All inspections: West London NHS Trust - Care Quality Commission

West London NHS Trust provides a range of community based mental health services for adults of working age throughout the London boroughs of Ealing, Hammersmith and Fulham and Hounslow. Some adults receiving services may be subject to conditions under the Mental Health Act 1983.

During this inspection, we visited the Mental Health Single Point of Access (SPA) and two crisis assessment and treatment teams (CATTs). This inspection was short notice announced (staff knew we were coming) to ensure that everyone we needed to talk to was available.

The SPA provides a single-entry point for referrals to secondary mental health services and support in a mental health crisis in the boroughs of Hounslow, Hammersmith and Fulham, and Ealing. The SPA is open 24 hours a day, 7 days a week, 365 days a year as a telephone triage service. The team screens all referrals and, if required, carry out assessments over the phone. This enables them to find out how they can help and then use that information to signpost patients to a service who can best meet their needs. At times of mental health crisis, the SPA works closely with partner organisations from across the public and private sectors and the CATTs, to direct people to the most appropriate services to aid their recovery.

The CATTs are mental health services based in the community. The West London NHS Trust CATTs support people in Ealing, Hammersmith and Fulham, and Hounslow. They support adults aged over 18 years old, in mental health crisis, or those needing intensive home-based support. CATT services aim to support people at home, so they don’t have to go into hospital.

CQC previously inspected this core service in August 2018, and we rated it as good overall, but requires improvement for safe, and outstanding for caring. During this inspection, we did not re-rate this core service as it was not proportionate to do so. This was because this was a focused inspection of the SPA service and two of the CATT services (Hammersmith and Fulham CATT, and Hounslow CATT), that covered the safe and well-led key questions in full, and one part of the responsive key question. This was due to intelligence we had received prior to the inspection. We did not inspect, or report on the key questions of effective and caring. We also followed up the concerns found in the last inspection.

Our rating of this location remained as good because:

Patients were very complimentary when talking about staff, reporting they were understanding, supportive, calm, caring and friendly. Patients told us they felt listened to and involved in their care.
The SPA and CATTs met target response times for responding to very-urgent, urgent, and non-urgent referrals.
The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and wider service.
Leaders had the skills, knowledge, and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service and approachable for patients and staff. They recognised that the teams still had work to do, and there were good plans in place to achieve this work. Staff in the CATTs spoke highly of the new service managers.
Staff felt respected, supported and valued. They said the trust promoted equality and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.

However:

Some patients in the Hounslow CATT did not have safety or crisis plans in place, and risk assessments varied in the consistency of how they were recorded. However, staff in the team had a good understanding of patient risk and knew what action to take if patients were high risk.
Staff in the CATT services were not following lone working protocols. Lone working devices did not often work properly, there was a lack of chargers and their usage was low.
Staff across the three services we inspected reported frequent problems with IT equipment and system outages.
Medicines reconciliation and medicines storage was not always safe in the Hammersmith and Fulham CATT. Controlled drugs were not stored safely, in accordance with The Misuse of Drugs Act 1971.

What people who use the service say

We gathered feedback from 13 patients across the SPA, Hammersmith and Fulham CATT, and Hounslow CATT.

Patients told us the services were excellent and wouldn’t suggest any improvements.

Patients were very complimentary when talking about staff, reporting they were understanding, supportive, calm, caring and friendly.

Patients told us they felt listened to, involved in their care and that they had copies of their care plans. They were aware of how to contact the service and had other specialist numbers to use too, if they felt very unwell.

Most patients told us the service had flexibility and choice in the appointment times available and appointments were rarely cancelled. Some patients said when appointments were cancelled, the service offered another appointment very soon after.

West London NHS Trust provides a range of community based mental health services for adults of working age throughout the London boroughs of Ealing, Hammersmith and Fulham and Hounslow. Some adults receiving services may be subject to conditions under the Mental Health Act 1983.

During this inspection we visited 3 Mental Health Integrated Network Teams (MINTs) which were part of the trust’s Community and Recovery Mental Health Services. There are 9 MINT teams across the 3 boroughs, with 3 MINT teams in each borough. Each MINT is aligned to 1 to 3 primary care networks, which are made up of a cluster of general practitioner surgeries.

The MINT teams were set up in 2020 and were developed to reflect NHS England’s long-term plan and the Community Mental Healthcare Framework. The MINT model focuses on supporting people’s mental health, alongside their physical health and social needs, providing joined-up, community-based care tailored for each individual. MINT supports adults 18+ who need a non-emergency response to a mental health issue. The MINT model expands the traditional community mental health model; under MINT, therapeutic intervention and support is accessible to a much wider range of people than was previously the case.

CQC previously inspected this core service in April 2022 and we issued an overall rating of requires improvement, with an inadequate rating for the safe key question. During this inspection, we did not re-rate the core service as it was not proportionate to do so. This was because it was a focused inspection of 3 MINT Teams (Ealing Acton, Hammersmith and Fulham South and Hounslow East), where we looked at the safe and well-led key questions in full, and part of the responsive key question. This was due to intelligence we had received prior to the inspection. We also followed up the concerns found in the last inspection. We did not inspect or report on the key questions effective and caring.

Since the last inspection in April 2022, the MINT teams that we inspected had made some improvements, with improvements made particularly to staffing, staff morale, staff engagement, and data quality and oversight of performance. However, the service still had work to do and was engaged in an improvement process. The service needed time to see the positive effect of recent improvements in staffing, to embed learning and new processes, and to deliver a number of planned work streams. The teams were still working with 2 electronic patient records systems, which caused the same frustrations as the last inspection. There was strong leadership in place across the MINT teams, including at senior level. Leaders were mostly aware of the issues we had identified during the inspection process and were working hard to make the necessary improvements.

The main concerns identified during the inspection were:

In Ealing Acton MINT team, the assessment rooms where staff saw patients did not have working panic alarms or effective mitigation plans in place while they waited for them to be repaired. This put staff and patient safety at risk.
Some patients did not have risk assessments and their risks were being recorded in their progress notes instead. This meant that risk and risk management plans were not always easy to access on the electronic patient record system. However, staff in all 3 teams had good understanding of patient risk and the issue related to the recording of risk correctly in records.
Most staff had received training in safeguarding. However, in Ealing Acton MINT team, 50% of staff had not completed the required safeguarding children and adults level 2 training. This meant that these staff may not know how to recognise and / or take necessary safeguarding actions to protect individuals. Safeguarding training had been booked for 19 November 2023 for all of the Ealing Acton MINT team to attend.
Similarly to the last inspection in April 2022, staff continued to use 2 electronic patient record systems. This meant staff had to review entries on both systems, this caused frustration for staff. We found that staff in Hounslow East MINT team were not regularly reviewing the waiting list for referrals on 1 of the electronic systems. Senior leaders were regularly reviewing the risk of using 2 electronic systems, and had a migration timeline in place to move towards 1 electronic system in April 2024.
Despite the service working hard to reduce waiting times for appointments. The MINT teams still did not meet trust target times for seeing patients from referral to assessment and assessment to treatment. However, compared to the last inspection, there had been a recent improvement in staffing and managers told us this should allow staff to work through a backlog of assessments. New staff also needed time to undergo their trust induction and local training. The issue continued to be monitored on the risk register.

However:

The service had made good improvements to staffing since the last inspection. There were low vacancy rates, with most vacancies covered by agency. The trust had active recruitment plans in place to fill vacant posts. Staff told us they felt that they had enough staff to safely meet the needs of patients. However, due to the high number of new recruits in teams, staff told us it may take time for new staff to make an impact on the day to day work as they undergo induction and learn new trust systems and processes.
Staff followed good lone working practices. This was an improvement from the last inspection, where teams did not consistently use effective lone working systems.
Apart from low safeguarding training in Ealing Acton MINT team, there had been improvements in mandatory training since the last inspection. Most staff had received basic training to keep them safe from avoidable harm. All 3 teams had received training in breakaway training and promoting safe and therapeutic services, these training modules had low compliance at the time of the last inspection.
The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s mental and physical health. However, not all staff were aware of the trust medicine’s policy around the re-use of long-acting depots.
The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and wider service.
Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed and were visible in the service and approachable for patients and staff. They recognised that the teams still had work to do, and there were good plans in place to achieve this work.
Staff felt respected, supported and valued. They said the trust promoted equality and diversity in daily work and provided opportunities for development and career progression. They could raise any concerns without fear.
Senior leaders were dedicated to improving the MINT service and had partnered with an independent healthcare innovation company to improve areas of identified challenges with access into the service. This included a workstream to improve the triage process.

What people who use the service say

Overall, feedback from patients was very positive about the care and treatment they received from staff. Patients told us that they did not have to wait a long for their first appointment. Patients said they felt involved in their care and listened to by staff. One person told us their named worker knew them really well and listened to what was important to them. All patients told us they were able to access support when needed and understood their crisis plan. All patients said staff treated them with dignity and respect. Most patients said they had enough time with staff to meet their needs.

We carried out this announced focused inspection to check on the safety and quality of the service at the women’s forensic service at The Orchard Unit. We looked at specific aspects of safe, effective, caring, responsive and well-led.

During this inspection, we looked at The Orchard Unit only. The Orchard Unit is a women’s service and provides low secure, medium secure and enhanced medium secure (known as WEMSS – women’s enhanced medium secure services) wards. There are a total of six wards. We did not inspect the thirteen male secure wards provided by the trust. The data we reviewed applied only to The Orchard Unit.

We did not re-rate the overall service following this inspection and it remained outstanding overall which was the rating at the last comprehensive inspection in December 2018.

We limited the rating for safe at this inspection to Requires Improvement as we found a breach of regulation. The effective, caring, responsive and well led domains were not rated at this inspection as we were not inspecting the whole forensic service and there was no breach of regulation.

We carried out this inspection because of information of concern shared with us through our national customer service centre.

As part of our inspection we visited:

Aurora ward – 10 bedded women’s medium secure admission ward

Garnet ward – 10 bed women’s medium secure rehabilitation ward

Pearl ward – 15 bed women’s low secure ward

Melrose ward – 10 bed women’s enhanced medium secure admission ward

Parkland ward - 10 bed women’s enhanced medium secure admission ward

The West London Forensic service covers eight boroughs in North West London – Ealing, Hammersmith and Fulham, Kensington and Chelsea, Harrow, Hillingdon, Westminster, Brent and Hounslow. It is part of the North London provider collaborative.

The previous comprehensive inspection of this core service was in September 2018.

At that inspection, we rated the service as outstanding. We rated the service as good for the domains of safe, effective and responsive. We rated caring and well-led as outstanding.

West London NHS Trust is registered to provide the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983

• Diagnostic and screening procedures

• Treatment of disease, disorder or injury.

Our findings from this inspection were as follows:

The ward environments were safe and clean. Patients told us that they were safe. Carers confirmed that their family members were looked after safely. All staff spoke about safety being a priority. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Staff from different disciplines worked together to make sure clients had no gaps in their care. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare.
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 and valued them as partners in their recovery. Staff actively involved patients and families and carers in care decisions. There was a strong person-centred culture which met patients’ unique needs and was embedded throughout the service. Staff helped patients with communication, advocacy, cultural and spiritual support.
Co-production and person-centred care were at the heart of the service. We saw numerous examples of patients being involved in changes and development of the service, including reducing restrictive practices, focus groups on restraint and the co-production of a patient leaflet on racism and its effects on patients and staff.
Staff planned and managed discharge well and liaised with services that would provide aftercare.
The service was well-led and the governance processes ensured that ward procedures ran smoothly.

However:

Whilst the service had a robust improvement plan for the recruitment, retention and development of qualified and non-qualified nursing staff, vacancy rates remained high.
Intermittent observations were recorded at regular and predictable intervals. There was a risk that the patients would know when observations would take place and they could plan any actions around this.
On Garnet ward, the connecting bathroom door in the seclusion suite was kept locked. There was a potential risk of injury to staff and the patient in seclusion whilst the bathroom door was being opened.
Long-term segregation (LTS) care plans did not contain sufficient detail about how LTS was to be brought to an end, did not reflect the patient voice and did not reflect the recommendations from external reviews.
On Parkland ward one medicine incident had not been reported in line with the trust policy.
Team meeting minutes varied in the quality of information recorded. Learning from incidents was not a regular agenda item.
Eight carers we spoke with did not have awareness of the carers forum. Minutes of the main carers meeting were not kept, which meant that there was no audit trail on any actions that required follow up.

The team that inspected the hospital comprised a CQC lead inspector, one inspector, one pharmacist inspector, two inspection managers, one Mental Health Act reviewer, one expert by experience and one specialist professional advisor who had experience of working in forensic services.

Before the inspection visit, we reviewed information that we held about the service. This was an inspection of this service.

During the inspection we asked the following questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive?

• Is it well-led?

During the inspection visit, the inspection team:

visited five wards at the hospital, looked at the quality of the ward environment and observed how staff were caring for patients
carried out a Mental Health Act review visit on Garnet ward
observed and attended three clinical team meetings, one handover meeting, one reducing restrictive practice focus group, one blanket restrictive practices women’s steering group, one community meeting, patient focus group and two long term segregation reviews
spoke with 16 patients who were using the service and nine carers or family members of patients who were using the service. Interviews with carers were completed by telephone. Our final carer interview was on 15 March 2023
spoke with the chief operating officer for forensic services, service director, clinical lead, head of social work and clinical director
spoke with 21 other staff members: including consultant psychiatrists, ward doctors, nurses, healthcare assistants, clinical psychologist, practice development nurses and the physical health lead
looked at eight care and treatment records of patients
reviewed medicine management on Parkland and Melrose wards
looked at a range of policies, procedures and other documents relating to the running of the service
carried out observation exercises on Aurora and Parkland wards

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

What people who use the service say

Feedback from patients was very positive about the care and treatment they received from staff. Patients told us they felt safe, valued and respected. They told us that staff treated them with compassion, kindness, dignity and were non-judgemental. Patients said staff listened to how they were feeling and supported them to understand their care. Patients told us that they were aware of their care plans and were actively involved in their development and review so that they had the support they needed in the way they wanted. Patients told us they had numerous opportunities to attend vocational courses, education and paid employment. Some of the comments we received included ‘I have made huge progress’, ‘here we are listened to, we have a voice, we are not judged, ‘they have helped me build my confidence and ‘I have developed new skills’.

