at ward level, staff were too slow to feedback to patients about what was being done in respect of any concerns they raised at community meetings.

Responsive

Good

Updated 4 June 2019

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

  • At this inspection we rated responsive as good in all three of the services. When these ratings were combined with the other existing ratings from previous inspections, two of the trust services were rated outstanding, 13 good and two were rated requires improvement.
  • Whilst the trust still experienced spikes in activity and pressure on beds, patient flow reported improvement with acute mental health beds for adults at 95% occupancy. Out of area placements increased slightly in month 10, but was still below the set target.
  • The trust had established a 24/7 single point of access to most of its mental health services and was achieving set access targets in many areas; including early intervention in psychosis and, in community healthcare, district nursing. Urgent access targets for mental health were also consistently achieved, but meeting access times for routine mental health services was more challenging, with only 77% achieving the threshold in month 10, against a target of 95%. We saw that the trust examined performance against the targets each month during its quality and performance committee and challenged managers to explain any breaches.
  • On acute mental health wards, where there was particular pressure on beds, the trust had adopted the ‘red to green’ system which endeavoured to make every day of a hospital admission productive and a step towards recovery and discharge. The trust was committed to helping patients to find and sustain employment and had established an employment service to this end.
  • The trust worked with people from diverse communities, with over 100 languages spoken in the areas it covers. Most staff were well-informed and sensitive to the needs of people from different communities. The trust supported its staff to do this by providing them with relevant policies and training. For example, it had recently revised its compassionate care after death policy to provide staff with guidance about the customs of different faiths.
  • The trust had an equality, diversity and inclusion strategy (EDI). Since our last inspection the trust had developed an EDI steering group to oversee the EDI aspects of workforce and service delivery matters. The steering group met quarterly and reported to the trust board through the Quality and Performance committee. The trust was particularly strong in supporting both staff and patients who were lesbian, gay, bisexual or transgender (LGBT+). The trust was supplying healthcare to a transgender unit within a prison and some of the wards had also developed expertise in this area of work.
  • Concerns and complaints were treated seriously, investigated and lessons learned from the results. Complaint responses were detailed, personalised and described the actions that the trust were taking. The trust offered contact details of staff in the event that the complainant wished to discuss the findings or required further support. The trust responded to 98 - 100% of complaints within the timescales laid out in their complaints policy in the first half of 2018-19. They had identified that concerns, complaints and negative comments tended to be about long waiting times for accessing services, lack of communication and information from staff or lack of support and communication from care coordinators.

However:

  • Although urgent referrals were flagged and given priority, some teams were not meeting the trust targets to assess people, whose referral was less urgent, in a timely manner. The target times set by the trust were 28 days for the referral to assessment for the community mental health teams and 14 days for the early intervention services. The median waiting times for the 6 months up to December 2018 were 42 days for the Hillingdon East and West community team and 38 days for the Milton Keynes assertive outreach team. Other teams met or nearly met the target. The teams kept in contact with patients while they were waiting to be assessed.

  • At the last inspection on the wards for older people with mental health problems, information which was provided was not routinely available in an accessible format for patients with dementia or cognitive impairment. For example, information on notice boards, leaflets, activity schedules and menus. At this inspection, some progress had been made, but there was still room for improvement.

Well-led

Good

Updated 4 June 2019

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

  • The trust had a highly experienced, skilled and respected executive leadership team. They were inspiring, committed and continuously challenged themselves to improve services to meet the needs of patients. Internal staff and external stakeholders commented positively on the leadership of the trust. Most of the executive leadership team had been in their posts for ten years or more which had provided considerable stability during a period where the trust had grown and managed considerable change. At the time of the inspection two of the executive directors had announced their retirement. Their succession had been carefully planned.
  • Leaders promoted a culture within the trust which was open, honest and responsive. This was reflected in how the trust managed the many challenging situations they faced. At all levels of the organisation they spoke openly about where improvements were needed and how they would be addressed. An example of this was in relation to safeguarding concerns at one of the inpatient sites where action was taken to ensure patients were safe and additional leadership input was provided to support the necessary improvements.
  • The trust board demonstrated a commitment to ensuring that people who use services and their families received the best care and treatment possible. The trust board gained insight into the challenges of delivering services through being linked to a division of the trust and board visits. Some clinically trained executive directors occasionally worked alongside staff within services to get a grass-roots perspective or to help during periods of intense pressure. Staff across the trust were positive about the visibility of the non-executive directors and members of the senior leadership team. Given the size of the trust, senior leaders’ knowledge of each service and the people working within them was exceptional.
  • The trust had a clear vision and values. These had been developed in partnership with patients, carers, staff and a wide range of stakeholders. The vision and values of the trust were understood by staff throughout the trust and they could articulate how these related to their work within the organisation and the care delivered to patients. Staff spoke passionately about how they would go the extra mile to meet people’s individual needs.

