• Organisation
  • SERVICE PROVIDER

Central and North West London NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

25 and 26 April 2023

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

This was an unannounced focused inspection of the two acute wards for adults of working age at the Campbell Centre, Milton Keynes. We carried out this inspection to follow up concerns raised following a serious incident in December 2022 when a patient died on Willow ward as a result of tying a ligature around their neck. This inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of patient risk on Willow ward. This inspection examined those risks.

This inspection has not been rated. This is because we only inspected two wards out of 17 acute or intensive care wards run by Central and North-West London NHS Trust. Hence, the findings from these two wards do not necessarily reflect the overall quality of acute and intensive care services provided by the trust.

Our last inspection of these wards was in November 2020. Following that inspection, we told the trust it must ensure that patients on Willow ward are protected from risks associated with inconsistent staffing and ensure that appropriate measures are in place to mitigate risks. During this inspection, we found that the trust had made some but not all of the required improvements.

We visited 2 wards during this inspection, both located at the Campbell Centre, Milton Keynes. Willow ward is an acute admission ward for up to 19 female patients. This is where the serious incident occurred. Hazel ward is an acute admission ward for up to 17 male patients.

The service is registered by the CQC to provide the following regulated activities:

  • Treatment of disease, disorder or injury
  • Assessment or medical treatment for persons detained under the Mental Health Act1983
  • Diagnostic and screening procedures.

Overall summary

We found the following areas the service needed to improve:

  • The nature and frequency of incidents on Willow ward indicated that the service was unable to ensure the safety of patients. The service had not addressed the concerns raised at the last inspection about the high number of safety incidents on Willow ward.
  • Staff did not carry out observations of high-risk patients on Willow ward in accordance with trust policy. One patient was involved in a ligature incident, despite being assigned to continuous observations. There were some gaps in observation records. Staff were required to carry out continuous observations of patients beyond the maximum period of time set out in the trust’s policy. Staff did not always maintain good professional standards whilst carrying out observations.
  • Staff did not discuss or sufficiently analyse risk incidents at multidisciplinary team meetings in order to understand the causes and mitigate the risk of such incidents reoccurring.
  • Staff did not manage the risks associated with prohibited items on Willow ward effectively. Staff did not carry out adequate searches when patients had been found with prohibited items that they had used to harm themselves.
  • Although staffing levels were consistent with national guidance, the staff were often not able to provide therapeutic care. Staff were not always able to respond to patients’ requests. Leave and activities were sometimes cancelled. Activities that were cancelled were sometimes replaced with an alternative activity.
  • Patients did not always have a regular 1:1 session with their named nurse. Staff were not pro-active in carrying out individual discussions with patients to understand their needs and monitor any changes in their level of risk.
  • The overall atmosphere on the wards, particularly on Willow ward, was not calm and therapeutic. Wards were often noisy. Wards could often become unsettled. Fights and disputes between patients were not uncommon. Staff were not pro-active in managing conflicts between patients.
  • Despite admitting high risk patients, staff on Willow ward did not always update risk assessments after safety incidents.
  • Staff and patients told us they did not always feel safe on the wards. Staff did not always respond when emergency alarms were activated.
  • Cleaning records were not available on Willow ward.
  • The trust did not provide training for staff in conditions presented by high-risk patients.
  • The service had high vacancy rates although there was active recruitment taking place..
  • Some staff found the electronic patient records difficult to use. It could be difficult for staff who were unfamiliar with the system to access information quickly.
  • Incident reports lack sufficient details of the circumstances surrounding the incident. The system for incident classification was not always able to reflect the seriousness of the matter.
  • Willow ward had not embedded some of the recommendations made in reports of investigations into serious incidents.
  • Handover meetings on Willow ward did not have robust discussions about risks or how to manage them, or provide a clear handover of tasks to manage patients’ risks.
  • Not all staff had completed and were up to date with emergency life support training although this was planned.
  • Staff were not having discussions with patients about their medicines and their potential side effects.
  • Staff morale on Willow ward was low. Staff struggled to cope with the pressure of their work. Many members of staff had been subjected to assaults from patients. The operational culture viewed this as part of the job. Staff felt the trust was not doing enough to address this.