We spoke with nine carers. Overall feedback from carers was positive about the care and treatment their family members received. They told us that their family members were safe and well looked after. Carers told us that they were involved as much as their family member wanted them to be. Comments we received included ‘my relative is in safe hands’, ‘staff are respectful and listen well’ and ‘I am really happy with the care’. Eight of the carers we spoke with did not have awareness of the carers’ forum.

Two carers told us that there was a lack of communication from the ward staff. One carer reported that they did not know when carer meetings were held and being invited to care programme approach (CPA) meetings at short notice. One carer told us that the lack of social worker on the ward made care coordination difficult but was aware that recruitment was taking place. Other carers told us they had regular contact with their social workers and were kept updated about Care Programme Approach (CPA) meetings and Mental Health Act tribunals.

West London NHS Trust provides a range of community based mental health services for adults of working age throughout the London boroughs of Ealing, Hammersmith and Fulham and Hounslow. Some adults receiving services may be subject to conditions under the Mental Health Act 1983.

We visited a sample of the locality teams in each borough. We inspected a combination of early intervention services and Mental Health Integrated Network Teams (MINT).

The Early Intervention Service (EIS) provides specific support and treatment for patients experiencing a first episode of psychosis. The EIS teams had been established for some years and subsequently expanded their remit to provide a service to people between the ages of 12 and 65 years, over a three-year period.

The MINT teams had recently been set up. The MINT model focuses on supporting people’s mental health, alongside their physical health and social needs, providing joined-up, community-based care tailored for each individual. MINT had been developed to reflect NHS England’s Long Term Plan for Mental Health and the Community Mental Health Framework for Adults and Older Adults. MINT supports adults aged 18+ who need a non-emergency response to a mental health issue. The MINT model expands the traditional community mental health model; under MINT, therapeutic intervention and support is accessible to a much wider range of people than was previously the case.

Our rating of the service stayed the same. We rated the service as requires improvement overall but inadequate for safe because:

The main concerns identified during the inspection were in relation to the MINT service.
The service had significant staffing issues across the teams. Overall vacancy rates in the MINT teams ranged from 25% to 35%. Staff told us that high vacancies and turnover rates made it difficult to provide a consistent, high quality service. In line with the new MINT model not all patients had or needed a care co-ordinator which may result in a risk of patients not having their needs met due to the high level of demand in the service. In one team a member of staff had left, and the patients who required a care co-ordinator had not been reallocated which meant they might not be appropriately supported. Patients told us they had experienced changes in their care co-ordinator.
Risk assessments for some patients were brief and did not always explain how a risk was mitigated. There were examples of where new risks had been identified, for example a deterioration in their mental health, but these had not been followed up in a timely manner.
The MINT did not meet trust target times for seeing patients from referral to assessment and assessment to treatment. Delays to patients accessing treatment were significant. Staff told us that these delays were due to increased demand which was 40% higher than anticipated and staff vacancies. Data produced by the trust was unreliable so it was not always possible to identify how many patients were waiting for specific treatments and how long this was taking.
Staff in most teams did not follow clear personal safety protocols, including for lone working. There were multiple systems in use for lone working; this meant that the process could be confusing and that staff may record visits on systems that were not being monitored.
Staff within the MINT teams were currently using two electronic patient record systems. In some cases, staff had to make duplicate entries on both systems which was time consuming, over-complicated and caused frustration for staff. At the time of the inspection the quality of data produced by the MINT teams did not facilitate sufficient oversight of outcomes and performance.
Some clinical premises we visited were not well maintained and one did not have panic alarms fitted.
Supervision rates for March 2022 in the MINT ranged from 17% to 33%. The supervision rates were better in the EI teams, however, there were still months when rates of supervision were low. There was the potential for staff to feel unsupported as a result.
Some staff training modules also had a low compliance rate. This reflects the trust’s decision to suspend courses which could only be offered through face to face teaching during the last two years of the Covid-19 pandemic, which led to a backlog of compliance. The trust told us that this issue is now being addressed. The courses with the lowest compliance rates were breakaway training, promoting safe and therapeutic services (PSTS). For example, the compliance rate was 43% for all staff for breakaway training. Therefore, there was a risk that staff may not be appropriately trained and may not respond appropriately to incidents.

However:

The EIS teams which were longer-established were providing a good level of care and were meeting the needs of their patients. Their prompt response to referrals had been confirmed by the National Clinical Audit of Psychosis (NCAP).
Staff provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. The service provided care and treatment including medication, psychological therapies, psycho-social education and signposting to social opportunities or specialist groups. Compared to the remit of the former recovery teams, the range of needs the MINT teams worked with was very broad.
The teams included or had access to the full range of specialists including peer support workers who met the needs of the patients. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation. The trust part-funded some local third sector organisations so people could receive support tailored to their specific needs.
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.
Overall, feedback from patients was very positive about the care and treatment they received from staff. Patients said that staff were kind and caring and they felt involved in their care.
Although areas of concern were identified during the inspection, senior managers were already aware of these issues which had been identified through the governance processes within the trust and were working to make the necessary improvements.

There are nine MINTs across the London boroughs of Ealing, Hammersmith & Fulham and Hounslow. Each MINT is aligned to one to three primary care networks, which are made up of a cluster of general practitioner surgeries. At the time of inspection there were nine MINTs, three teams per borough.

CQC previously inspected this core service pre-MINT in September 2018 and issued an overall rating of requires improvement. During this inspection we rated this core service as requires improvement overall and requires improvement for the safe and responsive domains.

This inspection was short notice announced (staff knew we were coming) to ensure that everyone we needed to talk to was available.

The CQC inspection team that inspected the service included four CQC inspectors, two inspection managers, one specialist advisor who was a registered mental health nurse and one expert by experience who contacted patients and carers on the telephone. Before the inspection visit, we reviewed information that we held about these services and information requested from the trust. During the inspection visit, the inspection team:

visited six services and looked at the quality of the environment
spoke with eight patients and six carers
spoke with six team managers
spoke with 44 other staff members including consultant psychiatrists, registered mental health nurses, clinical psychologists, counselling psychologists, mental health associates, occupational therapists and social workers
attended and observed seven meetings, which included a zoning meeting, triage meeting and a meeting with local primary care leaders
reviewed 24 care and treatment records
reviewed medicines management
looked at a range of policies, procedures and other documents relating to the running of 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

Overall, feedback from patients was very positive about the care and treatment they received from staff. Patients said that staff were kind and caring and that they felt involved in their care. Most patients we spoke to had received services from the trust for a number of years. They felt that there had been a huge improvement since the MINT transformation. The only issue occurred during the transition from the old system to MINT. Most patients told us they were not informed of the change and did not immediately understand the new model. Patients told us that now everything was very clear and positive with effective interventions and good quality of care. However, some patients also fed back that there had been multiple changes to their care-coordinator.

Feedback from carers was positive about the care and treatment family members received. Relatives told us that staff were supportive and they kept them involved in their loved one’s care.

We carried out this announced focused inspection to check on the safety and quality of the service at Broadmoor Hospital and whether improvements had been made as a result of the requirement notices issued at our previous inspection in June 2018. In December 2019 the hospital moved into purpose-built accommodation on a new hospital site. In addition, four existing wards were retained and incorporated into the new hospital. Unfortunately the patients had not yet fully benefitted from all the facilities and communal areas due to restrictions on patients mixing as a result of COVID-19 but the new ward areas had played a vital role in preventing the spread of infection as all patients now had ensuite bathrooms and easy access to fresh air.

Our rating of the service stayed the same. We rated them as good because:

The trust had successfully opened the new hospital and the patients had transferred across without incident.

Staff and leaders had worked hard to minimise the impact of the COVID-19 pandemic on the quality of care and treatment and patient safety. They had carefully explained the need for infection prevention and control measures to patients and received good cooperation when additional restrictions had to be imposed. As a result COVID-19 outbreaks had been well-contained.

Staff and leaders did their best to minimise the impact of national staff shortages on care, treatment, safety and security. Numerous recruitment initiatives were ongoing and the impact on patients and existing staff was kept under constant review.

Staff treated patients with compassion and kindness. Patients received exemplary care and treatment that was tailored to meet their individual needs and preferences. Staff spoke about patients with hope and had an excellent knowledge of each patient and the best way to respond to and interact with them.

Patients felt respected and valued as individuals and were empowered as partners in their care, both practically and emotionally. There was a strong person-centred culture and staff put the patients’ needs at the heart of care and treatment.

Staff provided care that was personalised, holistic and recovery-oriented. They respected patients’ privacy and dignity. Staff were proactive in involving families and carers in patient care, when appropriate. Staff understood how to protect patients from abuse and the hospital worked well with other agencies to do so.

Co-production with patients was central to the service. Staff were committed to ensuring the patient voice was embedded in decisions about the hospital, when appropriate. Their input was valued and patients had a significant influence on service improvement through patient forums, research and feedback.

The new hospital had been designed with full regard to the physical and emotional well-being of patients and safety for all. All patients, staff and carers described the new facilities as outstanding. Wards were clean and well maintained.

Staff proactively assessed and managed risks to patients well and achieved the right balance between maintaining safety and providing the least restrictive environment possible to facilitate patients’ recovery. One ligature risk in some garden areas had been identified but required further action and the hospital attended to this immediately. Staff followed best practice in anticipating, de-escalating and managing distressed behaviour. The hospital was piloting the use of a long-term segregation pathway which had resulted in segregated patients spending more time out of their bedrooms.

Staff had training in key safety skills and managed safety incidents well. The hospital had clearly defined and embedded systems, processes and policies to keep people safe.

Managers investigated incidents and complaints and shared the lessons learned with staff to minimise the risk of them happening again.

Staff from different disciplines worked together professionally and with mutual respect to achieve the best possible outcomes for patients using the service. They provided a range of care and treatment interventions consistent with national guidance on best practice.

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 in order to deliver holistic care. Teams collaborated with each other and with external agencies.

Staff reported the hospital strongly promoted equality and diversity in its work with patients. The hospital had set up a Black, Asian and minority ethnic (BAME) carers forum to specifically address concerns raised as a result of the Black Lives Matter movement. Work was progressing with cultural formulation and cultural care plans.

The hospital 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 promoted the values of the trust in all aspects of their work and spoke about the patients being at the heart of the service.

Managers demonstrated that they were very experienced, knowledgeable and highly skilled in their roles. They have been consistently open and honest with the Care Quality Commission about their successes and the challenges within the service during inspections and routine engagement.

The hospital collected, analysed, managed and used information well to support all its activities. Managers had access to the information they needed to provide safe and effective care and used that information to good effect.

However:

Whilst the hospital had made many improvements since our last inspection in June 2018, there were still high vacancy levels for registered nurses. This impacted on the care and treatment that patients received, affected staff morale and staff ability to participate in supervision sessions and team meetings. Staff recruitment campaigns and efforts to retain staff were comprehensive and ongoing.

Some ligature risks required further mitigations on Embankment, Victoria and Chepstow wards.

For some patients, multiple medicines were prescribed to manage the same health condition. Where patients had ‘when required’ oral and intramuscular medicines prescribed the care plans did not detail which medicine was preferred in which circumstances.

On Kempton Ward some staff had not completed the knowledge and understanding framework required to work with people on the personality disorder pathway, so may not have been fully equipped for their roles.

Patients on Kempton Ward had reduced access to psychology and occupational therapy.

Not all staff were familiar with the role of the Freedom to Speak Up Guardian or the process for raising concerns.

We carried out this short-notice announced focused inspection to follow up on concerns raised about the safety and quality of the service being provided. In February 2021 the local coroner published a Regulation 28 Prevention of Future Deaths Report following the death of a patient being cared for by the Hammersmith and Fulham crisis, assessment and treatment team (CATT). This inspection focused on specific areas of concern raised by the coroner, recommendations made following the serious incident investigation and the actions taken by the trust in response to this death.

We used CQC’s interim methodology for monitoring services during the COVID-19 pandemic. Three inspectors visited the CATT service on 26 and 27 May 2021 to complete essential checks. The remainder of our inspection activity was conducted off-site. This included staff, patient and carer interviews over the telephone and analysis of evidence and documents. Our final telephone interview with a staff member was completed on the 17 June 2021.

Hammersmith and Fulham crisis, assessment and treatment team (CATT) is part of West London NHS Trust’s mental health crisis services and health-based places of safety core service. This core service was last inspected in 2018 with a rating of requires improvement in the safe domain and good across the effective, caring, responsive and well led domains. The core service was rated good overall.

The trust has two other CATTs which cover the London Boroughs of Ealing and Hounslow. The CATTs provide initial assessments for patients in crisis referred to secondary mental health services, as well as providing brief interventions for periods of up to three months. The service refers to these different functions as (tier 1) crisis support and (tier 2) brief intervention therapy. The CATTs also support patients who are being discharged from hospital and gate-keep all inpatient admissions.

We did not rate this core service at this inspection. The previous rating of good remains. We found:

The service assessed and managed individual patient risk appropriately. They responded promptly to sudden deterioration in a patient’s health. When necessary, staff worked with patients, family and carers to develop crisis plans.
Changes had been made to risk management processes and clinical risk training. Twice daily handovers took place and arrangements for out-of-hours handovers were now set up. Twice weekly multidisciplinary meetings had been introduced where all patients on the crisis caseload were reviewed. Missed and cancelled appointments were reviewed daily and appropriate follow up action taken.
The service used systems and processes to safely prescribe, administer, record and store medicines. Staff working for the mental health CATT regularly reviewed the effects of medicines on each patient’s physical health.
Staff developed care and treatment plans informed by a detailed assessment and, usually, 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.
Staff supported, informed and involved patients, families or carers appropriately. Work was being undertaken by the team to further embed the Triangle of Care standards to improve patient and carer involvement.
Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.
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. Leaders had recognised the issues with the service and had developed an action plan which was reviewed regularly at both the team and service line clinical improvement groups.
Work was in the process of being undertaken to improve the quality of record keeping and address any gaps identified.