  • The trust continuously strove to meet the meet the needs of local communities. Since the previous inspection, the trust demonstrated this through its exceptional response to the Grenfell fire. The trust had been a partner in the response to address the immediate needs and longer-term trauma of this experience both directly and through co-ordination with other providers. In 2017/18 1900 adults were referred to CNWL services and 490 children. In such an unprecedented situation the trust had to work with the local community to identify bespoke solutions to meet the needs of the local population. The trust was now delivering long term services in the area.

  • The trust embraced partnership working and was willing to take either a lead or supporting role dependant on what was appropriate in that geographical area. The trust leadership team actively participated in the work of three sustainability and transformation partnerships. It worked with a wide range of local and specialised commissioners through its divisions and boroughs. The trust was part of two accountable care partnerships (ACP) in Hillingdon and Milton Keynes. ACPs are new models of care which seek to provide local people with comprehensive coordinated services in a partnership arrangement between the NHS, local authority and, sometimes, third sector providers.

  • The trust recognised the importance of promoting staff well-being and had won an excellence award from the London Healthy Workplace Charter backed by the Mayor of London. The trust had to meet a set of standards to meet the mental and physical healthcare needs of staff. One of the reasons for this award was that the trust had set up a fund to arrange a variety of classes including Zumba, yoga, mindfulness and playing the ukelele. The trust had also focused on the mental well-being of staff with their staying well at work service (SW@W). This supported staff on medication; without permanent homes; or needing help with redeployment. They also recognised the importance of providing financial support to staff and had won an award for a scheme called Money Wizard which was an online tool helping staff feel more in control of their finances.

  • The trust engaged effectively with staff and had a remarkably effective communications strategy which made full use of social media. The trust intranet was easy to navigate and information was provided through a range of mediums including ‘three-minute reads’, the clinical message of the week, the chief executive’s blog and three key messages after each board meeting. The trust also used on-line forums for staff to discuss topics and share good practice. Clinicians told us they could rely on receiving excellent updates on legislation and guidance through internal communications. The trust was creative in how they shared key messages with staff. For example, a professionally produced and performed video of staff singing and dancing to promote the staff having a flu vaccination had been well received and contributed to a 76% immunisation rate.
  • People who used services and had lived experience were involved in the work of the trust. Examples of this were the recovery college for people using mental health services and the user involvement work in sexual health services for people with HIV. There was also increased user and carer involvement in staff interview panels. Examples of this involvement were shared in the quarterly report on patient feedback and involvement. The trust employed a range of peer support workers with different skills and experience. They carried out a wide range of roles supporting patients and contributing to service improvements. For example, restraint and de-escalation training was co-produced and co-delivered with two full-time peer support workers working as trainers within the team that provided training in the therapeutic management of violence and aggression.

  • The trust was making good progress with their quality improvement (QI) work, and despite this approach only being in place for about a year and a half it was becoming established across the trust. The trust had received an award from the South of England QI collaborative for building capability and capacity. During the inspection many of the staff we met spoke about their involvement in QI projects. At the time of the well-led review there were 276 active projects and 32 completed projects. The trust had an excellent QI microsite which was accessible on the trusts website. This live site enabled staff to access resources, sign up for training events and record progress with their own project. This enabled services to identify similar projects and learn from each other. The trust was working with patients and carers and they were actively involved in 26% of the projects.
  • Staff at all levels of the organisation had access to a wide range of information to support them with performing their roles. Since the last inspection the trust had implemented a business intelligence tool. This provided live information at all levels of the organisation to support the clinical delivery of the service. For example, teams could know on an individual named basis which patients needed to have their care programme approach meeting or to be followed up within seven days of being discharged.
  • The trust provided its estates and facilities function through a wholly owned subsidiary which was very dynamic in its approach, looking for creative solutions to estate challenges. The subsidiary provided an estates and facilities service. It ensured that money raised by property disposals remained within the NHS and the model was attracting a lot of interest from other trusts.

  • The governance processes worked well at different levels of the trust through an overarching accountability framework. The accountability framework identified what must be shared at different levels of the organisation and oversaw the clinical effectiveness of services. Since the previous inspection divisions had become more self-reliant and self-governing entities whilst retaining trust wide oversight, accountability and control. The trust board had a good understanding of where services were experiencing challenges and how this was being addressed.

However:

  • There were some items discussed in part two of the board meeting which could be in part one. This included feedback from board visits and the trust risk register. The reason given by the trust for this, was that putting the papers in part two enabled an open discussion where specific services might be discussed in more detail. The trust recognised there was a balance to be struck between being open with the public and not sharing information which should be confidential and said they would review this.

  • The trust actively promoted a culture of supporting people to speak up and had a number of ways in which they could raise concerns. This was supported by staff having access to a Freedom to Speak Up Guardian (FSUG). However, the inspection found that staff had a mixed knowledge of the FSUG.

The inspection did find that some of the improvements recommended at the previous inspection had not taken place. This included ensuring patients on the wards for older people had access to specialist staff such as a dietician when needed, or that information was put into accessible formats for patients with dementia or other cognitive impairments.