However, we also found the following areas of good practice:

  • Since our last inspection in 2020, the service had reduced the number of bank and agency staff working on the wards from over 50% to 20%.
  • The service had introduced specific training on observations for temporary staff.
  • The service had introduced monthly emergency scenario training for staff following a serious incident.
  • All wards were clean and well equipped. The wards complied with guidance in relation to mixed sex accommodation.
  • Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly.
  • Staff made attempts to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.
  • Patients told us they enjoyed the activities on the ward.
  • Almost all staff had completed safeguarding training and knew how to report safeguarding concerns.

1 March 2023 to 21 March 2023

During an inspection of Child and adolescent mental health wards

Lavender walk is a children’s inpatient service provided by Central and North West London NHS Foundation Trust (CNWL). The ward offers assessment, management, and treatment on an inpatient and day basis for children and young people aged 13 up to their 18th birthday. The ward can accommodate up to 12 young people as inpatients and 4 as day patients.

The child and adolescent mental health wards core service was last inspected in 2015 with a rating of good across all domains and good overall. In 2020 we carried out a focussed inspection of a different child and adolescent ward within the trust and this inspection was not rated.

This was a focussed inspection where we looked at the domains of Safe, Caring and Well Led. Where we have found a breach of regulation, the rating for this domain is limited to requires improvement. Following this inspection, the ratings for Safe and Well Led were limited to requires improvement. The rating for Caring remained as Good, the same as the previous inspection.

The unit primarily accepts referrals for young people who are resident in or registered with a GP in any North West London borough.However, it also takes young people from London and surrounding counties if a bed is available. Providing care for young people with a primary diagnosis of mental illness and which does not exclude those with a mild learning disability, drug and alcohol problems or social care problems as secondary needs, some young people may require detention under the Mental Health Act. It does not accept referrals for young people with moderate to severe learning disability or those who require low or medium secure services.

The service is registered by the CQC to provide the following regulated activities:

Treatment of disease, disorder, or injury,

Assessment or medical treatment for persons detained under the 1983 Act

Diagnostic and screening procedures.

This unannounced inspection was prompted in part by notification of an incident following which a person using the service died. This inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of ligature. This inspection examined those risks.

At the time of the inspection the ward had reduced their inpatient numbers in response to this incident. During the first visit there were 7 young people and on the second visit there were 9 young people admitted to the ward.

We found several areas of good practice:

  • Staff had training in key skills and understood how to protect young people from abuse.
  • The ward was visibly clean and well maintained. Staff managed infection risk well.
  • The service used information from safety incidents to learn lessons and used information collected to improve the service.
  • Staff assessed risks to the young people and acted on them. They provided effective care and treatment and offered emotional support when young people needed it.
  • Most staff treated patients with compassion and respected their privacy and dignity. Staff provided emotional support to the young people, families, and carers.
  • Young people told us that they enjoyed the range of activities the ward offered including therapies and education.
  • Leaders were committed to running the ward well and using reliable information systems. All staff were committed to continually improving the service.
  • Staff we spoke to said they felt supported and valued.
  • The staff had improved their engagement with young people, families, and carers.

However:

  • The ward continued to have a high vacancy rate among nursing staff. Although this had reduced significantly, there was a continued reliance on agency and bank staff, particularly overnight. The service also had a higher turnover and sickness absence rate than the trust average. This meant nursing staff were not always familiar with the young people and their care and treatment needs.
  • The ward did not always manage risk well. We observed patient care and treatment records that were not always clear about a young person’s risk behaviour and how this should be safely managed.
  • Young people told us that they did not always feel safe on the ward and that some staff did not treat them with kindness and respect.
  • Governance processes related to medicines management on the ward were not always effective. On the first inspection visit we observed several areas of concern around medicines management. For example, there were several expired medicines in the clinic room.

What people who use the service say

Parents and carers told us they found the staff team very supportive, responsive, and helpful. They also said the staff were caring, polite and interested in the wellbeing of the young people. They told us staff supported them in their parenting role.