However:

Whilst staff were assessing and managing patient risk well through regular handovers and MDT meetings, recorded risk assessments were not always updated regularly. We identified this as a breach of regulation at our last inspection. At this inspection we found the provider continued to be in breach as the required improvements had not been made.
For two patients the risk management plans were not clear. Decisions made at handover meetings were not always recorded in the patient care and treatment record.

Our rating of this service improved. We rated it as good because:

• The service had made the required improvements since our last inspection in November 2016. This included ensuring environments met young people’s and visitors’ needs, ensuring medical equipment worked, ensuring staff learnt from incidents and improved staff engagement across the children and adolescent mental health service.

• 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. Staff assessed and managed risk well and followed good practice with respect to safeguarding.

• 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 the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.

• 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 criteria for referral to the service did not exclude children and young people who would have benefitted from care.

• The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

However:

• Some pathways within the service were not always easy to access. Some young people and families waited a long time for an assessment or to start treatment. In Ealing, the wait for 55 young people and their families to access a neurodevelopment assessment had been in excess of three years.

• Staff could not always access electronic records easily. We noted during the week of the inspection that there was a delay in staff being able to access documents that had been uploaded. Staff, particularly in Hounslow, commented on how the delays caused disruption to their work.

• Across the teams we visited, staff were recording children and young people’s care and treatment plans and risk information in different parts of the trust electronic system. This meant there could be delays in accessing key information across teams.

• Staff identified as having responsibilities to develop user involvement felt they did not have enough protected time to complete this work.

• Some line managers were not confident in using the electronic system to upload supervision records and continued to maintain paper supervision records. This meant that data regarding the frequency and overall compliance with supervision was not accurate.

Our rating of this service improved. We rated it as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices and usually followed good practice with respect to safeguarding.

• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.

• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

• 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 managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.

• The service was well led and the governance processes ensured that ward procedures ran smoothly.

However:

• Improvements were needed to ensure that patients who received rapid tranquilisation had appropriate physical health checks completed afterwards.

• Whilst the service had systems and processes in place to safely prescribe, administer, record and store medicines, further work was needed to ensure staff always followed these.

• Some staff on Askew Ward were not using personal alarms. A few staff on this ward told us they did not feel safe on the ward and managers were investigating their concerns.

• Further work was needed to fully embed the training in safeguarding staff had received into practice.

• Improvements were needed in how staff on Kingfisher Ward reported incidents where the patient had been restrained.

• The current audit programme had not identified issues with medicines, administration of rapid tranquilisation, reporting of restraint and Mental Health Act documentation that we found during the inspection.

• Improvements were needed to ensure that all staff discharged their responsibilities under the Mental Health Act well. For example, staff did not always update records to show that patients had been explained their rights in a timely manner.

Our rating of this service went down. We rated it as requires improvement because:

• The ward environment was not fit for purpose. The ward did not provide a therapeutic environment. There were some poor lines of sight and measures to manage and mitigate the risks from these were not always followed. The seclusion room was inappropriately located. The building was waiting for refurbishment, but commissioners had not confirmed this could proceed. There were also some outstanding repairs, which were completed by the end of the inspection.

• Risk assessments and risk management plans needed further work to make sure they all joined up and there was no discrepancy between risk assessments and the plans to manage the risks. The service audited this immediately we told them there was a problem and acted on their findings.

• Further specialist training was needed to ensure that staff from diverse forensic and CAMHS backgrounds had the right skills and experience to meet the needs of patients.

• Whilst governance systems were in place, these were not operating effectively at ward level to ensure that performance and risk were managed well.

• Aspects of the service, such as repairs and maintenance, were not being attended to as promptly as they should have been. Some staff felt the ward had been left behind and they told us the refurbishment delays were frustrating and demoralising.

• It was not always easy to access historical records that related to patient care and treatment. Staff did not always maintain complete safeguarding records. Improvements were needed to ensure that learning from lower level incidents was always shared and the identified actions were implemented.

However:

• The wards had enough nurses and doctors. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

• Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.

• Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider promoted equality and diversity in its day-to-day work. Staff felt able to raise concerns without fear of retribution.

• The trust has a strong track record in responding to inspection requirements and recommendations in a timely way. They addressed our concerns during the inspection period.

We rated this service as good because:

The leaders of the service had the vision, capability and drive to ensure that care pathways for women with perinatal mental health continually improved.

•Patients and partner organisations reported that staff were skilled, caring and motivated.

•Partnership work with other agencies was well-developed at both the strategic and operational level. The service led on work with other organisations to improve the care pathway. There were clear operational policies and referral systems and working relationships were positive.

•Staff organised pre-birth planning conferences which were very effective in ensuring that patients with severe and enduring mental health problems and their infants received holistic care and support.

•Staff were fully aware of the diverse cultural background of patients. They worked sensitively with patients and their support network to provide effective support. Patients said their views were always respected.

•The service had a proven track-record of successful and creative work in partnership with experts-by-experience to develop the service.

•The service responded promptly to crisis situations and managed risks effectively. Staff ensured that any safeguarding concerns were acted on.

•Staff reported an open and supportive team culture with many opportunities to learn and develop their skills.

Our rating of the trust stayed the same. We rated it as good because:

We rated the trust as good for effective, responsive and well-led. Caring was rated as outstanding and safe as requires improvement. We rated three of the four core services we inspected this time as good and one as requires improvement. In rating the trust, we took into account the previous ratings for the core services not inspected this time.
We rated well-led for the trust overall as good.
The overall rating for West London NHS Trust remained as good overall and it was evident that many improvements had been made. Leaders had completely revitalised much of the trust infrastructure, such as information governance, repairs and maintenance, complaints investigations, data quality and performance monitoring, which underpinned the clinical work. This put their clinical leadership teams in a strong position to develop their services further and improve consistency in order to achieve their ambition to become an outstanding trust.
The trust had sustained and, in many areas, enhanced the core service improvements required following our last comprehensive inspection in 2018. In three of the four core services we inspected this time we found that all the requirements and recommendations from our previous inspections had been rigorously addressed with board level monitoring.
Where problems remained, they were linked to individual teams, rather than issues with the trust’s systems or processes.
The trust had particular strengths in the following areas; leadership at all levels, the positive culture of the organisation, the strong patient-focus, partnership working, pro-active engagement and co-production with patients, carers, staff and other stakeholders, creative recruitment and retention, training and development opportunities for staff and timely and effective completion of action plans and similar.
Patients and carers spoke well of staff.
Staff told us the trust had become a kinder place to work and they had confidence in their leaders who were very visible. The trust had implemented new practices to root out any accidental or deliberate unfairness to staff.
The new Broadmoor Hospital demonstrated a bespoke and well-designed clinical environment for patients and staff and patient transfers to the new building had been without fault.
There were several areas of outstanding practice which are detailed in this report.

However:

The trust still has a number of sites which are not fit for delivering modern health services.
The trust had not paid sufficient attention to its child and adolescent mental health ward (The Wells Unit) whilst it was waiting for a decision from commissioners and this had led to a drop in standards. The trust gave six months’ notice to NHS England to end the contract shortly after our site visit concluded.
Some specific safety issues had not been resolved within certain inpatient wards, although the trust was working to address them.
The trust had not yet fully implemented the accessible information standard.

Our rating of the trust improved. We rated it as good because:

We inspected five key questions for seven core services; a total of 35 key questions. The rating improved for 21 key questions and for two questions it went up by two ratings. Two ratings decreased from good to requires improvement, but the overall picture was of a trust that had made significant improvements.
At this inspection we rated one service as outstanding, four services as good and two services as requires improvement. The two largest inpatient services provided by the trust, forensic and high secure, were outstanding and good. Forensic services had improved from inadequate to outstanding within a three year period.
When these ratings were combined with the other existing ratings from previous inspections, there was one outstanding service, five good services and four services requiring improvement.
We carried out a focused inspection of acute wards for adults of working age and psychiatric intensive care unit, one of the services requiring improvement, in January 2018. This service was not re-rated as we only looked at specific issues, but we found that it had made significant improvements in key areas. At a time of high pressure on acute mental health beds in London, the trust was able to provide patients with access to a bed when needed. Bed occupancy on the acute wards was at 87% and patients were no longer being placed in beds outside the trust unless they required a specialist service not provided by the trust. This was a major improvement since our inspection in 2017 when acute patients had to sleep in the trust’s rehabilitation wards, and the improvement had been sustained throughout 2018. This is not evident from the current rating for acute services which pre-dates the improvement.
We rated well-led for the trust overall as good.
The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to make the necessary changes to provide high quality care to their local communities.
The trust had a strong, cohesive senior leadership team which had succeeded in changing the culture of the organisation for the better and which was well regarded by trust staff and external organisations. The chief executive officer was recognised as an inspiring leader.
The board had good oversight of all operational issues. The system of committees and sub-committees ensured that both achievements and concerns were escalated appropriately. There were comprehensive clinical governance arrangements in place which were inclusive of staff and patients. We found senior leaders already had plans in place to address all but one of the concerns we identified.
The trust had a strong grip on its finances. In 2017-18 the trust fully delivered on its £9.4m cost improvement plans (CIPs). It had reduced its agency spend and was working to drive it down further.
The trust was fully committed to working in partnership with patients and, increasingly, carers. There were many examples of coproduction. For example, the design and delivery of training and staff induction. Patients were involved in the development of their care and treatment plans, as well as ward matters and clinical governance. The trust engaged effectively with inpatients, outpatients and the local community.
Patients were actively encouraged, through paid and other opportunities, to get involved in service development. Patient representatives were supported to participate in a range of meetings and events and de-briefed afterwards. There were similar opportunities for carers. Senior leaders led by example and worked closely with patients and carers at meetings and on projects.
Staff engagement (as shown by the staff survey) had improved. The experience of doctors in training was now positive (as shown by the General Medical Council survey). Leaders were very visible within the trust. The trust prompted staff to raise concerns with support from the Freedom to Speak Up Guardian. There was low take up to date, but local champions had been recruited to start raising awareness. Staff told us they had lots of different opportunities to raise issues with management.
The trust was committed to improving the safety of staff, patients and the wider community and there were a number of initiatives and programmes in place to try to achieve this. The arrangements for lone-working in the community had improved and good relational security was now well established in forensic services.
The trust was actively participating very effectively in local care systems and with NHS partners and academic institutions to drive progress and develop new models of care, such as community mental health rehabilitation services. The trust’s participation in the North London partnership for forensic services meant that an increasing number of patients were receiving their care closer to home.
The trust had succeeded in becoming a learning organisation; staff learned from success and also when things went wrong. This was achieved through mortality review meetings, clinical improvement meetings, team meetings, supervision, newsletters and emails. A trust-wide learning from experience event was scheduled to take place soon after our inspection.
Staff at all levels were supported to enhance their skills and knowledge through a wide variety of training, mentoring and coaching opportunities. Courses ranged from popular two-hour sessions to professional qualifications.
The trust had invested in the development of leadership skills. It offered all staff employed at band 3 or above the opportunity to develop them. In order to address the under-representation of black and minority ethnic (BME) staff in leadership roles, specific training was available for this group of staff. Graduates from the programme attended a BME forum and were consulted about issues relating to BME under-representation. The trust ensured a person with a BME background was present on all interview panels for staff at band 8 or above.
The trust was recognised as a Stonewall champion and had an active lesbian, bisexual, gay, transgender (LGBT+) network and made a point of being inclusive of all sexual orientations. The chief executive was included in the Financial Times 2017 OUTstanding Global Leading Public Sector LGBT+ executives list. Rainbow lanyards were in use to let patients know who they could approach if they wanted to discuss their sexuality or gender identity. We heard how the trust was working on some guidance about meeting the needs of individuals who identified as transgender.
The trust maintained a high level of compliance with mandatory training. It made it compulsory for all mandatory training to be up-to-date before specialist training could be accessed.
The trust worked to improve the quality of patients’ lives in hospital and in the community. Patients were supported to understand their condition and to acquire vocational skills and academic qualifications. The recovery college operated from a central base In west London and convenient satellite sites and Broadmoor had its own recovery college.
Staff and patient successes were celebrated. Teams and staff who had ‘gone the extra mile’ for patients were recognised by senior leaders and colleagues. There were regular awards and events for both patients and staff and they told us they felt valued as a result.
The trust had a range of measures in place to support staff returning to work from long-term sick leave and was particularly mindful of the needs of staff who had been injured at work. Affected staff told us they could not fault the support they received.
The trust supported staff, patients and carers to develop the skills and knowledge required to carry out quality improvement work. Many projects were underway and the trust was making progress with coordination and monitoring outcomes.
Clinicians were fully involved in digital developments to make sure they were fit for clinical use. We saw how the electronic patient information system was regularly adjusted to better capture important information, such as physical health checks. The trust had just introduced a new dashboard which showed managers how their ward or team was performing. A manager who was an early-implementer showed us its potential, but training was still being rolled out so its impact could not be fully assessed.

However:

Whilst we found significant improvements in most of the teams and wards we inspected, in most core services there was at least one team or ward which was not up to the standard of the rest. This lack of consistency impacted on the ratings we could award. The trust were aware that these wards and teams needed to improve and additional support was being provided.
Recruitment and retention of staff remained an issue for the trust; matters were improving and the trust was finding some creative solutions, but there was still a negative impact on the workload of some teams and the continuity of patient care.
The Tony Hillis wing at St Bernard’s hospital, which was the site for several inpatient services and other facilities, was not a suitable place to provide modern healthcare. It presented risks to the health and well-being of patients due to antiquated electrical, plumbing and heating systems which required constant repair and the number of ligature anchor points that had to be monitored. Parts of the current Broadmoor Hospital were also not fit for purpose, although a new hospital was being built next door.
The trust did not have good oversight of the performance of its health-based places of safety. In part, this was because activity within the three suites was mainly reported via the wards from which staff were drawn to work in them. This meant most of the data gathered was absorbed into the ward data and was not easily identifiable as data related to the health-based places of safety.
The trust needed to make sure there was more consistency in the storing of patient records, both paper and electronic. Staff kept records, but not always in the same place as their colleagues which made them hard to find, especially in an emergency situation.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RKL/reports.