Checks on specific services

Community-based mental health services for adults of working age

Good

Updated 4 June 2019

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

  • 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.
  • Patient risk was well-managed by most services and staff were aware of the key risks before visiting patients. Teams across the trust held regular meetings where clinical risk was explicitly discussed. However, some recorded risk assessments did not clearly state how the risk should be addressed, which could potentially mean that staff, especially if they were new to the team, might not know what steps to take.
  • 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 and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • 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 was well led and the governance processes ensured that that procedures relating to the work of the service ran smoothly.

However:

  • For some teams, assessments that were agreed to be less urgent did not take place in a timely manner.
  • Whilst systems were in place to protect staff who were lone working, some staff were not familiar with lone working procedures, particularly in Harrow and Brent. This could put staff at risk when working alone.
  • Some staff did not have a good understanding of the role of the freedom to speak up guardian so were unaware they could raise concerns through the guardian.

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

Good

Updated 4 June 2019

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

  • Throughout the inspection we saw good practice, particularly at the Campbell Centre, Northwick Park, some individual wards on other sites and in the psychiatric intensive care units. The site where there were the most concerns was at the Gordon Hospital where there had been a serious safeguarding incident. The trust was aware that this service needed additional leadership support and had put this into place.
  • Wards had made progress in minimising the use of restrictive practices and followed good practice with respect to safeguarding.
  • Medicines were mostly managed safely, although at St Charles, the Campbell Centre and Northwick Park, ‘as required’ medicines were not reviewed regularly or when not used by the patients for whom they were prescribed for over 14 days.
  • The service provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided, although there were some inconsistencies in both areas.
  • Ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards, although patients on the wards at St Charles had limited access to psychological therapies.
  • Managers ensured that ward staff received training 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 usually 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, whilst most wards had regular team meetings using a standard agenda to ensure all the necessary topics were covered, a few did not take place regularly or the record of the meeting read like a ‘to do list’.

However:

  • While most wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose, a few were not. Bedrooms on two wards at the Gordon Hospital were too small for safe use by patients in distress. At the Gordon Hospital, rooms designed to offer flexible accommodation for male or female patients were breaching guidance to eliminate mixed gender accommodation. Pond Ward at Park Royal was not clean in some areas. By the end of the inspection the trust had addressed all these matters and, where needed, taken rooms out of use.
  • Whilst the trust was working to recruit and retain staff, and most wards had safe staffing levels, a few wards were struggling to maintain safe staffing. Some wards did not have enough medical cover and some nursing staff told us they felt unsafe at night, especially when they had to attend to patient admissions as well as those already on the ward. We also heard from staff who said that patient leave was sometimes cancelled or that they could not leave the ward to attend training
  • Staff on most wards developed holistic, recovery-oriented care plans informed by a comprehensive assessment, but there was room for improvement on other wards.
  • Whilst staff generally understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff did not always request an opinion from a second opinion appointed doctor (SOAD) in good time. There were discrepancies in the completion of patients’ capacity assessments.
  • Most staff told us that they received regular supervision and they were happy with the content, but records were patchy on some wards. The trust was introducing an online system to monitor supervision, but this was at an early stage.

Wards for older people with mental health problems

Good

Updated 4 June 2019

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

  • Patients were looked after in a safe and clean environment by sufficient numbers of staff who were committed to meeting their needs. The service protected patients from the risk of abuse and avoidable harm. There were clear, open and transparent processes for reporting incidents.
  • The care and treatment for most patients was assessed, planned, delivered and reviewed regularly. Staff completed physical health checks and on-going healthcare investigations and healthcare monitoring. Staff participated in a wide range of clinical audits to monitor the effectiveness of the service, and they monitored the outcomes of patients’ care and treatment.
  • Patients and carers spoke positively about the care, support and treatment they received. They said staff treated patients with kindness, respect and compassion. Staff recognised and respected the totality of patients’ needs and they involved and supported patients, and those close to them, in decisions about their care and treatment.
  • Staff worked in collaboration with community teams within the trust and local social services to facilitate patient discharges.
  • The choice of food took account of special dietary requirements and religious or cultural needs.
  • Staff had a good understanding of the trust’s vision and values for the service and felt supported and valued by their managers. They described a positive culture and felt comfortable raising any issues to their managers. Staff were involved in quality improvement initiatives.
  • At the last inspection, not all staff received supervision, and the system for recording supervision was not robust. At this inspection, most staff had received supervision and the trust was implementing a system to check supervision took place regularly.
  • Most wards were in the process of applying for national accreditation (a quality assurance scheme) and Ellington Ward had achieved it.