All the young people we spoke with said they were happy with the activities on the ward, and they had plenty of things to do even at the weekend. They told us they enjoyed working with the education and therapies team.

The young people said most staff treated them with dignity and kindness. However, all of them told us they felt less safe overnight with staff they were unfamiliar with, and some young people told of us staff who did not treat them with respect and kindness.

11 - 13 October 2022

During an inspection of Community health services for adults

  • This was a focused inspection of 3 of the trust’s district nursing teams in the London Borough of Hillingdon. We looked at the safe domain only. This inspection was not rated as we did not look at any of the trust’s district nursing teams in the other boroughs in which it operates. We inspected this service because we knew of the pressures that all district nursing teams in London are under on account of the need to treat people at home whenever possible combined with district nursing staff shortages. We also received concerns about the management of pressure ulcers in the district nursing team.
  • The service had enough staff to care for patients and keep them safe. Flexible working had reduced staff vacancies. Staff we spoke to who had been recently recruited felt that flexible working made it attractive to work for the trust as it allowed them to practice alongside their domestic caring commitments.
  • Staff had training in key skills and understood how to protect patients from abuse. Mandatory training completion rates trust-wide for district nursing teams was 95%. The trust had an experienced nurse to support staff with induction, sign off on competencies, identify training gaps and liaise within the training department about staff training needs. Staff had a comprehensive district nursing induction pack for new staff.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Patient records were comprehensive; notes and care plans were clear and concise. Staff could consistently and readily access pertinent patient information in a timely way. Staff kept detailed records of patients’ care and treatment.
  • Staff assessed risks to patients and acted on them. Staff used recognised tools to assess the risk to patients and reviewed them after each visit. Staff reviewed all risk assessments every 12 weeks.
  • Staff considered patients’ needs holistically in handover meetings. Staff presented patient cases in handovers using situation, background, assessment, recommendation (SBAR). SBAR is a structured form of communication that enables information to be transferred accurately between individuals. We saw evidence of good interagency work, for example, with GPs, tissue viability and diabetic services.
  • Staff consistently recorded alerts in the patient record system and had up to date records for ‘Do Not Attempt Cardio-pulmonary Resuscitation’ (DNA CPR) where this was required. Records contained information about where to find a copy of the DNA CPR if this was needed. Immediate access to this information meant teams had the information needed to respect the wishes, and the comfort and dignity of patients.
  • Managers and staff carried out a programme of audits to check compliance with trust policies and improvement over time, such as a lone working audit; infection prevention and control audit environmental audit; and medicines audits. Medicines were managed safely. Infection prevention and control measures protected people and minimised the risk of infection. Staff kept equipment and their work area visibly clean.

However:

  • Although staff checked the defibrillators on a regular basis we found that the associated oxygen tube in the Oak Farm Team premises had expired in November 2019. We raised this issue with the staff who responded promptly and had a new defibrillator machine with up-to-date contents delivered during the inspection.
  • We highlighted to staff that there were no compressed gas signs for the oxygen cylinder kept at the Hayes and Harlington team. Again, staff responded promptly and added two compressed gas signs during the inspection.

How we carried out this inspection

This was a focused inspection of the trust’s district nursing services in the London Borough of Hillingdon. We visited 3 district nursing teams Hayes and Harlington team, Laurel Lodge and Oak Farm Team We did not look at their other district nursing teams.

We last inspected the trust in March 2015. The overall rating for community health services for adults was good. Community health services for adults had been rated good in safe, effective, caring, responsive and well led.

We inspected this service because we knew of the pressures that all district nursing teams in London are under on account of the need to treat people at home whenever possible combined with district nursing staff shortages. We also received concerns about management of pressure ulcers in the district nursing team. We did not inspect all areas of all key questions and the core service was not given an overall rating. We did not speak to patients or carers as we looked one key question:

• Is it safe?

Before the inspection visit, we reviewed information that we held about the location.