Our rating of this service stayed the same. We rated it as requires improvement because:

Services needed to improve access and waiting times. The recovery teams did not assess all referrals promptly. They did not meet the 28-day trust target to see the patient for their initial assessment from the day of their referral. Some patients had to wait for a long time for transfers between teams. Ealing West Recovery Team needed to have a better system for monitoring the safety of patients on their waiting list.
Some teams had staffing challenges due to high vacancies and high staff turnover. This meant that many staff in the teams affected had more patients on their caseload than recommended by national guidance. In Ealing Early Intervention Service there were not enough care coordinators for all the patients within the service.
Staff did not always manage medicines safely. At Ealing West Recovery Team, we found out-of-date medicine kept with in-date medicines. This increased the possibility that a patient may be given an out of date medicine.
Some teams did not assess and plan how to manage patients’ risks robustly. Patients’ risk assessments and care plans were not reliably updated following changes in circumstances or incidents. These documents were not regularly audited to check they were person-centred, accurate and up-to-date. Staff in the Ealing West Recovery Team also did not fully address risk in their ‘zoning meeting’.

However:

Senior and team managers across the teams had a good understanding of their teams and the challenges they faced. Senior managers had already implemented support and intervention plans for the two teams where we found the most concerns during our inspection. This demonstrated managers understood the risks associated with their teams and had acted to eliminate them or reduce them.
Despite the pressures faced by the teams, managers and staff worked well together to ensure patients received good care and treatment. There was an open culture and morale was generally good. The provider regularly recognised staff success within the service.
Staff had the necessary training to ensure they could deliver their role safely and effectively. Staff followed good lone working practice, which enhanced their safety when meeting patients. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff recognised incidents and reported them appropriately.
Staff demonstrated excellent working relationships with other teams, both internal and external to the trust, which ensured seamless and holistic care for patients. Staff offered interventions aimed at improving patients’ social networks, education and employment.
Staff used technology to support patients effectively and avoid missed appointments, such as by sending text appointment reminders.
Staff demonstrated good practice when using the Mental Health Act and the Mental Capacity Act.
Staff involved patients and, when appropriate, carers in decisions about care. They had implemented a way of working collaboratively with patients and carers. Teams supported patients, families and carers to understand their mental health and to develop strategies for dealing with its impact.
Patients told us that they could contact the service easily if they felt unwell or had any questions about their treatment.
Staff planned for patients discharge from services well. Teams had been involved in quality improvement projects, which aimed to improve the patient discharge pathway.
Patients knew how to complain or raise concerns. Information about how to complain was on display in the patient waiting room in the service we visited.
Managers had better access to data to help them monitor the performance of their teams. A new ‘dashboard’ had just been made available and the trust was rolling out training to support managers to get the best from it.
The teams had made good progress with addressing the recommendations made in the November 2016 inspection. This included access to psychological therapies, and staff receiving regular appraisals and supervision.
Improvements had also been made in the delivery of physical healthcare, but teams still needed to do more work to embed physical healthcare in their day-to-day practice.

Our rating of this service improved. We rated it as outstanding because:

Leadership within the service was highly effective. Leaders at all levels were supportive of staff and visible within the service. They supported each other to deliver the best possible service for all patients. Staff were supported to develop their leadership skills through a range of creative training, coaching and mentoring opportunities. This service had greatly improved since its inadequate rating at our first comprehensive inspection in 2015 and this confirmed that leaders had good skills and knowledge.
There was a strong ethos around patient involvement and it was integral to the way the service was provided. Patients were at the heart of any decision making about the way the service was delivered and in respect of their own care and treatment. We heard examples of changes that had taken place as a direct result of patient feedback.
Patients were inspired to have hope in their recovery by staff members and recovery and involvement (HOPE) workers. The service was focused on rehabilitation, with patients offered extensive opportunities for vocational training, education and personal development. Staff were committed to this approach. Patients told us that this was important to them and helped them progress through towards discharge.
The service provided individual care which reflected the holistic needs of patients. This meant that as well as needs relating to physical and mental health being assessed, monitored and reviewed, the patients’ social, cultural and spiritual needs were well met.
Staff had an excellent understanding of patients’ needs and this enabled them to take positive risks to aid patients’ recovery. For example, one ward escorted all its patients to a leaving party for one patient in the hospital café. The patients concerned said they appreciated the trust put in them and it encouraged them in their recovery.
The service had safely reduced the use of restrictive practices. De-escalation techniques were used well; rapid tranquillisation of patients had only been required on eight occasions in one year. There were fewer blanket restrictions in place and both patients and staff were better informed about those that were in place and the reasons for them. For example, previously, in the Tony Hillis wing, there had been a ‘one-size fits all’ approach to searches on return from unescorted leave, even though the wing accommodated both medium and low secure wards. Now patients on the low secure wards received searches in keeping with that level of security.
Patients had access to a full range of physical healthcare professionals at the on-site primary healthcare centre, which included a fully equipped dental surgery. Patients could be seen on the ward if they could not visit the centre so no one was disadvantaged. Patients were supported to make healthy lifestyle choices, such as using the gym facilities and selecting healthy snacks.
Plans were well underway to move some wards in the least suitable building to a newly refurbished building and to make sure those wards that remained behind also had improved facilities. Repairs and maintenance had not been put on hold in the interim period and were taking place throughout our inspection.

However:

Although all shifts were covered and recruitment and retention had improved, there were insufficient permanent nursing staff to ensure proper continuity of care for all patients.
Some records of seclusion were not comprehensive and did not record all the observations which had taken place to show staff were following the Mental Health Act Code of Practice.
A few patients in the women’s service may not have had all their physical healthcare needs met as on one ward diabetes care plans were not in place for four patients with the condition.

Our rating of this service improved. We rated it as good because:

Care professionals in the trusts single point of access worked closely with the health based places of safety and crisis assessment and treatment teams to ensure patients had access to services in a timely manner. For example, the health-based places of safety were open to young people under the age of 18, as well as adults and they did not turn away people who presented as intoxicated. Also the CATTs were now operating 24 hours a day.
The crisis services worked closely with other stakeholders including the police, local authority AMHP leads and psychiatric liaison teams to review services and address challenges in joint working.
Staff monitored patients’ physical health needs and ensured that any issues identified were addressed appropriately. Each CATT had specific physical health clinics to ensure that basic checks could be carried out and this information was recorded. In the health-based places of safety, each patient had a physical health check on admission and their physical health was monitored while they were awaiting an assessment. This was an improvement since our last inspection.
Staff in the CATTs offered a range of brief interventions and support groups which enabled them to provide care and treatment to a wide range of people. This was in line with recommendations in national guidance.
Staff teams were highly motivated and morale was strong in the teams we visited. Staff were positive about the support they received from managers and felt they were supported to develop, personally and professionally by the trust.

However:

In the health based places of safety, staff had not ensured that key information relating to the operation of the service was effectively captured and that other systems were working well. For example, data was not being collected accurately, such as the time the patient arrived (and therefore their length of stay) or when the service was closed due to staff shortages. Other essential records such as physical health observations and a record of patients being told their rights were not stored consistently in each service. Environmental audits and ligature risk assessments had not been completed and this was not identified until the inspection visit although this was addressed immediately. Incidents had been reported but were assigned to wards rather than the health based places of safety themselves which hindered oversight by managers and potentially, learning.
In the crisis assessment and treatment teams (CATTs) staff did not always keep appropriate records of patients’ care and treatment. Risk assessment documentation in Hounslow and Hammersmith and Fulham CATTs did not reflect the current patient risk. Some care planning documentation in all the CATTs had not been completed comprehensively to reflect the care that was being provided to patients.
Medication in the CATTs was not consistently reconciled which meant that medical and nursing staff in the teams did not always liaise with GPs and inpatient wards to ensure that the prescriptions and the medicines received by patients were consistent. As a result there were errors on a few prescription charts.

Our rating of this service improved. We rated it as good because:

There were significant improvements in the culture of the service and the responsiveness of leaders which had had a positive impact on staff morale and the quality of the service.
Staff took account of patients’ individual needs and preferences and treated patients kindly. They took care to make sure patients understood their care and treatment and brought in independent advocates if they had doubts about the patient’s ability to make a decision for themselves.
The wards were bright and cheerful and, although the ward layouts were not ideal, action had been taken to make the most of the environment and to improve safety.
Patients received a thorough assessment of their mental and physical health and were monitored for any deterioration. Care plans and risk assessments were in place for all patients.
Medicines were prescribed appropriately and at the lowest therapeutic dose and prescribers took full account of possible medicine interactions.
Staff were up-to-date with their mandatory training and were able to access other training opportunities too. They were aware of their responsibilities in relation to the Mental Health Act, the Mental Capacity Act and safeguarding children and adults.
A range of therapeutic activities was available across the service.
Families and carers were well-supported by staff and, when appropriate, fully involved in meetings to discuss the patient’s care and treatment.
Patient information was kept securely, but it was accessible to relevant staff members.
Ward managers could access timely information about the performance of their ward so they could attend to any emerging issues.
All the staff we spoke with were committed to ongoing improvement of the quality of the services they provided.

However:

Episodes of restraint were not always recorded, so managers could not effectively monitor its use.
The service found it hard to recruit registered nurses so there were a significant number of vacancies being covered by bank or agency staff.
There was not equal access to therapeutic activities across all the wards.

Our rating of this service stayed the same. We rated it as requires improvement because:

Whilst improvements had been made and embedded on Mott Ward, further work was still required on Glyn Ward. On Glyn Ward there had been changes in the leadership team and this had impacted on the operation of the ward and communication with staff. At the time of the inspection a new manager had been appointed. On Mott Ward there was some outstanding practice, but the ratings for this ward had been brought down by the performance of Glyn Ward. Senior leaders in the trust were aware of the challenges on Glyn Ward.
Last time we inspected the service patients did not have access to educational and vocational opportunities to support their recovery. This time they had good access at Mott House, but on Glyn Ward only basic educational and pre-vocational sessions were available to patients.
While patients at Mott House received structured rehabilitation with identified recovery goals to support the work towards discharge, for patients on Glyn Ward this was less well developed.
Staff were not regularly receiving supervision on either ward, so staff could not rely on having time with their supervisor to discuss their practice or learning or to raise any issues.
While the service had made some improvements in ensuring the privacy and dignity of patients since our last inspection, we observed patients receiving routine medical checks in full view of others in the lounge at Glyn Ward, which compromised their privacy.
Regular team meetings were not happening on Glyn Ward which meant that staff did not have sufficient opportunities to discuss the day-to-day running of the ward.
Repairs and maintenance were not provided promptly to Glyn Ward. The organisation and cleanliness of the clinic room on Glyn Ward was not up to the standard required and some first aid equipment was past its expiry date.
The service’s inability to recruit and retain sufficient numbers of nursing staff affected the continuity and consistency of the nursing team. It impacted on patients receiving one-to-one time with their named nurse on Glyn Ward.
Staff on Glyn Ward did not routinely update patients’ records when needs or risks changed. There was little evidence of updates between care programme approach meetings, which were six monthly, or following incidents.

However:

The trust had successfully implemented a range of measures to make sure patients who were admitted for acute care no longer had to sleep on the rehabilitation wards due to the shortage of acute beds. These improvements had been sustained throughout 2018 so there was no longer any impact on the rehabilitation wards.
There were sufficient therapy staff to support each patient’s rehabilitation. Doctors, nurses and other healthcare professionals supported each other to provide care.
Staff appraisals were being carried out and this was an improvement since our last inspection.
Doctors’ prescribing practice was very thoughtful; minimum effective doses were prescribed and potential side-effects were always taken into account.
Staff were good at supporting people to calm down when they were distressed so there was little need for physical interventions. There was evidence of positive risk taking.
Physical healthcare was exemplary, with patients with complex needs receiving specialist care from acute hospitals.
Patients spoke positively about staff and regular staff knew them well and understood their needs.
Patients were now much more involved in developing their care plans and understanding their medicines. They were supported to voice their opinions by a peer support worker and in a regular independently run forum. There was evidence that staff made changes in response to patient views.

Our rating of this service improved. We rated it as good because:

The care and treatment provided was in line with national guidance for children and young people. The unit had adopted a therapeutic model of care, the “wellness and recovery action plan” (WRAP), and staff had received training to deliver it. A range of therapy and was available for all patients.
Staff were skilled in helping distressed patients to calm down and there had been few incidents of restraint. When restraint did occur, the standard of recording had improved. Any incidents were analysed and learning from them was shared with the staff team.
The premises were safe, secure, clean and well-maintained. The environment was regularly checked.
Risks for individual patients and the environment were discussed, documented and managed. Staff were aware of them.
Most staff had attended most mandatory training sessions, including training on the Mental Capacity Act and consent for under 18s. This was an improvement since our last inspection.
Medicines were managed in line with best practice.
Patients’ mental and physical health was assessed and monitored. Staff knew how to identify improvement and deterioration using appropriate tools.
Patients were encouraged and supported to make healthy lifestyle choices using challenges and reward schemes. Patients had access to equipment that encouraged activity, such as an outdoor sports pitch, gym and table tennis table.
Staff were supported in their roles through supervision meetings, annual appraisals, regular reflective practice discussions and training and development opportunities. Staff told us their morale was good.
Patients said staff treated them well and they and their families or carers were routinely involved in meetings to discuss their care plans. They also had opportunities to give their feedback about the unit and carers could attend the trust’s quarterly carers meetings.
A buddy system was in place so existing patients supported new patients to get used to the unit.
Admissions and discharges were well planned and discharge planning started immediately to minimise the risk of delay.
Staff were responsive to individuals’ needs and care plans took account of patients’ cultural, religious and social needs. Staff knew how to access interpreters and materials in a range of languages if needed. When appropriate patients were supported to attend activities in the community.
There had been two formal complaints about the service and information about how to complain was on display and staff knew what to do on receipt of a complaint.
Senior managers were visible and supported quality improvements. The unit regularly audited some aspects of its work and was participating in a national quality scheme.

