Central and North West London NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

Some aspects of care were not always safe.

Staff did not report all incidents and did not always manage identified risks consistently. At the Campbell Centre, we observed examples of too much force being used with some patients during physical restraint. There were not always enough staff to support the therapeutic needs, activities and leave for patients. We identified some issues with medicines.

At our last comprehensive assessment, published in June 2019, we rated this key question Requires Improvement. At this assessment the rating has remained as Requires Improvement.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive culture of reporting and learning to improve safety, but needed to address inconsistencies in what staff reported and how incidents were scored. We saw that staff reported most incidents using the trust electronic system, but at the Campbell Centre, we identified 5 incidents in patient notes that had not been reported or did not include sufficient detail. At Park Royal, we saw inconsistency in how staff graded incidents.

Staff told us and records confirmed, that staff could access post incident debriefs after most incidents. Patients involved were usually offered a debrief post incident.

During an inspection of the Campbell Centre in April 2023, we asked the trust to ensure that staff fully embed any learning from incidents. During this inspection, we saw that the trust had introduced or strengthened initiatives for immediate and long-term learning. For example, adding incidents from the last day to staff safety huddle meetings, reflective learning sessions and including immediate lessons in incident reports. We saw these things in practice across wards and that there had been an improvement in how learning was shared and embedded. However, there was more work to do in sharing important learning across sites. At the Campbell Centre and Northwick Park, not all staff could give examples of trust wide learning from incidents at other sites.

Staff could describe responsibilities under the duty of candour, in being open and transparent, and gave patients and families a full explanation if and when things went wrong.

The service’s referral and admission processes ensured that essential information about the patient was received to determine if the patient’s needs could be met.

Staff had access to or knew how to refer to necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

There were policies and procedures for staff to manage sexual safety. Patients and relatives said they told staff if they were concerned about behaviour of other patients and one relative said their concerns were taken seriously. Despite this, 3 relatives told us the patient did not feel safe on the wards due to other patients, noise levels and safety concerns from the opposite sex.

At an inspection of the Campbell Centre in April 2023, we asked the trust to reduce the number of safety incidents on the wards. During this inspection, we saw the trust had introduced and partially embedded a number of approaches to do this and were tracking the reduction over time. The work included new treatment pathways, staff education sessions, increased activity in therapeutic timetables and improving the quality of care plans. The site introduced a 2pm staff huddle in addition to the morning huddle. This was to improve oversight of safety incidents, leadership and multidisciplinary team participation and safety planning. Meetings were chaired by a senior member of staff who had focussed on improving the effectiveness of the meetings.

In most records we saw that safeguarding incidents were reported in line with trust policy and associated risks had plans in place for their management. In a small number of cases, we identified this had not been done. For one patient with identified safeguarding risks to others, including staff, there were no plans to manage this on the ward and after discharge.

Senior staff had identified low reporting from some wards and had plans in place to improve knowledge and practice.

Data on safeguarding alerts was shared in a quarterly report with the divisional director of nursing and the integrated care board. There was, however, limited thematic analysis of this information.

94% of staff had completed mandatory training in safeguarding adults and 96% in safeguarding children.

Across the trust staff were involved in several quality improvement projects to reduce or improve restrictive practise and we saw these in practice.

The trust had some restrictions in place at St Charles with regards to types of snacks available, due to safety work underway to reduce the identified risk of choking. The impact of these restrictions on patients was fed back to the trust, which is taking this into account as part of the work underway, to reduce risk in a proportionate way.

Staff kept clear records of seclusion and reviews. However, most records did not include a clear rationale for the termination of seclusion.

We found one area of serious concern. Not all wards were practising physical intervention in line with the trust’s restrictive interventions reduction programme or the Mental Health Units (Use of Force) Act 2018. At the Campbell Centre, we observed examples of inappropriate restraint and too much force being used at this site on CCTV recordings. We raised this with the trust immediately and took enforcement action. The trust took immediate steps to address this.

Staff assessed risk but did not always manage risks to patients and themselves well.

We looked at 28 patient records. In a small number of these, we saw that staff had not created clear management plans for identified risks and staff did not always update risk assessments after incidents. Across Northwick Park and Riverside, 3 records did not include up-to-date information about known risks. In 5 of 16 records across St Charles and the Campbell Centre, there was no evidence of risk mitigation after risks being identified.

At St Charles, there were some patients who had a risk of choking. Not all staff could clearly explain which patients were at risk nor identify mitigation plans. For one patient, whose risk management plan stated he needed to be observed while eating, patient records indicated sometimes this was taking place and sometimes it was not. For one patient, who had suffered an incident of choking, staff did not create a management plan for this risk until three days later.

There was ongoing improvement work across St Charles in the management of choking risks. This included regular simulation exercises and increased staff training on patient assessment and risk identification supported by a newly appointed Speech and Language Therapist for the unit. The service were piloting a newly developed choking risk assessment specifically designed for acute mental health patients. The service had undertaken research which has been published nationally into choking risks on Acute wards.

During inspection in November 2020, we asked the trust to ensure there were appropriate measures in place to manage and mitigate known risks for individual patients. Although we saw risk was being managed well for some patients, this was not consistent, so this is still an area of concern.