During the inspection visit, the inspection team:

  • spoke with 12 staff members including the clinical service manager, district nurses, community staff nurses; palliative link nurse, deputy district nurses
  • conducted a tour of the service environments
  • reviewed 5 incident records
  • reviewed 14 patient care records
  • observed 3 handover meetings
  • reviewed team allocation and daily diary
  • observed a district nurse home visit
  • looked at a range of policies, procedures and documents related to the services we visited.

You can find information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

24 November 2020 to 27 November 2020

During an inspection of Child and adolescent mental health wards

This was an announced focused inspection of the Collingham Child and Family Centre, part of the child and adolescent mental health wards core service. We carried out this inspection to follow up on concerns raised about the safety and quality of the service being provided. We used CQC’s interim methodology for monitoring services during the COVID-19 Pandemic.

The child and adolescent mental health wards core service was last inspected in 2015 with a rating of good across all domains and good overall. As this was a focused inspection, we did not inspect and rate against all key questions. The ratings from the previous inspection remain in place.

Collingham Children and Family Centre is a children’s inpatient service provided by Central and North West London NHS Foundation Trust (CNWL). The centre offers assessment, management and treatment for children up to the age of 13 who present with severe and complex mental health problems. The centre is able to accommodate up to 12 children as inpatients or day patients. Many of the children admitted for inpatient care have home leave over the weekend.

The service is registered by the CQC to provide the regulated activities: Treatment of disease, disorder or injury, Assessment or medical treatment for persons detained under the 1983 Act and Diagnostic and screening procedures.

We found the following areas of good practice:

  • The ward was clean, well equipped and mostly well furnished. Children had been involved in painting murals on the wall and had access to fresh air via a playground and a garden.
  • Staff did a risk assessment of every child on admission and updated them regularly. Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe.
  • Staff assessed the mental health of all children on admission. They developed individual care plans, which were reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs, were personalised, holistic and recovery-oriented.
  • Staff were observed to be interacting well with the children. Their interactions seemed kind and age appropriate. The children appeared to enjoy being around staff. Staff involved children in care planning and actively sought their feedback on the quality of care provided. They ensured that children had easy access to independent advocates.
  • Staff informed and involved families and carers appropriately and provided them with support when needed.
  • Staff from different disciplines worked together as a team to benefit the children. They said they felt able to raise concerns without fear of retribution.
  • The service treated concerns and complaints seriously. They investigated them and learned lessons from the results. Parents and carers were encouraged to provide feedback on the service.
  • Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed. They were visible in the service and approachable for children and staff.
  • Staff actively engaged in local and national quality improvement activities.

However, we also found the following areas for improvement:

  • We had concerns about how the service met the complex needs of the young people and kept them safe. This included how young people could call for help when needed. The service had acquired alarms specifically designed for the young people which they could access based on their individual risk assessments but these had not been used in practice.
  • The service did not always have enough nursing staff available. An incident was noted when children were left unsupervised on the upper level of the ward whilst staff cared for patients in the de-escalation room on the lower level. The ward had recognised this and additional staff were now rostered on duty. Whilst feedback regarding staff was mostly positive some patients did comment that one or two staff were less supportive.
  • Staff reported restraint and seclusion was only used as a last resort. However, there was some confusion noted when speaking with staff as to when seclusion had begun and how these incidents should be documented.
  • When reviewing incident reports we noted that staff had not recorded all the necessary information about which staff were involved in the physical restraint of a child.
  • As the profile of patients referred to the unit changes, the service should keep under review the composition of the multidisciplinary team. For example, at the time of our inspection, a large proportion of patients were noted to have an eating disorder or to be limiting their dietary intake. Whilst a dietitian was part of the multidisciplinary team, they were only available on the ward one day each week, which may mean that they are not able to appropriately support each child who needs them.
  • At times the ward could become too hot and uncomfortable. Staff were aware of this concern and were working to resolve this. Staff completed incident reports on each occasion and had escalated this to senior managers.