However:

The seclusion room did not fully protect patients’ privacy and dignity.
Meals were not always served at the recommended temperatures.
Patients were not enthusiastic about the main meals provided.

We rated the High Secure Hospital managed by West London Mental Health NHS Trust as good because:

The trust had made significant improvements within the hospital since our last comprehensive inspection in November 2016.
Patients were very positive about the staff and we observed staff interactions with patients which were respectful and kind. Staff spoke about patients with hope and knew the patients they worked with very well. We heard many positive examples of staff going the extra mile to provide a caring service which made patients’ needs central.
Staff took into account patients’ culture, religion and social interests when planning and delivering care and treatment. Staff had an excellent understanding of the individual needs of the patients they worked with and they demonstrated patient-focused and patient-centred practice which put patients’ needs at the heart of the work they did.
The hospital and staff were committed to ensuring that the patient voice was embedded in the governance processes and in decisions about the strategic development of the hospital’s clinical model. Patients were actively involved in a range of forums, groups and surveys, so they could raise issues and also identify areas for improvement. They had been engaged in the development work of the new hospital environment and the decisions made by the patient group had led to changes.
While there were still staff vacancies, the hospital had focused on ensuring that the patient experience was affected as little as possible in terms of activities being cancelled.
The hospital had undertaken significant work to reduce the use of long term segregation. This involved specific projects on several wards; including staff supporting patients to spend as much time out of their rooms as possible.
Staff could articulate learning from incidents and how they had changed practice because of incidents, complaints and feedback.
Staff morale had improved further since the last inspection. Arrangements were in place to keep staff informed and enable them to escalate issues they wanted addressed.
The trust had a strong ethos of research and developing best practice and innovative solutions including using technology to improve the outcomes for patients in their care.

However:

The hospital continued to have high vacancy levels for nurses and this had an impact on the delivery of care. Some activities were cancelled due to staff shortages.
Some medication was not stored at the recommended temperature and staff were not seeking advice or reporting incidents consistently when this was the case.
Some emergency medication was not immediately available to all staff. It was not clear that the potential impact of this had been considered and mitigated.
Some emergency equipment had been checked but had expired.
Staff did not assess and record patients’ capacity to treatment consistently. Staff had not recorded some seclusion reviews correctly and some patient records did not clarify why patients were subject to long term segregation.

We did not re-rate this service.

While good progress had been made in some key areas, we found the following areas that the service needs to improve:

Some maintenance work in the wards had not been carried out in a timely fashion and some faulty equipment had not been reviewed. There was no system in place at the Hammersmith and Fulham site to identify recurring faults so they could be properly addressed.

The trust had started environmental work across the wards to address ligature risks and blind spots. However, there was further work outstanding to mitigate a few remaining blind spots and the ligature action plans, while comprehensive, were not always clear about the timescales for this work.

There were high vacancy rates for nurses at the St Bernard’s site.

While some wards had been reconfigured to reduce the incidence of female patients being secluded on male wards, this work needed to continue. The trust was not able to provide us with accurate data relating to numbers of incidents of seclusion.

There were gaps in the data supplied to ward managers to help them monitor their ward. In particular, there was a risk that the information they received about incidents of seclusion was not comprehensive. This potentially limited their ability to identify any themes and could prevent them from responding appropriately.

Some incidents, which should have been reported through the trust reporting system, had not been reported which meant that data provided about the quality of service was sometimes incomplete.

There was no evidence in the service’s risk registers or the minutes of clinical governance meetings that the data accuracy or the lack of incident reporting had been identified or was in the process of being addressed.

While most staff had a good understanding of safeguarding and their responsibilities to patients at risk on the ward, some staff did not follow the trust’s safeguarding policy which required them to record the reason behind any decision to not refer concerns about a patient to the local authority.

However, we found the following areas of good practice:

The trust had undertaken considerable work to better manage patient flow. This had resolved the issue of patients receiving care on one ward while sleeping on another ward because no beds were available where they were receiving treatment.

Permanent and contracted agency members of staff were receiving supervision regularly. Staff across the service told us that they felt supported by their managers and that they were able to raise concerns.

Patients had up to date risk assessments and care plans.

Records showed physical health screening was carried out regularly with follow up intervention when required.

The service had started to undertake some quality improvement projects. Members of staff were positive about this.

The divisional management and local service managers had a good understanding of the acute and PICU services and knew about key risk areas in the services they managed. While work on some areas of risk or concern was not complete, most of the issues we found had been identified internally and work was planned.

Although there were gaps, ward managers had access to improved information about the ward to support them to manage the service.

Following this inspection the warning notice was removed and replaced by requirement notices. This was because the hospital had put the systems and processes in place to make the necessary improvements, but further work was needed to complete and embed these changes and ensure patients consistently received access to appropriate levels of meaningful therapeutic activities.

The hospital had a recruitment strategy that was resulting in additional staff being recruited. The trust and hospital management had an understanding and oversight of the concerns which related to staffing in the hospital and had regular up to date information regarding the current status of recruitment and retention. The focus was not only on recruitment but also looking at ways to improve retention rates for staff at the hospital.
There were improvements in patients’ access to therapeutic activities. Most patients we spoke with were positive about the support provided in the hospital and some told us that there had been an improvement in access to activities since our previous inspection in November 2016.
The leadership team at Broadmoor and in the trust were committed to making the improvements and were closely monitoring the progress being made. They recognised the areas where further work was needed.

However:

While there had been considerable work undertaken to recruit additional nurses in the hospital, there were still significant vacancies, which continued to adversely impact on the consistency of patients’ access to meaningful activities, association time (for those who were subject to the conditions of long term segregation) and therapeutic engagement with ward staff.
The hospital had started to work on a more systematic way to record meaningful activities offered to patients. This was a way of providing assurances both internally and externally that every patient was offered a minimum of 25 hours meaningful activity weekly. This information was inconsistently recorded and not yet embedded. This meant staff could not guarantee data was always accurate.

We rated specialist community mental health services for children and young people as requires improvement because:

The staff working in the teams were not all having the opportunity to hear about and learn from incidents which had occurred across the service.
Some clinical equipment was not being regularly checked to ensure it was working accurately.
Some of the clinic environments were not meeting the needs of young people and staff, for example they did not have sufficient rooms for appointments or provide reliable disabled access. Sessions were disturbed by alarms ringing and lights going on and off.
Whilst many staff said they had good morale a smaller number did not feel so positive and further work was needed to improve staff engagement.
Team managers did not have access to timely and accurate management information to support their role.
There were several different paper and electronic patient records and information was not always stored consistently.
There were long waiting times for the neurodevelopmental service although it was acknowledged that this was linked to how the service was commissioned.
Young people sometimes experienced long waits for accessing specific psychological therapies.

However:

Staff could access advice from psychiatrists and see urgent referrals quickly. They assessed risks regularly, used effective crisis plans, knew how to make safeguarding referrals and managed medicines appropriately.
Staff planned and provided personalised and holistic care. Young people could access a range of evidence-based therapies and fed back about their experiences positively.
Staff reported good working links with external services.
At the last inspection we recommended that staff ensure rooms were soundproofed. The trust had completed this work.

We rated other specialist services (high secure wards) as requires improvement because:

In our inspection in June 2015, we found that staffing levels were not adequate as they had not ensured that patients had access to therapeutic and recreational activities that they were scheduled to have access to. This continued to be the case. In November 2016 we served the trust with a warning notice.
There were some records relating to seclusion and long term segregation which did not evidence that the required monitoring had taken place.
The trust had not consistently arranged external three month reviews of patients who were in long term segregation for more than three months.
There were some assessments of capacity which had not been completed in a way to determine that a comprehensive discussion had taken place with patients about the impact of their treatment. This meant that there was a risk that capacity assessments were not sufficiently robust to either prove capacity or the lack of it.
Staff throughout the hospital reported to us that their morale had not improved significantly over the year since the last inspection in June 2015.

However:

Staff had a good understanding of their patients and patients reported that staff treated them with kindness and respect.
There were good systems in place to embed the patient voice including the patient forum, the development of the peer support role on Leeds ward and a commitment to coproduction.
The service had put significant effort into reducing long term segregation and there had been a reduction in the use of long term segregation across the hospital. This was particularly notable on Epsom ward but other projects had been undertaken on Cranfield, Ascot and Woburn wards.
Staff were aware of the incident reporting system and were able to give us examples of learning from incidents.
There was a strong medicines management process in place and pharmacists were available to provide both staff and patients with advice and guidance where necessary.

We rated long stay/rehabilitation wards for working age adults as requires improvement because:

This core service had been inspected in June 2015 as part of a comprehensive inspection of the trust. We had produced a list of actions the provider should take to improve following our last inspection. The service had managed to address most of these. However, we found that more work was needed in some of these areas.

Whilst work had taken place to improve staff engagement across the trust, further work was needed on both wards to ensure staff felt able to raise concerns and feel respected by senior ward staff.

We also said at the last inspection that the trust should ensure that maintenance and repairs are carried out in a timely way at Mott House. On this inspection it appeared that maintenance and repairs were being addressed at Mott House, but there were hold ups with maintenance and repairs at Glyn ward.

During this inspection we also identified additional areas that required improvement. The practice of acute patients sleeping at night on the rehabilitation wards needed to stop as this presented potential risks to both groups of patients.

There was more work needed to support the patients to access vocational and educational opportunities and to increase their self-help skills such as self-catering and self-administering medication as part of their rehabilitation process.

More work was needed to measure outcomes for patients to ensure the wards were fulfilling their aims of supporting people to achieve greater independence.

Restrictive practices were in place that could be further reduced for patients using a rehabilitation service, such as access to snacks and bedroom keys.

The psychology post across both wards was vacant at the time of the inspection, although the service was working to recruit to this post.

The dignity of patients at Glyn ward was compromised. Viewing panels into patient’s bedrooms were covered by an exterior curtain that could easily be opened by people in the corridor. Staff called out patients medications from a hatch in front of others. Patient confidential information displayed in the nurses office could be seen from the corridor.

Staff had a poor working knowledge of incidents that had taken place on both wards because incident data couldn’t easily be pulled from the computer system. There was mixed learning from incidents.

Staff at Glyn ward were not all having regular supervision or an appraisal.

Physical healthcare records were not consistently stored in the same location at Mott House, and staff had difficulty locating them. They would therefore be difficult to locate in an emergency situation or at short notice.

However:

Despite ongoing challenges with nursing recruitment, staffing levels could easily be adjusted according to the changing needs of patients and the service was safely staffed. There was good access to occupational therapy input.

Care plans were detailed and contained recovery oriented goals. Patients were positive about the care they were receiving and felt as though they were recovering.

Patients could access a comprehensive programme of activities during the week. There were plenty of activity rooms and facilities available for patients to participate in art therapy and cooking activities.

Work had taken place to reduce patients’ length of stay. A graded discharge model ensured that patients could return to the ward during the weeks following discharge if required. The service had plans to offer more step down options such as an outreach service in the future.

Medical staff were dynamic and flexible. They worked hard to find the best possible treatment for their patients. There was good access to physical health care and staff showed a good understanding of patients physical health needs. We observed good staff interactions and patients got on well with staff.

We rated community health inpatient services as good because:

Magnolia ward provided support to patients so they could avoid an acute hospital admission, be supported with their rehabilitation and ideally regain enough independence to return home.

Staff were very caring and provided support in a sensitive manner that met the needs of each patient and their carers.

Magnolia ward was a safe and clean environment that was well maintained.

Magnolia ward had a skilled multi-disciplinary team that considered the needs of each patient and provided appropriate care and treatment. Medicines were managed well on the ward.

Staff were mindful of potential risks for patients, such as the risk of falls and worked to mitigate these as far as possible.

Staff on the wards worked well with other professionals such as GPs and social services to ensure patients needs were fully met.

Staff on the ward were skilled and had opportunities for learning and development.

However:

Staff needed access to regular individual supervision that was recorded. They also needed to attend regular team meetings.

More work was needed on staff engagement, especially while the service was going through ongoing review and change.

Managers needed to have clear performance information, well presented to facilitate their management of the service.

Patient records needed to be reviewed to move away from using paper records.

We have rated West London Mental Health NHS Trust as requires improvement overall:

We have rated nine of the eleven core services that we inspected as requires improvement and the other two as good.

The trust requires improvement for the safe; effective; responsive and well led key questions. We have rated the trust as good for the caring key question.

The inspection took place at a time when the trust was going through considerable strategic change. They were in the process of transforming their adult inpatient services to reduce the number of people needing inpatient beds. This involved increasing services in the community. Since the previous inspection the trust had created a single point of access, enhanced assessment and treatment teams and a new primary care mental health service.

The trust was also working to improve existing care and the processes that support this. We were able to see many areas of improvement however, there was more to do and the changes needed to be embedded and sustained.

The main areas for ongoing improvement were as follows:

The trust continued to have a problem with staff recruitment and retention. Since the last inspection recruitment had improved but many new staff were leaving within a year. This was having an impact on the care received by patients. The most significant concern was in the high secure services where access to therapeutic activities and time with staff and other patients was restricted. This was an ongoing concern from the previous inspection and as a consequence a warning notice was served.

The trust had made improvements in the assessment, monitoring and treatment of patients’ physical health. This had been implemented well in some areas but in others still needed to improve. For patients cared for in the community, trust staff did not always establish effective working links with GPs and other professionals providing support with the person’s physical health care.

