Central and North West London NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders at all levels were knowledgeable, experienced and capable. Leaders had a clear vision for quality improvement and a proactive governance framework, enabling senior leaders to have a good oversight of the service. Most staff reported a good team morale and confidence in senior management.Staff raised concerns regarding estate issues and lack of space. The service was aware of the impact and were in the process of looking at ways to mitigate these ongoing issues.

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 had a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and communities.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing.

The service had inclusive leaders with the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

Senior leaders were skilled, experienced and knowledgeable. They had a strong understanding of the services they managed. They could explain clearly what improvements had been made and what they expected to be achieved in the near future.

The service manager was skilled, knowledgeable and experienced. Staff told us that they found the manager approachable and knowledgeable.

The service trust had a Freedom to Speak Up Guardian. Information on how to contact the Freedom to Speak Up Guardian was available to staff. Staff said they felt confident in raising concerns about poor professional practice or inappropriate conduct towards patients.

The service worked towards an inclusive and fair culture by improving equality and equity for people who worked there.

The service trust had a variety of support networks set up for staff. These included a multicultural network and a network for lesbian, gay, bi-sexual and transgender staff.

The service employed a diverse team of staff from international backgrounds. Employment practices promoted equality of opportunity. Staff did not raise any concerns about discrimination.

The service had clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support.

The service held monthly senior management team meetings, clinical quality meetings and a business meeting for the team. There was a clear framework of what must be discussed in meetings to ensure that essential information, such as learning, was shared and discussed. Clinical quality meetings covered standard agenda items including learning from incidents, service user feedback and quality improvement.

The service had a risk register. This was a perinatal wide risk register for the five boroughs and not service specific. Three items were on the register and reflected the areas staff and managers were aware of and had plans to mitigate. This included estate issues, access targets and recruitment for a clinical psychologist.

Staff did not undertake a wide range of clinical audits. Managers were aware of this and said that they were looking at making improvements to the existing audit schedule. Audits support assurance processes and allow staff to act on the results and make improvements where required. There was an audit for handwashing and care plan and risk assessments.

The service worked well with other agencies including health and social care professionals and the local authority. Where they had identified areas for improved communication and joint working, the service had plans to meet and discuss ways in which they can improve joint working.

Staff engaged with their professional bodies and undertook specific roles within these organisations.

The Trust uses QI methodology which encourages a culture of continuous improvement through PDSA cycles. The service is currently undertaking a QI project in relation to female asylum seekers and the support they needed andcould access.

The service was a member of the Perinatal Quality Network with the Royal College of Psychiatrists and undertook annual peer reviews. The service had not applied for accreditation because of lack of clinical psychological input. At the time of the inspection a advert was active to recruit into this role.