How we carried out the inspection

During this inspection we:

  • spoke with six members of staff, including the ward manager, unit matron and consultant psychiatrist
  • spoke with five children
  • spoke with two children’s relatives or carers
  • looked at the care and treatment records of five children
  • reviewed five incident reports made by the ward
  • observed both the nursing handover and the multi-disciplinary team handover
  • conducted a tour of the ward environment and observed how staff communicated with the children
  • looked at a range of policies, procedures and documents related to the service

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

What people who use the service say

We spoke with five children and two carers.

Both carers were very positive about the service. They reported good communication from the ward, they felt staff were caring and they felt involved in their child’s treatment and care.

Children said staff were mostly caring, helpful and approachable. However, three children mentioned there were one or two staff members who they felt were not caring.

16 Jan – 2 Apr 2019

During an inspection of Community-based mental health services for adults of working age

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.

10 - 11 September 2018

During an inspection looking at part of the service

We rated the service as good because:

  • Improvements had been made following the serious incident that occurred in June 2018 in which a patient was injured after fixing a ligature. The window fixtures had all been replaced. Changes had been made to the admission process so that both a doctor and a nurse made a joint initial assessment of patients. Additional checks were made during each shift to ensure the alarm system was working.

  • Overall, the service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents. Staff and patients were debriefed and offered support following incidents.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Comprehensive assessments were completed on admission to the service. Care plans were personalised, holistic, included the patient’s views and were regularly reviewed and updated. Staff monitored patients’ physical health and took appropriate action when needed. Outcome measures were used to measure the effectiveness of treatment programmes. Regular clinical audits were completed.

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. There were always enough staff to safely deliver care and treatment.

  • The service made sure staff were skilled and competent for their roles. Managers appraised staff’s work performance and held regular supervision meetings with them. The service provided mandatory and specialist training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

  • The service assessed and managed individual patient risks appropriately. An individualised approach meant that patients were not subject to blanket restrictions.

  • Staff gave patients specialist care to ensure their nutrition and hydration needs were met safely and their health improved. They used special feeding and hydration techniques when necessary and staff were trained in these areas.

  • The service prescribed, gave, recorded and stored medicines safely. Patients received the right medicines at the right dose at the right time. A pharmacist visited the ward each week and completed a regular audit to check that medicines were managed and administered safely by staff.

  • Staff of different disciplines worked together as a team to benefit patients. The service also worked well with external teams and professionals.

  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

  • Staff cared for patients with compassion. Patients were partners in their care. Staff worked hard to involve patients’ families and carers, despite some of them living far away.

  • People could access the service when they needed it. Most patients were admitted to and discharged from the unit to the outpatient part of the service. Staff planned effectively for patient discharge and worked well with other professionals and teams to ensure effective transfers of care.

  • The service had suitable premises and equipment and looked after them well. The service was clean and well maintained and staff followed infection, prevention and control procedures. The facilities promoted comfort, dignity and recovery.

  • The service took account of patients’ individual needs and staff worked hard to meet the diverse needs of the patient group. This included providing support to make LGBT+ patients feel welcome and protect their needs. Staff supported patients’ engagement with ongoing education opportunities and important relationships.

  • The service had managers at all levels with the right skills and abilities to run the service effectively. Staff also told us that senior leaders had been especially supportive following the serious incident that took place in June 2018. Managers across the service promoted a positive culture that supported and valued staff. Staff achievements were recognised by local leaders and through a trust wide annual awards ceremony.

  • Governance systems to ensure the effective running of the service were in place. The trust had effective systems for identifying risks and managing and reducing these. The service treated concerns and complaints seriously. Staff understood their responsibilities regarding complaints and made sure information was available for patients.

However;

  • Whilst appropriate arrangements were in place to protect patients against the risks associated with ligature anchor points, the unit ligature risk assessment did not include some ligature anchor points and did not clearly state how staff should mitigate the risks that had been identified. This was escalated to the manager at the time of the inspection.

  • Whilst overall the service managed patient safety incidents well, further improvements were needed to ensure that lessons learnt were always consistently shared with the whole staff team.

  • The induction process for temporary staff was not formalised which meant there was no assurance that temporary staff could consistently meet the specific needs of the patient group.