The trust was not always able to provide a bed on an acute ward for patients who had a clinical need for this service. This meant that at times, patients on the acute ward were being asked to sleep on a rehabilitation ward. This was disruptive for people’s care and potentially unsafe.
Some inpatient environments where patients received care were of a poor standard. Since the last inspection, the new Three Bridges medium secure unit had opened which had improved the care for patients. However, for other patients especially on the St Bernards site being accommodated in the Wolsey and Tony Hillis Wings, despite some building improvements, their privacy and dignity was impacted by the poor inpatient environments.
The trust had made changes to the governance processes but more was needed. This was to ensure that from board to ward the correct information was available in an appropriate format to support assurance processes and management. Where there were potential risks identified, clear actions needed to be in place and timescales for improvements to be made.

The trust had made progress in many areas since the previous inspection.

Four areas stood out as being very positive:

We found that staff morale was greatly improved. Staff talked about how the culture of the organisation had changed and most people felt this was now much more open. The area where this change was most notable was in the West London forensic services. There were still some pockets where further work was needed.

Blanket restrictions had been reviewed, involving staff and patients. This had looked at ‘rules’ that had been in place and whether they were needed for everyone in the service or just based on individual patient need. This had led to a large number of restrictions being reviewed and where appropriate reduced.
More incidents were being reported and the trust had promoted a culture where staff understood the importance of doing this. A new online reporting system had been introduced. The trust had also carried out its own review of patient deaths following the Mazars report and had an ongoing process for reviewing all deaths.
Work with other agencies and partners had progressed. The trust was working closely with commissioners. The new single point of access was working with GPs and hospital doctors, the police and paramedics, prison staff and members of the public as well as others.

There had been a number of changes in the leadership of the trust. The new chief executive was received positively across the trust. The senior leadership team at the time of the inspection was capable and had the potential to make the necessary improvements, although there was a great deal to be done.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

We rated mental health crisis services and health-based places of safety as requires improvement because:

Since the last inspection the team configurations had changed and in July 2016 the new crisis assessment and treatment teams had been launched. This meant that while changes from the last inspection had been started, they had not all been robustly completed and embedded. At the previous inspection in June 2015, we found that the trust had not implemented governance systems to ensure compliance and address areas where improvements had to be made. At this inspection we found that whilst some systems were in place, local auditing procedures were variable, there was insufficient oversight of safeguarding referrals in one team, and inconsistent completion and storage of risk assessments. There were also not clear systems to collect feedback from patients to identify further areas for improvement.
The trust figures for compliance with target times from referral to assessment across the crisis assessment and treatment teams, indicated that they were not always met, and there had been some significant breaches. Team managers were not aware of this data, and therefore unable to take any action to improve the situation.
Where there were delays in the assessment of people admitted to the places of safety, staff were not recording the reason for this delay. In addition, staff were not always recording that they had informed patients admitted to the places of safety of their legal rights.
Further work was needed on staff engagement with significant numbers of staff saying they did not feel senior managers communicated with them sufficiently about ongoing changes.
Whilst it was recognised that the crisis assessment and treatment teams were fairly new, the staff appraisal rates needed to improve. Also staff would benefit from some more training on topics relevant to their roles, for example, working with people at risk of suicide, or people with eating disorders.
Staff from the crisis assessment and treatment teams were mostly supporting patients in their own homes and some were not following the lone working protocols.
Patients supported by the crisis assessment and treatment teams fed back that they would like to see the same staff more often and have more consistency of care.

However:

Improvements had been made to the physical environment of the health-based places of safety following the inspection in June 2015. Following an external review a number of immediate changes were made. A new health based place of safety was opening in January 2017 at Lakeside which will accommodate two people at any one time.There were still a few other minor changes needed to reflect the Mental Health Act Code of Practice.
Patients were positive about the support provided, including some innovative support from particular staff members.
Staff treated patients with respect and compassion, and provided flexible support according to their needs.
At the June 2015 inspection we found that staff were not receiving sufficiently regular supervision. However, at the current inspection it was clear that improvements had been made and staff were receiving regular supervision sessions.
Monitoring of incidents and complaints was taking place, with action plans developed as learning points from these.
Staff across teams demonstrated sensitivity and understanding of the cultural and religious needs of the population they served.
There was an improvement in support for patient’s physical health, being rolled out from the Ealing team across the crisis assessment and treatment teams.

We rated community based mental health services for adults of working age as requires improvement because:

Staff did not monitor patients’ physical health consistently. This put patients at risk of physical health conditions going undetected.

In some teams, the majority of non-medical staff had not received an appraisal in the last year. One recovery team reported no appraisals for non-medical staff in the last 12 months. Staff in one recovery team did not receive individual managerial supervision.

At the inspection of June 2015, we found long waiting lists for psychological therapies. At this inspection, no improvement had been made. Waiting lists for psychology had become longer. The longest waiting time was 24 months in Ealing and the shortest 15 months in Hammersmith and Fulham.

Mental health support workers in the single point of access team had received no formal training to carry out their duties, especially responding to crisis calls at night time, before taking up their posts. Staff vacancies in the single point of access team were high at 70%. The service said it was difficult to recruit to the role due to the lack of face to face contact with patients.

The number of patients not attending appointments was quite high. The rates had largely stayed the same over the last 6 months, with no plans to reduce this or engage patients in other ways.

Team managers could not always access key performance monitoring indicators in order to understand the performance of their team and make improvements.

At the inspection of June 2015, we found that staff did not all have lone working devices or bring them when they went on home visits. Whilst we did find that this had improved and all staff received their own personal alarm from the trust, some staff did not use them whilst out in the community.

However:

At the inspection of June 2015, we found that patients’ crisis plans could not easily be found and were not always kept up to date. At this inspection, there had been improvements. We saw crisis plans had been updated and were easy to find. The teams had good systems in place for assessing and managing risk. Patient risk assessments were updated regularly.

At the inspection of June 2015, we found that some of the premises presented a risk due to the layout or the alarm systems in place to keep staff and patients safe. At the current inspection, we found this had improved. All rooms where staff saw patients had alarms fitted to the walls or staff kept personal alarms on them. One team had moved from unsuitable premises to safer accommodation.

At the inspection of June 2015, we found that community recovery teams had large numbers of patients supported by duty workers and caseloads for junior doctors were very high. At the current inspection, we found this had improved. Care co-ordinators and doctors had smaller caseloads. Patients had a named care co-ordinator and relatively small numbers of patients were waiting for a care co-ordinator to be allocated.

At the inspection of June 2015, we found that staff supported patients over the age of 65 without any training about how to meet their specific needs. Since the last inspection, most staff had received training in supporting older people and were better equipped to meet their needs.

Patients said staff treated them with dignity and respect.

Staff morale was good despite staff feeling busy and dealing with complex caseloads.

We rated child and adolescent mental health wards as requires improvement because:

Staff did not all have the necessary level of training to support patients. They did not have access to specialised training for supporting people in a forensic CAMHS setting.

Only half the staff had completed training in the Mental Capacity Act and did not understand the principles and how to apply Gillick competency in terms of the young people giving consent. Training on Gillick competence was provided a week after the inspection.

Parts of the unit were not well maintained and repairs did not take place in a timely manner. A shower had been broken for nearly a year and all the patients had to use the one remaining working shower. The football pitch needed refurbishing and the kitchen was out or order.

Staff needed to improve how they recorded restraint. Staff did not document the type or length of time of restraints.

During the last inspection we found that patients in seclusion could not use the bathroom without having to wait for staff to unlock the door. The trust had still not completed work to change this, although senior management said there were plans in place to improve access.

Whilst staff morale had improved there was still further work needed on staff engagement. Staff felt isolated from the rest of the trust.

However:

The service had completed many improvements since the previous inspection. At the last inspection in June 2015, we found that the service needed to improve how staff recorded the physical observations of patients in seclusion, ensure staff involved patients in their care, work on improving staff engagement and morale and ensure staff logged informal complaints. At this inspection we found the service had completed improvements in these areas.

The unit was secure and patients said they felt safe on the ward. There were safe staffing levels, low vacancies and sickness rates.

Staff regularly assessed risks, knew how to make safeguarding referrals and managed medicines appropriately.

The unit had a full range of mental health disciplines and workers providing input to the ward. Staff planned and provided personalised and holistic care and managed patients’ physical healthcare well. Patients had access to a good education department and could access a range of evidence-based therapies. Staff reported good working links with external services.

Staff ensured patients had discharge plans in place.

The unit had a full range of rooms and equipment to support treatment and care. Patients said there were a range of activities on offer which they enjoyed.

Staff handled complaints appropriately.

The ward manager had good working relationships with senior management. The Wells Unit participated in a national quality improvement scheme.

Following this inspection, we rated the forensic inpatient/secure wards as requires improvement because:

At this inspection we found the trust had made considerable progress from the previous inspection in June 2015 but in some cases this was not yet fully completed or embedded. There were some areas where we have asked the trust to do some further work and some new areas for improvement have been identified.

The trust had improved the state of its seclusion rooms considerably and they were all in a good state of repair, but two of the seclusion rooms in the Tony Hillis Wing still compromised patient’s privacy and dignity. These seclusion rooms were in areas where the rest of the ward patients walked past regularly, being in the main corridor of the wards.
The trust had reviewed and reduced many blanket practices, however some blanket practices were still in place especially for low secure patients which did not reflect individual need and were not individually risk assessed.
The trust had worked to improve the recruitment and retention of staff. It had also ensured that the number of hours staff were working was managed so they were not excessive. However, more work was needed to ensure there are sufficient staff with the correct skill mix on the ward and that patient leave is not cancelled as a consequence of staff shortages.
There were ligature anchor points throughout all the wards on the Tony Hillis Wing and these were hard to monitor.

In some seclusion records, we found that staff were not following the Mental Health Act Code of Practice in relation to two hourly nursing reviews and four hourly medical reviews.

The staff did not always take into account patient’s learning disabilities, where these had been identified. We found that the care plans and risk assessments of patients with a learning disability did not take into account their extra needs. There were no accessible versions of patient’s care plans or other ward information.

Supervision records were poor and there was no system of auditing the quality of supervision given to staff.

The physical environment in the Tony Hillis Wing was poor and did not provide a safe or therapeutic environment for the patients.

The food in the Tony Hillis Wing was poor and the portions were too small.

However:

The Thames Lodge men’s medium secure and the Orchard wards were bright, well maintained and clean, with few ligature anchor points.
Staff said that since the last inspection in June 2015, staff morale had improved and engagement with staff had improved.
Considerable work had taken place to improve areas such as ensuring safeguarding alerts were made in a timely manner, making sure that restraint and seclusion is appropriately recognised and recorded, and that staff monitored patients on high dose antipsychotics in line with national guidance.
The trust had implemented a new care pathway for patients which made the whole process of caring for patients more recovery focussed.
The trust had started the ‘safe wards’ project on some wards, which was having a positive impact on staff and patients.
The trust had improved the quality of patients’ risk assessments which were generally up to date and staff were monitoring patients after they received rapid tranquilisation medication.
Many of the patients we met with spoke highly of the staff; they said that they were compassionate and skilled.
The trust provided a vocational pathway to support patients develop work skills. The staff we spoke to demonstrated the trust’s vision of improving the quality of the service and caring with compassion.
Patients said that they had noticed positive improvements because of the trust’s improvement strategy.

We rated community-based mental health services for older people as good because:

At our last inspection in June 2015, we found that nurse caseloads in Ealing and Hounslow were higher than the target of 60 set by the trust. At this inspection, we found that the trust had taken action, in partnership with other agencies, to develop the service. At this inspection, caseloads in Ealing and Hounslow had started to reduce due to the fact that cases were being transferred to five new link workers in Hounslow and seven new link workers in Ealing.
All the CIDS teams operated from safe and suitable premises. The trust had improved the waiting area for patients and carers at Ealing east since our June 2015 inspection.

Patients and carers were able to access information and leaflets in languages other than English. This had improved since our June 2015 inspection.

CIDS teams were well staffed, with agency staff covering vacant posts. Permanent and agency staff were skilled and experienced. Managers ensured staff received one to one support and training to carry out their work role. Staff were positive about their work and the support received from their managers.

Patients and carers were fully involved in assessments of need and care and treatment processes. Carers and patients gave us very positive feedback about the sensitivity and professionalism of staff. Carers spoke very highly about the support staff gave them. They said staff treated them and patients with dignity and respect. Care and treatment plans complied with best practice guidance. The CIDS offered a range of psychosocial interventions to patients and carers. The service supported care homes in relation to managing behaviour which challenged staff.

Staff knew how to recognise abuse and neglect. They raised safeguarding alerts when necessary. Staff understood and put into practice the key principles of the Mental Capacity Act.

The Ealing and Hounslow teams were accredited by the Royal College of Psychiatrists in January 2016. The CIDS included a clinical trials unit. This helped to promote a learning culture within the service and enabled patients to participate in research if they wished.

However:

Although nurse caseloads in Hounslow and Ealing CIDS had started to reduce, in some instances caseloads were still high, for example at 90 in one instance.

The site used by the CIDS team at Hammersmith and Fulham was leased by the trust from another organisation. The trust had identified issues with the safety and suitability of the premises and was in communication with the owner of the property. However, at the time of the inspection there was not an agreed action plan in place to resolve these issues.

We rated wards for older people with mental health problems as REQUIRES IMPROVEMENT because :

Whilst many interactions we observed between staff and patients were kind and thoughtful and took the time to meet their individual needs we also observed interactions that were task orientated and instructional. We observed some examples of poor care practice.

Staff were not consistently applying the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) appropriately in their practice. Deprivation of Liberty Safeguards were sometimes not applied for in a timely manner and records were not readily accessible. This meant staff were not always clear about whether the patient had a DoLS in place or not. There were not robust systems in place to monitor adherence to the MCA and DoLS.

The physical environments across the three wards needed to improve. The decoration in all the wards was tired and in need of an update. Patients could not always reach the alarm in their bedrooms, especially from their bed or a chair. Showers and baths did not always meet the needs of the patients.

