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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

Governance processes had not ensured that all patients were receiving consistently safe care and identified risks were always managed appropriately.

The trust had addressed and improved several areas since the last inspection. There remained a few areas from previous inspections that needed continuous or further work.

However, successes were recognised and celebrated. The trust engaged with external stakeholders well and collaborated with them. The trust had a proactive approach to quality improvement, and we saw the positive impacts of several projects.

At our last assessment, published in June 2019, we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had visions and values in place. Although we saw these values displayed in many areas of care, there were still improvements needed to ensure all patients received consistently safe care and identified risks were appropriately managed.

Senior staff had identified areas for improvement and developed approaches to embed these, but there were a number of additional areas of improvement identified during the inspection that we highlighted to the trust.

Leaders recognised celebrating success and this was supported and encouraged by initiatives and events across the trust.

The trust had a freedom to speak up policy and system in place. Staff told us they were aware of this and most said they were comfortable to access it. We saw posters about how staff could raise concerns with the Freedom to Speak Up Guardian or senior staff. The Guardian collated themes and feedback in order to promote organisational improvement and learning.

A small number of staff told us they would not trust this process to be confidential, therefore had not accessed it with issues they may have wanted to raise. At the Campbell Centre, feedback from some staff was that their voice was not heard as well as it could be, when feedback was given about experiences at work. The trust had done focussed work at the Campbell Centre to improve mechanisms to gather and hear staff feedback and was continuing to strengthen this process.

The trust valued diversity in the workforce and had several initiatives to promote an inclusive and fair culture, improving equality and equity for their staff. Staff were able to access several staff networks. These were the lesbian, gay, bisexual and transgender (LGBT+); Black, Asian and ethnic minority (BAME); carers; women; lived experience of mental health stigma transformation; and disability.

The trust took part in internal and national programmes of equality monitoring to gather information and identify areas for improvement, if needed.

There were service level and ward level governance processes in place to give managers and leaders information about performance, risks, and needs, in order to identify and drive improvements across all wards. This included data on training compliance, action plan compliance, incidents, risks, audits, as well as information from staff listening events, engagement with relatives and patient feedback forms. Teams had clear frameworks of what must be discussed at different meetings to ensure staff were kept up-to-date with important information.

Our findings from the other key questions demonstrated that localised governance processes were not always effective in identifying issues or driving improvement. At ward level, there were several audits in place, but these did not always pick up issues. Audits had not identified some errors or gaps in patient notes, delays in uploading documents or some medicines issues. On several wards we identified environmental risks or issues not identified in audits.

The trust still had work to do in comprehensively addressing a number of issues identified in previous inspections. For example, consistent safe management of identified risks.

Staff had access to equipment and information technology to support them to do their work.

Managers and senior staff were able to manage performance issues appropriately. Managers and senior staff had access to a range of information about the performance of the service, staffing and patient care.

The trust ran a programme of scenario-based simulations for emergencies and disruptive events.

Services and leaders understood who their partners and communities were and engaged with external stakeholders. For example, commissioners and organisations such as Healthwatch. Services shared information and learning with partners in order to collaborate on improvement. The trust had worked with Healthwatch to support focussed work on patient engagement and feedback at the Campbell Centre.

The trust had a positive approach to quality improvement, and we saw that staff were involved in several quality improvement projects across sites. Staff were given time and support to consider opportunities for improvements and innovation and we saw examples where this had led to changes. Eight wards across different sites took part in an improvement programme from July 2023 to July 2024 aiming to reduce the number of episodes of seclusion and time spent in seclusion. At St Charles wards, there was a significant reduction in time spent in seclusion, with a 39% decrease. This continued to be maintained after the programme closed. Shore Ward were able to reduce episodes of seclusion and had none in a 6.5 month period. Danube Ward had reduced average length of stay from 100 days in August 2023 to 19 days by May 2024.

At Riverside, the manager had supported an idea from staff for an outdoor gym in the ward garden. The wards had also successfully introduced the use of patient tablets to use on the ward instead of phones with cameras. They reported this had reduced incidents as patients could engage in various activities such as listening to music.

The trust was embracing digital technology in some areas of care. Although some practice still needed embedding and connectivity needed improving in some areas. This was working well in electronic medicines prescribing systems.

The trust was part of the NHS benchmarking network and took part in annual national mental health benchmarking projects.

The trust had an environmental sustainability plan that came into place in January 2022. There were green champions in place and a sustainability steering group, with progress reviewed every three months. The trust's energy was from clean renewable tariffs, and they did not have waste going to landfill from mental health facilities. Using an electronic patient records system and other electronic systems, the trust had reduced paper usage and the need to print documents.