  • A small number of patients said that some temporary staff had occasionally acted in an abrupt manner.

  • Staff we spoke with were not aware of who the trust’s freedom to speak up guardian was or how to contact them.

October 2016 to May 2017

During a routine inspection

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

After this most recent inspection we have changed the overall rating to good because:

  • Following the last inspection In February 2015, the trust had implemented a comprehensive improvement plan.
  • In February 2015, we rated one of the sixteen core service as inadequate and a further two of the sixteen core service as requires improvement. At this inspection we found the trust had worked to make improvements and the trust had taken action to meet the requirement notices issued following the February 2015 inspection.
  • In February 2015, we recommended the trust should take a number of actions to improve services. At this inspection we found that the majority of recommendations had been met and improvements had been made.
  • Following the this inspection, we have changed ratings of the following key questions from inadequate to requires improvement:
  • the safe key question for wards for adults of working age and PICU
  • Following the this inspection, we have changed ratings of the following key questions from inadequate to good:
  • the responsive key question for adults of working age and PICU
  • Following this inspection, we have changed ratings of the following key questions from requires improvement to good:
  • the well led key question for wards for adults of working age and PICU
  • the effective key question for wards for older people with mental health problems
  • the caring key question for wards for older people with mental health problems
  • the responsive key question for wards for older people with mental health problems
  • Following this inspection we have changed the ratings for the following key questions from good to outstanding:
  • the effective key question for wards for people with learning disabilities or autism
  • the caring key question for wards for people with learning disabilities or autism
  • the responsive key question for wards for people with learning disabilities or autism
  • Following this inspection we have changed the rating of one core service from inadequate to good. This is the core service for wards for adults of working age and PICU.
  • Following this inspection we have changed the rating of one core service from requires improvement to good. This is the wards for older people with mental health problems.
  • Following this inspection, we have changed the rating for one core service from good to outstanding. This is the core service for wards for people with learning disabilities and autism.
  • Following this inspection the rating for one core service remains as requires improvement. This is the core service for community services for adults of working age.
  • We have not yet re-inspected the rehabilitation mental health wards and crisis services and health based places of safety. The requirement notices for these services will be checked at future inspections.

  • We also carried out a ‘well led’ review and found that the trust had continued to strengthen its senior leadership team and refine the trust governance processes.

27 and 28 Mach 2017

During an inspection of Wards for people with a learning disability or autism

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.

30,31 January and 3 February 2017

During an inspection of Wards for older people with mental health problems

Following this inspection, we rated wards for older people with mental health problems provided by Central and North West London NHS Foundation Trust as good because:

  • During this most recent inspection, we found that the services had addressed the issues that had caused us to rate effective, caring and responsive as requires improvement following the February 2015 inspection.The provider had made many improvements since the last inspection and had addressed all previous breaches of regulation and almost all of the previous recommendations.

  • The wards for older people with mental health problems were now meeting Regulations 9, 10, 12, and 13 of the Health and Social Care Act (Regulated Activities) Regulations 2014

  • Wards were clean and well maintained. The risks for individual patients were identified and managed to ensure that patients were safe.

  • Staffing levels supported the delivery of care. Escorted leave and activities were rarely cancelled due to staffing levels although some staff said they did not always manage to complete one to one sessions with patients or to take a break during their shift.

  • Patients’ needs were comprehensively assessed upon admission. Care records reflected patient’s individual needs, choices, preferences, and staff had the knowledge and skills to meet these.

  • Patients had good access to physical healthcare including access to specialists when needed.

  • Staff told us that they were supported with their work, training and professional development to effectively meet patients’ needs.

  • Patients described staff as caring and kind and told us they were treated with dignity and respect. Where patients were unable to tell us, we saw staff treat patients with kindness and compassion. Relatives and carers told us staff appropriately involved them in planning and reviewing patient care.

However:

  • However, there were findings at this most recent inspection that led to a continuation of rating safe as requires improvement.

  • Staff at St Charles MHC were not clear about the reporting of incidents of restraint when used to deliver personal care.