However:

  • Whilst there had been a number of improvements since our last inspection and there was a good standard of care across the service as a whole, there were inconsistencies that impacted on patients and staff on specific wards, which the trust needed to attend to.
  • Not all wards had timely access to specialists to meet the needs of older adults. For example, Kershaw and Redwood wards had not had regular access to a dietician since November 2018. Arrangements were put into place by the trust immediately after the inspection. Whilst access to psychological therapies had improved since our last inspection, patients at Beatrice Place were still experiencing delays.
  • Not all staff had received training in dementia despite the fact that a large majority of the patients had dementia or a cognitive impairment. This was not in line with National Institute for Health and Care Excellence (NICE) guidance, which states that people with dementia should receive care from staff appropriately trained in dementia care. Following our site visit, the trust arranged for relevant staff to complete dementia care training by 29 March 2019 and put arrangements in place to monitor attendance going forward.
  • The quality of staff supervision records was poor on Redwood Ward.
  • At the last inspection, information which was provided was not routinely available in an accessible format for patients with dementia or cognitive impairments; for example, information on notice boards, leaflets, activity schedules and menus. At this inspection, some progress had been made, but there was still further room for improvement.
  • The trust had some good practice in falls prevention such as non-slip socks, access to falls mats and adjustable bed heights. There had only been one serious incident reported in a year attributable to a fall. However, a few patients did not have a completed falls risk assessment on admission, which was not in line with the trust’s policy for prevention and management of falls.
  • The large size and layout of Kershaw Ward and Redwood Ward did not allow staff to observe all parts of the ward. Although staff had put mitigations in place, we observed during our inspection that staff were not always present in areas of the wards due to its large size, which left patients unattended. On Redwood Ward, the environmental risk assessment had not identified all of the potential blind spots on the wards. These blind spots made patient observation difficult. However, following our inspection, the trust installed mirrors for these blind spots.
  • At the last inspection, there was no tracking of informal complaints. At this inspection, most wards had made improvements but Kershaw Ward and Redwood wards did not keep a log of their informal complaints to identify any themes or learning.
  • At the last inspection, there was a lack of systems in place to learn from incidents across the divisional structure of the trust. At this inspection, although this had improved, we still found there were no formal arrangements in place for staff across the older adult wards to share learning and good practice. Some staff were unaware of incidents on other older adult wards, but knew about serious incidents that had occurred elsewhere.

Wards for people with a learning disability or autism

Outstanding

Updated 14 June 2017

We rated wards for people with learning disabilities or autism as outstanding because:

  • Patients received an exemplary service that was tailored to meet their individual and diverse needs and preferences. There was a truly holistic approach to assessing, planning and delivering care and treatment to patients which focused on each patient’s strengths and needs. There was a strong focus on recovery. Staff engaged with patients in a positive way which promoted their well-being. There was an open and positive culture which focussed on patients.

  • Patients and others important to them were fully and actively involved in all aspects of the planning and delivery of their care and worked in partnership with the staff team. Staff delivered care in a way that ensured flexibility and individual choice. Patients told us they felt safe.

  • Risk management arrangements were robust and staff promoted a culture of positive risk taking. Patients were involved in managing risks to their care.

  • The service used every opportunity to learn from incidents to support the improvement of the service. Learning was based on a thorough investigation and analysis and was embedded throughout the service.

  • The standard of care provided was outstanding. Staff delivered a wide range of evidenced based, therapeutic treatment interventions which meant that patients received effective care, treatment and support. Patients and carers spoke very highly of the staff and the quality of the care they received.

  • Staff monitored and reviewed patients’ physical healthcare needs effectively.

  • Staff from different disciplines worked together professionally and with mutual respect to achieve the best possible outcomes for patients using the service. There was a multi-disciplinary approach towards every aspect of the patient journey from admission to discharge. Staff were committed to partnership and collaborative working and there was an embedded culture focussed on the delivery of holistic care.

  • Staff were supported by regular supervision and appraisals and had access to specialist training which was designed around the needs of the patient group. The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring and improving high quality care and support provided.

  • Staff were confident in managing behaviours which were challenging to the service with clarity and thoughtfulness. We saw exceptional use of positive behaviour support to effectively understand, anticipate and meet patients’ needs. Staff monitored and reviewed restrictive interventions robustly. Staff were committed to reducing the need for restrictive interventions such as restraint. Patients contributed to their own positive support plan using their preferred communication method.

  • Staff had an in-depth understanding of each patient. They supported patients to communicate effectively because staff had undertaken comprehensive communication assessments and used appropriate communication methods/styles to support people’s individual needs. We saw excellent examples of information that was presented to people in ways they could understand, such as the use of transition calendars, easy read leaflets for 35 psychotropic medicines and the use of photographs to put together booklets to support patients with different aspects of their care such as planning for discharge.

  • Consent practices and records were actively monitored and reviewed to improve how the patients using the service were involved in making decisions about their care and treatment. Staff demonstrated an excellent understanding of consent practices and how these supported patient’s rights.

  • We saw exemplary practice with the patient–led care programme approach meetings and ward reviews. Patients took a role in chairing their care programme approach meetings if they wished to. Staff in conjunction with the patients had developed new care programme approach documentation to support patients so that they could understand the process better and monitor their progress.