There were few adaptations on the ward to meet the needs of patients with cognitive impairments such as dementia, for example, the use of symbols and pictures as well as words in signage. Information was not available in easy read formats or large prints. Menus were in small print and did not use pictures to aid patient choice of food.

Physical health assessments were taking place when patients were admitted. However, there was variable understanding of the appropriate action to take to physical health checks that were of concern. This meant that the patients were at risk of not receiving appropriate care and treatment.

Whilst governance processes were in place, ward managers did not have access to clear and accurate information in a user-friendly format that monitored the quality of the service being delivered on each ward and identified where the ward was an outlier and improvements needed to be made.

However:

The provider had made improvements following the previous inspection in June 2015 where it was found that patients were not always moved safely and that appropriate equipment to support patients with their moving and handling was not always available. Staff had received training and equipment such as hoists were now available.

The provider had also ensured following the previous inspection that restraint was being recognised, reported and therefore monitored to ensure it was being used appropriately. Training had been provided and the numbers of recorded incidents of restraint had increased.

The ward physical environments were safe. Potential ligature risks were appropriately managed and mitigated. Regular environmental checks were carried out by staff. Each ward had grab bags containing resuscitation equipment that could be used in an emergency. Wards were visibly clean, although there were a few rooms with unpleasant odours on Meridian ward.

Comprehensive and timely assessments of patients were completed on admission. Care plans were up to date, holistic and recovery orientated. Risk assessments had been undertaken on admission for patients and these were updated regularly.

Staff knew how to make a safeguarding alert and did this when needed. Appropriate arrangements were in place for the management of medicines.

Safe nursing staffing levels were maintained over the three wards, using temporary staff where needed. Appraisal rates were above the trust target rate.

Carers were positive about their involvement in the care and treatment provided to their relative. Carers were encouraged to attend regular carer meetings and felt that they had opportunities to feedback on the services provided. Jubilee ward participated in John’s campaign, an initiative, which allowed carers to stay with patients outside of set visiting hours, to contribute towards better quality of care for patients. Patients had access to an independent advocacy services.

Activities took place on all the wards we visited. A choice of food was available including a vegetarian option at lunchtime on all three wards. Specialist food consistencies and supplements to meet assessed needs were available.

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

At this inspection we found the trust had made considerable progress from the previous inspection in June 2015 but in some cases this was not yet fully completed or embedded. There were some areas where we have asked the trust to do some further work and some new areas for improvement have been identified.

The trust had made improvements to the location and environments of seclusion rooms, but further improvements to the location of seclusion rooms were needed at Hammersmith and Fulham and Lakeside. Also the seclusion room on Finch ward required some repairs to the environment.

The trust had implemented a new ligature management policy with a range of actions to reduce the risks from ligature anchor points across the trust. Considerable work had already taken place but some further work was needed to ensure the new approach was fully embedded and these risks had been reduced as far as possible.

Work had taken place to improve patient risk assessments but these records were not always being updated following incidents.

Work had taken place to improve the safety of medicines management but fridges used for the storage of medication were not always in the correct temperature range and this was not being addressed.

Patients were admitted to acute wards and then sleeping on rehabilitation wards, especially at St Bernard’s in Ealing. This was not safe or appropriate practice. We have therefore rated the responsive domain as inadequate.

Staff were not all receiving an appraisal or regular individual supervision. The quality of the supervision was not monitored.

Junior doctor out of hour’s rotas needed to be reviewed to ensure they were safe.

Ward managers did not have access to clear and accurate information in a user-friendly format that monitored the quality of the service being delivered on each ward and identified where the ward was an outlier and improvements needed to be made.

The trust had carried out a great deal of work to improve the physical health assessment of patients though there were some gaps in the consistency of physical health monitoring.

Care planning was not consistently recovery focussed and the patient views, goals and aims were not included in all care plans.

Access to psychology services was limited across the service and not all patients were receiving prompt psychological assessment and intervention.

Some ward environments, especially at St Bernard’s did not provide an appropriate therapeutic environment due to the ward layout and lack of communal space.

However:

Many patients spoke positively about the service and many staff engaged pro-actively with patients.

Staff said that since the last inspection in June 2015, staff morale had improved.

Considerable work had taken place to improve areas such as assessing and monitoring patients physical health, monitoring patients in seclusion and after the use of rapid tranquilisation.

We did not rate this service.

We found some areas which the provider needs to improve

At our last inspection in June 2015, we found that 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 we found that while there was demonstrable evidence of an effort to increase recruitment to nursing posts within the service, there were still vacancies, particularly on Parkland and Melrose wards which were the enhanced medium secure services. This meant that some nurses were moved between wards and patients told us that escorted leave as well as therapeutic and leisure activities were sometimes cancelled. This had impacted the quality of care across the service. This was an area where further improvements were needed.
At our last inspection in June 2015, we found that restraint and seclusion were not appropriately recognised and were not only used when needed and recorded so that the use could be reviewed. At this inspection we found that while the staff in the service were recognising the use of restraint and seclusion appropriately and only using it when needed, the recording still needed to improve. There continued to be significant gaps in the paper records relating to seclusion on a number of wards. For example, some records had gaps where staff had not completed records of continuous observation every thirty minutes and some records did not include regular nursing or medical reviews. This meant that we could not be provided with assurance that the correct observation and monitoring had taken place when patients were subject to seclusion. This was an area where further improvements were needed.
Incidents of restraint were recorded comprehensively on incident reporting forms. However, staff on the wards, including ward managers, did not have access to information about the type and length of time that restraint was carried out in the electronic records.
Some seclusion rooms, particularly on Melrose and Garnet wards, were on occasion registering temperatures above 25°C. This meant there was a risk that temperatures were not maintained at a comfortable level. The service was mitigating this by trying to use other seclusion rooms where possible and managers within the service were aware of this.
While incidents were recorded, all information about incidents was not available to ward managers if they had been signed off by another member of staff. This meant that there was a risk that ward managers would not have an oversight immediately of the detail of all incidents on their wards.
Some staff on Parkland ward told us they had not had regular supervision in the year prior to the inspection; however, this had improved recently. This had not been identified as a concern at the previous inspection in June 2015.

However, we also found some good practice.

We saw that the service had made significant improvements since the last inspection in June 2015 and that they were focussed on continuing to improve.
At our last inspection in June 2015, we found that staff engagement and morale was poor and that staff identified that they did not feel comfortable raising concerns within the service to their managers and to senior managers in the trust. During this inspection, we saw that work on staff engagement had been positive and most staff reported that they felt supported by their managers at a ward, service and trust level. There had been a significant improvement in this area.
At our last inspection in June 2015, we found that the trust had been using blanket restrictions inappropriately on wards and that these did not reflect individual patient needs. During this inspection we saw that there had been a focus on reducing restrictive practice and blanket restrictions across the service. This had had a positive impact on the care and treatment of patients and the culture within the service by ensuring that care was more person-centred. This was an improvement since the last inspection.
At our last inspection in June 2015, we found that patients did not consistently have records of physical health checks. During this inspection we found that patients had access to physical health care from primary health care services which were provided on site, regular physical health checks by nursing and medical staff on the wards and access to acute general hospital when necessary and that these were recorded to demonstrate that they were taking place. This was an improvement since the last inspection.
At our last inspection in June 2015, we found that audits were not consistently completed on the wards and that information from audits was not always used to drive improvement. During this inspection we found that there were robust governance arrangements in place including the use of clinical improvement groups throughout the service to ensure that information about incidents, complaints and audits was disseminated through to ward staff as well as up to the service and trust management teams. There had been improvements in the governance processes and how this impacted on practice on the wards since the last inspection in June 2015.
Patients in the service had access to multi-disciplinary support including occupational therapy, psychology and social work as well as nursing and medical support.
Staff had introduced the ‘safe wards’ programme into the unit which included person-centred work aimed at reducing violence and aggression on the wards. For example, by focussing on the use of language through the soft words project which focussed on the impact of language on care.
Most patients reported that staff were kind and caring. This reflected our observations on the wards when we visited.
Patients had access to a wide range of therapeutic and leisure activities, including work-focussed activity such as work in the on-site café, library and shop.

The Gender Identity Clinic is a service which treats people who have or experience gender dysphoria and other issues related to gender. The service operates from a base in Hammersmith, however, it accepts referrals from across the United Kingdom. We have not rated this service because this was a focussed inspection.

We found that the service needs to improve as follows:

Administrative systems were causing problems for people who used the service. There were delays in letters being sent to people who used the service and to other professionals. Appointments were being cancelled, sometimes at the last minute when people were already travelling to the clinic. People using the service were not always told why appointments were cancelled and would sometimes have to wait long periods of time for appointments to be re-arranged. There was sometimes a lack of responsiveness to telephone calls. This was reflected in feedback from people who used the service as well as complaints which had been made to the service.
There were long delays between people being referred to the service and having an assessment and treatment. The target timescale was 18 weeks but people were waiting 10-14 months. Action plans had been developed with commissioners but these were still being implemented.
While some people were well-engaged with the service on an individual basis and the service carried out feedback surveys, there was no formal engagement strategy with people who used the service.
Some people using the service were not sure how to complain or were worried that if they complained this would have a negative impact on their care.
There was a disconnect between the trust and the team working in the service. Staff told us that they felt well-supported locally but felt detached from the trust. Staff within the clinic told us that they felt detached from the trust and did not feel that the work and care being provided by the service was sufficiently recognised by the trust. This had an impact on staff morale.
Clinical governance meetings had been recently established after a year long gap. However, there was no evidence of learning from complaints and incidents documented through minutes and formal governance processes.

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

The clinic delivered care and treatment provided by experienced, knowledgeable clinicians. Most of the feedback we received from people who used the service was positive about the quality of care and treatment which was delivered. The staff team were enthusiastic and strongly committed to provide an excellent standard of care for people who used the service. We heard examples of how staff were willing to go the extra mile to meet the needs of people using the service.
The trust senior management were aware of the challenges around governance and were open about sharing this information with the inspection team. They had been taking active steps with the local management to address the identified issues and some improvements had been made.

We rated community-based mental health services for older people as good because:

The clinic environments were safe and clean with equipment which was maintained.

Risks to people using the service were managed well.

Staffing levels were maintained using agency staff where needed.

Staff were aware of how to raise safeguarding alerts and did so when necessary.

Very few incidents had occurred in the past twelve months, and staff had learnt from these.

People had a detailed assessment and comprehensive care plan.

People using the service, and their carers, were involved in the development of the care and treatment plans.

Teams supported people in line with best practice guidance.

Teams worked to help care homes improve the support for people living with dementia.

Staff were suitably qualified, trained and supervised. Staff regularly met and exchanged knowledge and expertise to benefit the well-being of people using the service.

The Mental Capacity Act was understood and its use was well-documented throughout the service.

Staff were responsive, respectful and offered appropriate emotional and practical support.

We had extremely positive reports from patients regarding the support offered by staff. Consistent themes fed back to us included the prompt responses by the service, the helpfulness of individual nurses and clinicians, and the clarity and detail of explanations, and the fact that carers felt listened to by professionals.

Staff showed a good understanding of the individual needs of patients. Visits were person centred, with patients fully involved in discussions and not ‘talked over’.

The service responded promptly to referrals and requests for help. It was flexible in engaging with people who needed the service but who had difficulty attending appointments or acknowledging their need for help.

Information about services were available, and interpreters were readily available when required.

Staff knew how to respond to complaints. There had been very few formal complaints in this service in the past year.

Staff worked in ways that reflected the trust’s visions and values.

Senior managers had become more ‘visible’ to teams.

Teams were able to submit items of concern to the trust risk register.

There was commitment to innovative research, such as the clinical trials unit and the dementia research register.

There was a positive atmosphere in all teams, with low sickness and turnover. Staff consistently cited good team work and support as a factor in high morale.

We gave an overall rating for the specialist community mental health services for children and young people of good because:

Incident reporting took place and the learning from these was shared across the teams.
Risk assessments were comprehensive and regularly updated.
Staff knew how to raise a safeguarding children referral and there was good support from managers with this role.
Assessments were completed in a timely manner with multi-disciplinary input.
Care plans were detailed, personalised and enabled holistic evidence based care. New care plan templates had been developed in conjunction with young people and their families to increase involvement in care.
The services were using the latest guidance to support their work.
There was effective multi-disciplinary and multi-agency working.
Staff showed compassion and understood the needs of young people and their families.
The service recognised gaps in service user involvement and implemented projects to include younger people who had less of a voice in service development.
There were a number of ways for young people to be engaged in their care and the service.
All teams had access to meeting rooms where young people and their families could meet with staff in private. The rooms were well-maintained, light and airy.
Staff worked to ensure young people attended their appointments. Numbers of patients who did not attend were closely monitored.
People who used the service and staff were aware of the complaints process and using it appropriately.
Staff were very committed and reflected the values of the trust.
There were team meetings in place and access to other information to support the management of the teams.

However the team bases need to be reviewed to ensure staff can call for assistance where needed and rooms are sufficiently soundproofed to avoid confidential conversations being overheard. There is also a need for some ongoing work on staff engagement to ensure staff feel supported and able to raise issues with the confidence that they will be listened to and addressed.

We rated the community based mental health services for adults of working age as requires improvement because:

Community recovery team had large numbers of patients being supported by duty workers and the caseloads of junior doctors were very high. There were not enough staff deployed in in the teams to safely meet the needs of all the patients on their caseloads.
The premises in which some of the teams were based could present a risk to staff due to the alarm systems or the layout of the premises.
Patient crisis plans were not always kept up to date. Plans to mitigate risks to patients in a crisis were not always in place or were not stored where they could be easily found in a crisis.
Records of patient care and treatment were not always accurate or up to date.
Records of patient care were not always easy for staff to find.
Staff in the recovery teams were supporting people over the age of 65 but needed training to meet their specific needs

However, patients we spoke to, and comments cards we inspected, were mostly very positive about the service they received. Staff had a good understanding of safeguarding adults and children policies and the procedures to keep people safe from abuse. Local leaders were visible and accessible to staff and despite high caseloads, most patients told us they could get appointments when they most needed them. Patients told us that they could easily contact their care co-ordinators when they needed to speak with them. The service worked well with other teams and agencies to enable patients to move between services as their needs changed.