  • Environmental risks such as plastic bags and some blind spots had not been considered on Kershaw and Redwood wards. There was no overall environmental risk assessment and the ligature risk assessment for the garden at TOPAS ward was insufficient.

  • Staff at Beatrice Place did not receive clinical supervision in line with the trust policy.

  • Two capacity assessments at Beatrice Place contained very brief information, lacked detail about any assessment or discussions that had taken place. The legal status of one patient on Kershaw ward regarding their DoLS application had been incorrectly recorded.

1,3,4,5 and 6 October 2016

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

Following this inspection, we rated acute wards for working age adults and the psychiatric intensive care unit (PICU) as good because:

  • In February 2015, staff on the wards were not properly managing ligature risks that they had identified. When we visited in October 2016, staff were taking appropriate steps to manage ligatures.

  • In February 2015, staff were not effectively managing blind spots on the wards and observing patients safely was difficult. When we re-visited in October 2016, staff were managing blind spots appropriately.

  • In February 2015 staff were not putting appropriate measures in place to help reduce the numbers of patients absconding from the wards. During this inspection we saw that measures had been put in place to reduce the numbers of patients absconding.

  • In February 2015, not all staff were trained in how to undertake the safe physical restraint of patients. During this inspection we found that staff had completed necessary restraint training.

  • In February 2015 the records completed by staff relating to the seclusion of inpatients did not provide clear evidence that staff had undertaken seclusion in accordance with the Mental Health Act Code of Practice. During this inspection we found that records overall showed that staff had secluded patients appropriately and monitored them when this had taken place.

  • In February 2015, staffing levels were not sufficient to guarantee the safety of patients and staff and that the lack of staff had a significant impact on the quality of life of patients. During this inspection the wards had sufficient staff on duty to meet patients’ needs.

  • In February 2015 the wards were over-occupied and there were no plans to managed needs which impacted upon the experience of patients using the services. During this inspection we found that plans were in place to manage these issues more effectively.

  • Bed management across the inpatient sites had improved considerably since the last inspection and was closely monitored by the trust.

  • In February 2015, we saw that information had not been available to inform patients how to make a complaint on the PICUs. At this inspection, we saw that information about complaints was visible on all the wards we visited.

  • In February 2015 we found that patients were not always able to make phone calls in private. At this inspection we found that all patients were able to make private calls.

  • Patients told us that they felt safe on the wards. Wards across all sites were clean and well maintained.

  • Multidisciplinary teams were consistently and pro-actively involved in patient care, support and treatment.

However:

  • In February 2015 we found staff were not always attending adequately to patients’ physical health needs and monitoring of physical observations following administration of rapid tranquilisation RT tranquilisation (RT). At this inspection we found that some improvements had been made but there were still gaps in the recording of physical observations.

  • Staff did not always keep good records when physical restraint was used.

  • Further work was required to monitor and reduce the use of restraint and prone restraint across the service in line with national best practice guidance.

  • Systems to monitor patients physical health and to ensure that where the patient was deteriorating, appropriate help was made available were not being used consistently.

13 February 2015, 24-27 February 2015, 4-5 March 2015, 9 March 2015

During an inspection of Community-based mental health services for adults of working age

We gave an overall rating for community based mental health services for adults of working age requires improvement because:

  • Not all services had properly maintained automated external defibrillators (AED) machines to be used in the event a person had a cardiac arrest.
  • The standard of some risk assessments was poor. They were out of date and lacked detail. Important information was not included.
  • There were insufficient staff available to work as care co-ordinators which meant that duty workers in some services were responsible for supporting a number of patients. This meant the safety and welfare of patients was potentially at risk.
  • Patients were not always referred for regular physical health checks when they should have been.

However, overall the quality of care and treatment was good. Staff were respectful, compassionate, caring and committed to their work. Learning from incidents and complaints led to improvements in care. Urgent referrals were prioritised and urgent assessments took place promptly. Most patients felt involved in their care. Services used a variety of strategies to meet the needs of a very diverse population particularly in Brent and North Westminster.

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.

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.