  • The service had an excellent advocacy service. Patients had their voice heard on issues that were important to them and all staff genuinely considered individual views and wishes when patients made decisions.

  • The service undertook numerous initiatives to ensure that patients were engaged and involved in the care they received. This included a focus on collaborative risk assessments, patient-led care programme approach meetings, staff recruitments and representation at the care quality meeting.

  • There was excellent use and implementation of ‘this is me’ life history documentation to provide person-centred care.

  • The provider used innovative and proactive methods to improve patient outcomes. Re-admission rates had reduced as the service had developed a comprehensive transition plan to support patients leaving the service. This included facilitating specific training for staff in the patient’s future service, reviewing the community provider’s risk assessment and risk management plan for the patient, to determine if the community provider could provide appropriate care and treatment.

  • The service had a positive, open and inclusive culture which centred on improving the quality of care patients received through empowerment and involvement. Throughout our inspection we saw that staff embedded the values of the trust in all aspects of their work and spoke about the patients being at the heart of the service.

Community dental services

Good

Updated 19 June 2015

We gave an overall rating for community dental services of good because:

Overall we found dental services provided safe and effective care. Patients’ were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.

Dental services were focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practices within the service. There have been some difficulties recruiting staff to all posts however the service has been able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of the service.

The patients we spoke with, their relatives or representatives said they had very positive experiences of their care. We saw good examples of care being provided with compassion as well as sensitive and empathetic interactions between staff and patients. We found staff to be hard working and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At each of the clinics we visited the staff responded to patient’s needs. We found the service sought the views of patients using a variety of means. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs and at the right time. Through effective management of resources, delays to treatment are kept to reasonable limits.

The service was well-led. Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff were aware of the vision and way forward for the organisation and said that they generally felt well supported and that they could raise any concerns.

End of life care

Good

Updated 19 June 2015

Overall rating for this core service Good

We gave an overall rating for end of life care good because :

The specialist palliative care teams were aware of the process for reporting any incidents. Staff we spoke with were able to explain what constituted a safeguarding concern and the steps required to report concerns. There were clear guidelines for medical staff to follow when prescribing anticipatory drugs to patients. A large percentage of staff had completed their mandatory training and that this was updated on a regular basis. We observed that patients’ needs were risk assessed and managed on an individual basis.

Clinical staff made a comprehensive assessment of patients when they were referred to the service. Multi-disciplinary meetings were arranged for patients who were approaching their end of life. These effectively arranged services in partnership with other health care professionals and GP’s involved in patients care. We looked at 12 DNACPR forms and found that in 5 cases patients had been involved in the discussions, and for the other cases where the patient had been identified as lacking mental capacity, a mental capacity assessment had been undertaken and a best interest decision made.

Throughout our inspection we saw patients being treated with compassion, dignity and respect by staff. We observed staff interactions with patients and families that were professional, sensitive and appropriate at all times. Staff ensured that privacy was maintained when they assisted patients with their needs. Patients told us their clinical nurse specialist would carefully explain pain control and involve them in their care plans.

Patients and families were able to access 24 hour 7 day per week palliative care services. Patients and relatives told us that they were very happy with the service they received and that had information on how to make a complaint. Staff were aware of the diverse needs of all the people who use the service and patients and relatives told us that they had been able to access interpreter services though the teams.

Staff knew the vision and values of the organisation. There was a good governance structure in place and the risk register was used to highlight any issues of immediate risk and these were reviewed on a monthly basis. Staff spoke positively about their team leaders and senior management. Staff felt supported and involved in the delivery of the service.

Community health services for adults

Good

Updated 19 June 2015

We gave an overall rating for community adult services of good because:

We directly observed staff treating patients with dignity and respect. All the patients we spoke with told us they had received good and compassionate care. Often telling us staff had been very flexible and had done more than was expected of them. Staff consistently involved patients and their families in their care. We observed staff giving patients detailed information about their treatment and discussing this with them. Staff we spoke with were aware of the importance of gaining patient’s consent and had an understanding of the Mental Capacity Act. Additional training was being provided in some areas.

Staff teams received equality and diversity training and consistently reported good access to interpreters. People using the services received information and care in a manner that met their individual needs in terms of their language, culture, religion and disability. Teams told us they had good access to patient equipment which was usually delivered in a timely way.

Leaflets had been given to patients on how to complain and where possible complaints were addressed quickly at a local level. Where formal complaints took place they were addressed thoroughly and staff learnt from the complaints.

Staff knew how to report incidents and there was learning from these events. The organisation was open when things went wrong and would keep the patient informed of the action they were taking. Safeguarding matters were correctly alerted and there was learning where needed. Medicine management varied between teams depending on local arrangements. In most cases infection control was managed well although this needed improvement in Hillingdon.

