Central and North West London NHS Foundation Trust

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The service provided regular multidisciplinary reviews and tailored therapeutic interventions. They provided a range of treatments suitable to the needs of the patients in line with national guidance about best practice.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service planned and delivered people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

Staff provided a range of care and treatment interventions suitable for the patient group.

Staff completed a plan of care after an assessment and sent this in a letter to the patient.

The service offered advice on the risks and benefits of using mental health medication in pregnancy and breastfeeding, care planning for pregnant women with severe mental health problems, planning for the postnatal period to promote wellbeing and prevent relapse. The service also facilitated access to the most appropriate type of psychological interventions suitable to the patient’s needs.

The service had set up two groups for patients to join; the peer support worker group, the baby massage group and a singing group, which was facilitated by an occupational therapist.

The service offered training and education to service users and their partners, relatives and friends, health and social care professionals.

Staff took part in case and risk assessment audits every three months, leaders said that where areas for improvement in care planning and risk assessment was identified for the team, they had plans in place to offer training to staff.

Staff held regular and effective multidisciplinary meetings. There were professionals involved in the assessment and review of patient’s health, care and treatment, wellbeing and communication needs.

Staff shared information about patients at effective handover meetings within the team. The multidisciplinary team met each day to review patient risks.

The team had effective working relationships with other teams in the organisation. Staff told us that they worked well together with most services. For example, GP’s, maternity wards and health visiting teams. They had identified two external teams/services (Social Services and Community Mental Health Teams), where communication and working together could be improved and managers told us that they had plans to meet with these services to discuss how they can work together to improve communication of information.

The service supported people to manage their health and wellbeing so they could maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

Staff supported patients to live healthier lives. For example, staff discussed healthy eating advice and supported patients to change their eating and exercise habits. The service ran a walking group and a baby massage group. The importance of hydration and breastfeeding advice was offered to patients. The negative impact of drugs and alcohol were discussed with patients and referrals could be made to external services for support with living healthier lives.

Staff supported patients to access services to support their physical health care, including specialists as required. Patients could access physical healthcare monitoring and tests via their GP. The service offered physical healthcare checks/monitoring or tests if required, this was in line with NICE guidance.

Staff continuously monitored patients’ health, their mental state and well-being. A daily risk meeting, staff noted details of patients’ risks and compliance with medication. Any changes in a patient’s presentation were discussed at the daily meeting.

The service used an electronic record system which was used daily. Each system had clear categories to identity what documents each stored. We found that all staff were using the system, however some of the information would be stored in different places making some information difficult obtain.

Staff used recognised rating scales to assess and record the severity of patients’ conditions and care and treatment outcomes. For example, the team routinely used the Health of the Nation Outcome Scales (HoNOS) to measure mental health and social functioning. They also used Core 10 question assessment for all patients, this tool measures psychological distress over the past week. Other measures used were EPDS, GAD- 7, SASPD and the Antenatal and Postnatal Maternal Attachment scale and this was used on a case-by-case basis.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff considered each patient’s capacity to consent to assessment and treatment and recorded this where necessary.