At an inspection of the Campbell Centre in April 2023, we asked the trust to ensure staff updated risk assessments after patient safety incidents. During this inspection, we found this was not yet consistent. Work to improve this since the last inspection included daily checks on reported incident links to risk information and weekly audits shared with senior staff. In March 2024, Willow Ward achieved an 85% compliance rate.

At Riverside, staff had developed white board meetings to review patient risks and management.

Staff carried out necessary physical health reviews for patients in seclusion. Staff could use an electronic vision-based monitoring system to record patient respirations when activated, which was less disruptive to the patient.

The trust assessed the safety of the physical environment and used staff observations, convex mirrors and CCTV in communal areas to monitor patients.

Annual ligature assessments detailed locations of risks and mitigations, but new risks were not always identified. On Shannon Ward, we identified risks in the garden and alerted the team immediately. We observed two patients access spaces without necessary staff supervision.

In April 2023 we asked the trust to ensure that ligature assessments at the Campbell Centre were comprehensive and we now saw this in place.

The wards complied with guidance on mixed sex accommodation.

Staff and patients had easy access to alarm systems which were serviced promptly. The trust had successfully addressed this as an area of concern from an April 2019 inspection.

Wards were compliant with fire safety requirements.

All sites had seclusion rooms which allowed clear observation, had a toilet, intercom and clock. Some rooms had a screen fitted that allowed patients to play games, watch TV and listen to music.

Clinic rooms were fully equipped, with accessible, regularly checked resuscitation equipment and emergency drugs.

Staff carried out different levels of observations, determined by assessed need. At an inspection of the Campbell Centre in April 2023, we asked the trust to ensure that observations of patients on Willow Ward were carried out in accordance with trust policy and comprehensively recorded. To address this, the Trust introduced an IT application to allow for the electronic recording of observations. To allow for robust record keeping, data is captured even if there is a lapse in connectivity and will be synced when reconnected, so the accuracy and completeness of records is maintained.

Although the trust calculated safe staffing levels for each shift and ward based on patient numbers and acuity, we observed there were not always enough staff to support patient's therapy needs, escorted leave or activities. This was an area the trust had put significant effort into since an inspection in April 2023 at the Campbell Centre, but remains an area for improvement across wards.

Feedback from some staff was that the number of tasks allocated to 1 person was not always achievable. On Amazon Ward, 2 staff were meant to be present during mealtimes to mitigate risks from choking, but staff said often only 1 could do this due to staffing levels and other tasks taking place, such as dispensing medicines.

Patients at St Charles and the Campbell Centre said not enough staff were always present in communal areas. At 2 points during our inspection of the Campbell Centre in August 2024, there were no staff visible in the communal ward areas. At the Campbell Centre, patients told us they sometimes attempted to intervene in incidents with other patients when there were not enough staff. We saw one example of this on CCTV recording.

Since an inspection of acute wards in November 2022, we saw the trust had successfully ensured care was delivered by a more consistent group of staff on Willow Ward.

The service had enough daytime and night time medical cover.

Staff had a range of mandatory training modules and the compliance rate for was averaged at 87% across all wards. The lowest compliance rates were in immediate life support, with 10 wards between 54% and 64%.

The trust provided face to face emergency physical health and resuscitation simulation training including ligature response, choking and cardiac arrest. Choking was also included in basic life support and emergency life support.

Managers supported staff with appraisals, managerial and clinical supervision. Completion rates were 91% and 92%. Staff, including bank staff received an induction.

Staff completed regular audits of the environment to assess areas for maintenance and cleanliness. However, during our inspection at the Campbell Centre, the seclusion room had a strong malodour and had bodily fluids on some parts of the walls and furniture. There was no evidence that staff had identified this in a timely way.

The trust were aware that some wards had mice present and had a contract with pest control to try to address this.

We identified several areas that needed addressing in the management of medicines.

Controlled drugs stock checks were carried out daily, but we saw entries in the controlled drugs register scored out and incomplete controlled drugs order book entries. This was not in line with legal requirements. Furthermore, we found discrepancies with the running balance of a schedule 2 control drug which had not been identified by staff.

In 12 records across several wards, recording of post rapid tranquilisation physical health monitoring was either inconsistent or incomplete. The trust had identified this as an area for improvement and was embedding improved practice in this. A trustwide audit from September 2024 showed that compliance with vital signs monitoring post rapid tranquilisation was 91%.

We were not assured that ‘when required’ (PRN) medicines to manage anxiety and agitation were being used appropriately. Clinical documentation of patients’ presentation did not always reflect the reason patients were given PRN medicines.

Medicines were stored safely and securely. We observed staff administering medicines in a caring and dignified manner.

Allergies were clearly recorded in the electronic prescribing and medicines administration system

Staff reviewed each patient’s medicines regularly and provided advice to patients and carers about their medicines. Most patients told us they were aware of the medications they were taking and had spoken to staff about them.

During this inspection we saw that the trust had addressed concerns raised from an inspection in November 2020 about specific processes to manage and administer medicines safely on Eastlake ward.