There were sufficient staff available to provide services, although this could at times be challenging and required ongoing monitoring. Staff said they had regular supervision, a recent appraisal and felt well supported within teams. We were consistently told that the trust supported and encouraged access to training. Arrangements were being made to monitor the frequency of supervision to ensure a consistent approach. There was good multi-disciplinary working and effective handover and multi-disciplinary team meetings. Staff consistently told us they had good links, and access to, a wide range of other services. Staff said they felt well supported by team leaders and most senior managers. Most staff felt valued and respected by the organisation.

We saw clear referral processes to teams often with duty staff to triage referrals received. Referral and transition process varied across the teams we visited and where there were challenges these were being reviewed.

A range of audits had been completed and improvements made to services in response to the findings. Teams were informed of changes to national guidance and practice had changed as a result of new guidance. There were good examples of innovation and close working with local clinical commissioning groups. We were told these innovations had been well supported by senior managers. The trust annual gem and team awards celebrate such developments.

Record keeping was generally good but needed more work to be of a consistency high standard.

Specialist community mental health services for children and young people

Good

Updated 19 June 2015

We gave an overall rating for the specialist community mental health services for children and young people of good because:

  • Incident reporting and learning from incidents was apparent across teams. Staff had been trained and knew how to make safeguarding alerts. Staff managed medicines well.

  • Young people referred to teams were seen by a service that enabled the delivery of effective, accessible and holistic evidence-based care.

  • Staff demonstrated their commitment to ensuring young people received robust care by being proactive and committed to people using the service, despite the challenges they faced at times with limited resources.

  • There was strong leadership at a local level and service level across most of CAMHS that promoted a positive culture within teams.

  • There was a commitment to continual improvement across the services.

Community health sexual health services

Outstanding

Updated 19 June 2015

We rated sexual health services as outstanding.

Patients were receiving safe care from appropriately trained, qualified and skilled staff. An extensive programme of training was in place. Staff confirmed that this prepared them for their roles and responsibilities.

All the patients we spoke with told us they were very satisfied with the care and treatment delivered to them, and felt included and involved in their care. The services were easily accessible and staff really focused on the individual needs of each patient.

Care and treatment provided to all patients were based on national guidelines, directives and research. The care and treatment was audited to monitor its quality and effectiveness, and where needed action had been taken to improve the service.

Managers were dynamic, inspiring and approachable and gave support daily not just when required.

The services were a centre for national and internation research and innovation. This meant that patients were benefitting from this work and receiving the latest treatment from staff who were committed to improving care and treatment for patients across the world.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 19 June 2015

We gave an overall rating for long stay/rehabilitation mental health wards for working age adults of good because:

Patients were provided with care in clean and safe environments. Environmental and ligature risk audits were undertaken regularly and mitigation plans were in place where necessary. Some services did not meet same sex accommodation guidelines.

There were some areas in the service, in particular at Horton, where there were high vacancy rates for nursing staff, however, managers had access to temporary staff, usually regular bank staff and the trust was taking action to actively recruit into vacant posts.

Staff had a good understanding safeguarding processes locally and were confident in reporting concerns. Incidents were reports and learning from incidents was disseminated through the service.

Risk assessments and care plans were up to date and regularly reviewed. There were strong multi-disciplinary teams based in the services who provided a wide range of support for patients on the wards. There were varying experiences of working with agencies external to the trust, depending on availability and coordination with services depending on their location. Staff had a good understanding of the Mental Health Act and the Mental Capacity Act.

Patients reported that they received good care and we observed kind and thoughtful interactions with staff. There were regular meetings on wards for patients to feedback information about the services. Availability of advocates varied but there was information on the wards about contacting advocates. Wards were well-equipped with rooms for activities although there were significant differences between the wards within this service.

Services were able to adapt to meet the needs of the local communities and there was access to interpreting services and food to meet cultural and religious needs.

The services had a strong recovery focus which staff embraced enthusiastically. The senior leadership within the service was visible and accessible. Staff told us that they felt confident in raising concerns. Information available at a ward level related to staff training and there is additional work being done to extend the amount of data available but currently this is monitored through ward managers. The service has participated in some research programmes and is working on a new online version of care planning to involve people more in their own care plan process.

Community mental health services with learning disabilities or autism

Not sufficient evidence to rate

Updated 19 June 2015

There was insufficient evidence to rate the Bent and Harrow Community Learning Disability teams:

Assessments were completed for each person referred to the team, based on their individual needs and the reason for their referral. Care plans had all been discussed and shared with the people using the service and their carers. Care plans covered all the areas of individual need for each person and were regularly updated. Staff monitored people’s medicines as part of a shared care with the person’s GP.

People who use the service had risk assessments that were updated on a regular basis to reflect the current individual needs of the person. People using the service all had individual crisis plans in place. People’s records showed that individual healthcare needs were clearly identified and closely monitored.

Both teams were multi-disciplinary and offered support based on the persons individual needs.

Staff members of the team worked closely where needed with primary care, colleagues in social services and a range of other care providers.