We rated mental health crisis services and health-based places of safety as requires improvement because:

The health based place of safety at the Lakeside mental health unit was not suitable for purpose. At Lakeside mental health unit the place of safety was based on Kestrel ward, a male ward, at the end of the corridor with other patients. Although there was a separate entrance to the place of safety, people could not be transferred here without compromising their privacy and dignity. Females could not be admitted to the place of safety on the male ward. Women who had been detained under section 136 were taken through a separate entrance onto Grosvenor ward where they would be initially assessed in an interview room. The trust had plans to relocate the place of safety within 12 months as it was not considered fit for purpose.
The records across the teams were not consistent and accurate especially in terms of updating risk assessments, medication records and care plans. This could potentially place patients at risk of not having their current needs met.
The number of staff being supported by receiving regular supervision was very low.
Governance processes across the home treatment teams were not working well. Audits were not always taking place. There were variations for example in the quality of record keeping, the regular supervision of staff, supporting patients with their physical health and staff understanding and use of the Mental Capacity Act. These could all potentially present a risk to the safety of patients.

However staff we spoke with across services reflected the values of the trust. They were committed and caring about the people they worked with to deliver care. Monitoring of incidents and complaints took place, with action plans developed as learning points from these. Staff across teams demonstrated sensitivity and understanding of the cultural and religious needs of the population they served.

The trust had been working with the police, local authority and other agencies and to develop effective policies and protocols for the use of the places of safety to ensure the principles of the crisis care concordat work were firmly implemented. For over a year no patient under a section 136 had been held in a police cell. The trust was working with local commissioners to improve access to crisis care.

We rate West London Mental Health Trust child and adolescent mental health wards as good because:

A ligature risk assessment had been completed and improvement work was scheduled to take place, identified risks were being mitigated with individual risk assessments and observations as required.
The required equipment and medication were available, accessible and being checked regularly and the ward was clean and well furnished.
The staff members had alarms and knew how to respond to incidents.
The number of staff on shift was adequate to meet the needs of patients.
Patients could access a range of activities and escorted leave and this was facilitated by staff.
Patients had up to date risk assessments completed by a nurse and were involved in writing these and the assessments were reviewed regularly and after incidents.
There was low use of restraint and we heard good practice from staff members regarding using de-escalation and preventing the need for restraint.
There were detailed assessments of both mental and physical health for all patients and care plans reflected the information in the assessments.
Patients received physical health checks and could access a GP as required.
Care plans were up to date, holistic and recovery orientated.
Systems to record patient information were easily accessible to staff and contemporaneous records were being maintained.
There was access to individual and group psychology and occupational therapy sessions.
There was a strong multi-disciplinary team
The MDT meetings were well attended and the holistic needs of patients were discussed and included in minutes and care plans.
Staff showed a good understanding of the Mental Health Act, code of practice and guiding principles and consent to treatment and capacity requirements were met.
Patients had their rights explained to them on admission.
Positive, kind and caring interactions between staff and the patients were observed.
Staff knew patients and their individual, holistic care needs well.
Patients were routinely involved in their care planning and community meetings.
Families and carers were welcome on the ward and involved in care planning and decision making.
The facilities were good and these were used well to meet the individual needs of patients.
The food was an adequate quality and snacks and drinks were available at all times and dietary needs were met for those of different cultures and religions.
Patients had access to a telephone on the ward.
There was a good range of group and individual activities on the ward both therapeutic and social activities.
Staff members reflected the values of the trust and were committed and passionate about the work they did with young people and families.
The ward was organised and was meeting the needs of the young people using the service.

However work was needed to ensure effective staff engagement so a culture of open and transparent behaviour can be promoted on the ward. There should be an effort made to work with patients to make the communal areas and entrance more inviting, age appropriate and recovery oriented. The seclusion room facility should be reviewed to ensure it meets the needs of people using the facility. Seclusion records should be accurately maintained. Informal complaints should be logged so that they can be reviewed and lessons learnt.

We gave an overall rating for long stay/rehabilitation mental health wards for working

age adults of good because:

Both units fully complied with same sex accommodation guidance.
There were enough staff to carry out observations and support patients with their individualised care plans.
There was an increasing rate of incident reporting on the ward, with a developing culture to report and learn from incidents.
Staff on both wards were well trained in carrying out physical health checks and good physical health care monitoring took place.
Staff had a good understanding of safeguarding procedures.
Individual risk assessments were up to date and risk was discussed at handovers.
Care plans were individual and recovery-oriented.
Records were up to date and regularly reviewed.
There were effective multi-disciplinary team meetings with opportunity for discussions with patients.
The services followed current best practice and patients had access to a range of therapies.
Staff were supported with regular supervision, mandatory training and access to specialist training.
Observations of staff attitudes and behaviours when interacting with patients were seen to be both caring and respectful. Staff provided appropriate practical and emotional support.
Feedback from patients was mainly positive about all staff, including clinical and domestic staff.
Patients engaged in day to day decision making through daily planning meetings and weekly community meetings. On Glyn ward the weekly community meeting was chaired by a patient.
There was involvement of families and carers.
The wards provided environments that met the needs of the patients for example kitchens where people could do their own cooking.
Patients had access to a range of activities and vocational opportunities that promoted their rehabilitation.
Patients were supported to follow their cultures and religions where they wished to do so.
Patients knew how to make a complaint and felt that these would be addressed.
Staff were familiar with the trust vision and had developed this further at a local level. Patients had co-produced their vision and values which aligned to the organisations values.
Staff were patient focused with a strong emphasis on recovery.
There was a commitment to service improvement with the wards participating in the Royal College of Psychiatrists’ accreditation for inpatient mental health services.

We rated forensic/secure wards overall as inadequate because:

Staffing levels in the West London forensic services had not been maintained consistently at levels which guaranteed patient safety.
Also low staffing levels at Broadmoor and West London forensic services meant that patients did not always have access to therapeutic activities, individual sessions with their primary nurse and association time in high secure services. In the West London forensic services some patient leave was being cancelled.
In West London forensic services some nursing staff were working excessive hours.
Some ward environments, particularly the seclusion rooms in the West London forensic services were not in a good state of repair and did not afford the maintenance of patient dignity.
There were some blanket restrictions in the West London forensic services which had not been assessed according to the type of service and individual patient needs. Examples included searches of wards and the use of protective gowns in seclusion in the womens service.
Records for restraint and seclusion in the West London forensic services were not consistent and accurate. Some seclusion and restraint was taking place and not being recognised, or being used when it was not clear if this intervention was needed.
In the West London forensic services some patients were being prescribed medication at levels higher than the recommended maximum dose without the national guidance for this being applied.

Many staff across both sites, at Broadmoor and at the West London forensic service spoke of feeling disempowered and of suffering from poor morale.
In the West London forensic services staff expressed specific concerns about the longstanding culture of bullying linked to race, religion and culture.

Staff based at Broadmoor Hospital told us that they felt detached from the central trust based in London.
While the trust had identified the key concerns and issues which were raised through the inspection process. Whilst action had been taken this had not yet had sufficient impact to address all the concerns which were highlighted especially with staff engagement in the West London forensic services.

However, we found that patients at Broadmoor Hospital were very positive about the quality of care which they received. There were many excellent examples of patients being engaged in their care and the work of the trust. Staff were aware of how to report incidents and there were systems in place to ensure that learning from incidents was shared through the services and the trust.

We gave an overall rating for wards for older people with mental health problems of good because:

The staff were kind and respectful to patients and had a good understanding of individual needs. Positive work took place with the carers of patients, to provide support and involve them in their relatives’ care. The wards were very aware of the diverse needs of patients and made positive attempts to meet their individual needs. The wards provided different therapeutic activities to support patients during their stay.
Clinical staff made an assessment of patients’ needs on their admission to the wards. This included an assessment of physical health needs. Where needs had been identified, these were developed into care plans so that staff knew each patient’s needs. Staff completed risk assessments and developed management plans to minimise risks to patients and staff.
Multi-disciplinary teams worked effectively in the care and support of patients.
The wards were clean and generally well-maintained. Emergency equipment, including automated external defibrillators and oxygen were situated on the wards. It was checked regularly to ensure it was fit for purpose and could be used effectively in an emergency.
Staff had been trained and knew how to make safeguarding alerts. Staff received appropriate training, supervision and professional development.
Staff had an understanding of the Mental Capacity Act 2005, and there were positive examples of their working within this to assess patients’ capacity, and ensure decisions were made in the best interests of the patients. This was particularly evident at the Limes.
Staff were committed to the vision and values of the organisation and felt connected to the trust. There were local governance processes that helped identify where the services needed to improve. Audits were being used well to monitor and improve services and clinical care.
There was evidence of clear leadership at a local level, from ward managers through the service lines to clinical directors. Ward managers were visible on the wards during the day, were accessible to patients and provided support and guidance to staff. The culture on the wards was open and encouraged staff to bring forward ideas for improving care and developing the service.

However we rated the safe domain as requires improvement because:

Staff on Meridian ward lacked a clear understanding of what constituted restraint, such as arm holding. As a result, the use of restraint was being under-reported by the ward and accurate information on the use of restraint could not be established.
Staff were trained in the safe moving and handling of patients though did not always use appropriate moving and handling techniques to assist patients to move and there was a lack of equipment for this on Meridian ward.

We rated West London Mental Health Trust’s acute wards and the psychiatric intensive care unit as requires improvement because:

Not all staff knew the incident reporting thresholds, therefore all incidents were not reported.
Female patients were required to access seclusion on the male PICU ward. The location of the seclusion rooms could compromise patient safety as people had to be supported, whilst in a distressed state to move between floors.
Not all areas of the ward were included in the ligature audits. Ligature audits did not indicate timescales when works were scheduled to be carried out. Patients’ personal items posed potential ligature risks on the wards.
The use of rapid tranquilisation was not clearly recorded on patients’ prescription charts on some wards and the monitoring was not always happening.
Medication was not managed consistently well across all the wards. On Grosvenor ward the controlled drugs register was not always completed accurately.
All patients did not have physical health assessments completed that were thorough and were followed up in a timely manner including ongoing physical health checks where needed.

Governance processes across the wards were not working well. Audits were not always identifying issues or being followed up. Some basic checks were not taking place as planned. The quality of record keeping was variable. These could all potentially present a risk to the safety of patients.

However most staff were caring and respectful with patients, recognising their individual needs and there were many positive examples of patients and carers being engaged in their care and the service. Patients had access to a programme of therapeutic activities. Staff had access to appropriate training and supervision. Learning from incidents was shared and used to improve the safety of the care delivered.

We have given an overall rating to West London Mental Health NHS Trust of requires improvement.

We have rated one of the nine core services that we inspected as inadequate, three as requires improvement and the other five as good. The services that were inadequate are the forensic and high secure services. The services that require improvement are the acute admission wards for adults, the community based mental health services (mainly the community recovery teams) and the crisis services. The latter include the home treatment teams and health based places of safety.

The forensic core service report covers both the high secure services at Broadmoor and the West London forensic services. We were most concerned about the West London forensic services.

At the start of the inspection, the chief executive of the trust gave a presentation about the areas they were proud of and the challenges faced by the trust. Our inspection findings reflect the priorities identified by the trust. This demonstrates that the senior trust managers had identified many of the problems that they needed to address. However, we believe that our inspection identified that the scale and speed of change that was needed was very significant. They must address these as a matter of urgency.

The three main areas for improvement were as follows:

The trust had a substantial problem with staff recruitment and retention. There were too few staff to consistently guarantee safety and quality in the forensic services, high secure services and community based mental health teams (mainly the community recovery teams). There were staffing problems in some other areas but these are not as severe.
The trust had a problem with low morale and poor engagement with front-line staff in some of its services. This particularly affected those in working in the forensic services. Poor morale can adversely affect the quality of care and make staff reluctant to show openness, transparency and honesty that are essential to safe care.
The trust must improve its practices in relation to restrictive interventions such as the use of restraint and seclusion. They have started to tackle this problem but there is much more to be done. The problem is most serious in the forensic, high secure, adult admission and older peoples’ wards. The trust must ensure that its seclusion rooms meet the required standards, that staff use restraint only as a last resort, that they minimise the use of restraint in the prone position, that they accurately document and record the use of restrictive interventions and that they make the necessary physical health observations after a patient has been given an injection to manage disturbed or distressed behaviour

Despite these problems there was much for the trust to be proud of. The problem of low morale was not endemic. In many services that we visited, staff were very positive about the work of the trust and in most places care was delivered by hard working, caring and compassionate staff. This was particularly noted at Broadmoor where staff showed a real concern for patients on an individual basis and a desire to see them progress towards recovery.

Three other areas stood out as being very positive.

The trust actively encouraged the personal development of its staff. It supported them in this and enabled them to access training and other development opportunities. We heard of many examples where staff had been able to extend their skills and develop their career within the trust and as a result provide better care to patients.
The trust was making real strides with user and carer engagement. An example of this was the support it offered to the West London Collaborative. We also found many examples across the services where staff involved people in their care and in the wider service.
The trust worked closely with statutory and voluntary sector partners to improve mental healthcare in the wider community. For example it had worked with the police to better support people in a crisis. This had resulted in the police not having to take a single person detained under section 136 to a police cell for over a year.

The trust was developing a strong leadership team which had good insight into the challenges they faced and were working to create a more open and positive culture within the organisation. The management restructure into two clinical services units was leading to clearer accountability. The trust was improving the quality of its integrated performance report which it used to monitor the quality and safety of its services. The recent introduction of clinical improvement groups for each ward and team was leading to better sharing of information.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

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.

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.

These reports, under our old approach to inspection, involved us assessing a whole provider against the standards we expect.

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.

As well as standard inspection, intelligent monitoring and Mental Health Act Commissioner reports, there are other types of report that we have published under special circumstances.

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