Staff talked about people in a way that demonstrated kindness, dignity and respect

People using the service were supported to be involved in their care planning and to attend meetings with their families and carers. Meetings often took place in the persons home or day service rather than at the team base.Team members worked closely with families and carers who knew the people using the service well.The service had recently piloted a survey of people using the service to get feedback on the quality of their support.

The number of people who did not attend appointments was generally low and people who missed appointments were contacted. We saw examples of two complaints. On both occasions lessons were learnt, staff received feedback and an apology was offered by the trust

Staff were aware of the service’s vision and values. Staff told us they felt valued and that managers were approachable and listen.

Child and adolescent mental health wards

Good

Updated 19 June 2015

We gave an overall rating for child and adolescent mental health wards as good because:

  • The service was well-staffed and staff felt well supported in the service.
  • The team worked together to formulate individual care plans and we saw good detail was provided within these.
  • NICE guidance was followed.
  • Children’s feedback was sought and used to inform service development.
  • Cultural and diversity needs were supported.
  • There was a culture of openness and transparency and staff felt listened to.
  • There was evidence of clear leadership at a local and service level.

Community-based mental health services for older people

Good

Updated 19 June 2015

We gave an overall rating for community based services for older people as good because:

The support provided by the older persons’ community mental health teams and the memory services was thoughtful, respectful and considered peoples individual needs. The teams also worked closely with carers and relatives.

The teams had appropriate staffing levels. Where there were recruitment challenges, there were plans in place to attract new staff. Bank and agency staff were used where needed. Staff had access to a range of training to perform their roles and felt well supported.

People using the service were assessed and had care plans and risk assessments in place. Further work should be done to ensure physical health needs are covered in all care plans and the care plan format is accessible to people using the service and their carers. The staff were making very good use of the Mental Capacity Act to support people to make complex decisions.

Waiting times from referral to assessment varied between teams, with people referred to services in Hillingdon experiencing longer waits. People who made the referrals were advised they could contact the team again if the person’s needs changed while they were waiting for an assessment. Services were delivered in a reliable and flexible manner to accommodate people’s individual circumstances.

The teams were able to follow best practice guidance and there were examples of innovative developments.

Mental health crisis services and health-based places of safety

Good

Updated 19 June 2015

We rated mental health crisis services and health-based places of safety as good because:

In general, the teams were well managed. Staff supported people with complex needs in a caring and supportive manner. Staff received mandatory training and were appraised and supervised, incidents were reported and investigated, staff participated in audits, and safeguarding and Mental Health Act procedures were followed. Staff knew about the whistle-blowing process.

Staff morale was high in most of the teams we visited. Many staff told us they were proud of the job they did and felt well supported in their roles.

However in the responsive domain we found that:

  • People who were assessed as requiring inpatient beds experienced long delays before being admitted. The delays in accessing inpatient beds meant that some people received care that did not meet their needs.
  • The places of safety at the Gordon hospital and Park Royal had no separate access.This meant that people had their privacy compromised as they arrived at the places of safety.
  • In the North Kensington team based at St Charles the interview rooms were divided by a door with a glass panel covered by a small curtain. Private conversations could easily be overheard in either room. This meant their privacy and dignity was not maintained.

At the Gordon Hospital the two place of safety rooms both contained ligature points. The toilet for use of people was also not ligature free. Although staff could manage risk through observation, the environment meant people could not be supported safely without compromising their privacy. The trust had agreed to the refurbishment of the place of safety and work was starting in April 2015.

Substance misuse services

Updated 19 June 2015

This service was not rated

Suitable numbers of staff were employed at each site, with appropriate arrangements in place to cover vacant posts with regular staff, ensuring consistency of care and treatment. All of the services we visited valued the contribution of volunteers and peer support workers who had previously received treatment. At all sites, staff were engaged in partnership working, in line with current best practice. Staff received appropriate training, supervision and professional development. There was effective multi disciplinary team (MDT) working taking place. Each of the services we visited had developed good working links with partners and external agencies, such as GPs, social services and mental health services.

The premises that we visited were clean and free from clutter. Each had a suitably equipped clinical room. Appropriate arrangements were in place at each site to manage medicines and to dispose of sharps and clinical waste safely.

Initial patient assessments were completed in a timely manner and care and treatment was delivered in line with individual care plans. Overall, care plans were regularly reviewed and updated. The majority of patients were aware of their care plan and felt that they included their views. A standardised patient risk assessment was in use. We found that across all sites where potential risks had been identified there was not always a management plan to address these.

Patients received regular medical reviews with a doctor employed by the service.

At the time of our inspection no waiting lists were in operation at the services we visited. Patients were initially assessed on the day that they attended the service. Each of the services was able to offer a rapid medication pathway. The services that we visited had arrangements in place to follow up with patients who disengaged. Patients we spoke with knew how to complain and staff we spoke with knew about the complaints procedure and how to deal with complaints appropriately.

We found each service to be well-led. There was evidence of clear leadership at a local level. The culture of each service was open and encouraged staff to bring forward ideas for improving care. Staff we spoke with also told us that they felt supported by their service managers and felt that there was two way communication from “the board to the ward”. Each service had access to systems of governance that enabled them to monitor the quality of service provision and a range of measures were in place to gauge the performance of each site.

Community health inpatient services

Good

Updated 19 June 2015

Services were found to be effective, caring, responsive and well led. There was a holistic approach to providing treatment and care to the patient which included involving their family members. Patients and their relatives reported they felt involved in the planning of their care and treatment. Support and training were provided to family members so they could provide safe and effective care and support when patients were discharged and returned home.

Services aimed to meet patients individual needs. It had been identified that high numbers of patients admitted to the wards were living with dementia. Some wards had been refurbished to promote a dementia friendly environment and work was on going at South Wing, St Pancras.

There was an embedded culture of reporting incidents. The trust had worked with staff to ensure risks would be reported in the correct manner, and to ensure incidents were fully investigated and action was taken to reduce the risk of similar incidents occurring.

Areas were clean and appropriate infection control practices were followed. Staffing levels met the planned staffing numbers through the use of agency staff. An active recruitment strategy was in place.

Medicines were managed to ensure the safety of patients. There were arrangements at all hospitals so patients had access to medical treatment in a timely and responsive manner. For patients at Hawthorn unit, Hillingdon the service was being improved with the introduction of seven day working for some therapists.

Staff reported they had access to training other than the required mandatory training. There was good multidisciplinary and integrated working between staff, who were respectful and caring.

There was good local leadership for staff and staff reported an open and supportive culture. Individual wards and departments had their own quality improvement plans. This allowed them to take ownership of their service and the changes they made to improve outcomes for patients.

Forensic inpatient or secure wards

Good

Updated 19 June 2015

We gave an overall rating for forensic/secure wards of good because:

Care was provided to people in a clean and safe environment. However the location of the seclusion room on a different floor could cause potential risks to the safety and dignity of patients when they need to use this facility.

Staff were competent and aware of how to report incidents and safeguarding concerns. Incidents were investigated and staff were aware of where learning could take place.

All admissions were assessed prior to admission and further assessments and management plans took place on admission. Risk plans were developed and updated as necessary. However some of the recording systems in place did not reflect the staff understanding of patients’ needs.

Staff were provided with regular supervision, annual appraisals and had access to mandatory and specialist training and training provided within the division.

Staff were confident about raising concerns and felt supported by their managers.

All admissions were planned and there was a very small waiting list for beds. The wards were part of a wider offender care pathway where support was provided by in-reach, outreach and inpatient services.

The service was sensitive to the differing needs of patient groups although there were some difficulties regarding disability access and outdoor access from Tasman ward.

There were strong clinical governance systems in place through the offender care pathway. However, as this was a small inpatient service within a larger division, there was a risk that learning from other inpatient wards and similar services such as the rehabilitation pathway within the trust were not strongly embedded.

Community health services for children, young people and families

Good

Updated 19 June 2015

Overall rating for this core service - Good

Staff treated children and young people with respect and dignity and delivered care which was sympathetic and inclusive during clinics, school and home visits. Parents and children were involved in planning care. Feedback from parents and their children was consistently positive and they said they were treated with dignity and respect. Staff were dedicated, highly motivated and worked diligently in delivering a first class service.

Services for children and families were being adapted to make them more accessible and responsive to people using the services. The services were mindful of meeting the needs of children in vulnerable circumstances. The trust was able to provide interpreters and information in a range of formats to support staff in meeting the individual needs of children and their families in terms of their diversity. Staff were very sensitive to peoples culture, religion and beliefs.

The trust had a good track record on safety. Where concerns were found these were reported and addressed in a timely manner. The individual teams fostered a learning culture and the processes for responding to adverse incidents were robust. Infection control procedures were in place and were being monitored. Safeguarding processes were in place and child protection plans were reviewed and audited.

Staffing was very stretched especially for health visitors but work was prioritised based on risk. An active programme of recruitment was taking place particularly in Hillingdon. Staff were trained and appraised and there was a positive learning and sharing culture. The children and family services provided many examples of good multi-disciplinary and multi-agency work. Information was provided in a number of formats to help children and families understand and implement the treatment. Staff understood and applied the principles of consent in their work with the children, young people and families.

There was a strong culture of completing clinical audits to ensure care and treatment was delivered in line with best practice and providing positive outcomes for the children. Information about how to complain was available and complaints were addressed thoroughly with lessons learnt.

All staff were aware of the principles and values of the organisation. Some staff told us they felt inspired by the passion of the chief executive and felt innovation and originality in how services were provided was welcomed by the senior management team. Staff told us they felt confident with their immediate managers and staff worked together across all disciplines for the benefit of the children and families. Governance processes enabled information to be provided to services to support their monitoring and management.