All inspections: Central and North West London NHS Foundation Trust

We inspected Central and North West London NHS Foundation Trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall.

We inspected four of the mental health services provided by the trust. We completed full inspections of the trust’s forensic inpatient or secure wards and long-stay or rehabilitation mental health wards for working age adults. We completed a focused inspection of mental health crisis services including health-based places of safety, psychiatric liaison services and some new assessment services. We also carried out a focused inspection of one child and adolescent mental health ward for young people with a learning disability. We chose these core services as we knew there had been some challenges including serious incidents or where the service was more likely to become a closed culture.

The trust provides the following mental health services, which we did not inspect this time:

Community-based mental health services for adults of working age

Acute wards for adults of working age and psychiatric intensive care units (PICUs)

Wards for older people with mental health problems

Community-based mental health services for older adults

Specialist community mental health services for children and young people

Community mental health services for people with learning disabilities or autism

Wards for people with learning disabilities or autism

Specialist eating disorder services

Substance misuse services

The trust also provides the following community health services, which we did not inspect this time:

Community health services for adults

Community end of life care

Community health services for children, young people and families

Sexual health services

Community health inpatient services

Community dental services

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

We rated safe as requires improvement, caring as outstanding, and effective, responsive and well-led as good. We also carried out a well-led inspection and rated the trust as good.

We rated two out of four of the trust’s services that we inspected. Long-stay or rehabilitation wards for working age adults were rated requires improvement and forensic inpatient or secure wards were rated good. We did not rate the other two services as we only partially inspected those services.

In rating the trust, we took into account the current ratings of the mental health and community health services we did not inspect this time.

The inspection took place at a time of complexity for the trust board as the decision to have a chair in common across three trusts in North West London had just been made. The board and other senior leaders needed the time to think through the implications including opportunities for more joined up working to better meet the needs of the local population.

There had been significant changes in the executive leadership team and non-executive directors, these had gone well and provided an opportunity to improve the diversity of the board and introduce people with the breadth of experience needed to support the strategic direction of the trust. Senior leaders demonstrated commitment, enthusiasm and a willingness to innovate to deliver the best services. They were open and honest about recognising and sharing the challenges faced by the trust but also solution focused when looking at how these could be addressed.

Patient and carer involvement had progressed significantly since the previous well led assessment and was well embedded throughout many areas of the work of the trust. For example, 80% of the 345 active quality improvement projects included people who use services. The trust had an involvement register which had grown and enabled people with lived experience (experts by experience) to join and help deliver this work. At the time of the inspection there were around 100 people on the register. There were many examples of where experts by experience had contributed to the work of the trust. The trust had also made progress with the employment of 134 peer support workers, although they recognised that further work was needed to ensure they received the right support. In October 2022 the trust launched the volunteer to career programme. Since then,156 volunteers had been placed in a variety of settings; 29 new volunteer roles had been created; 25% of volunteers had moved into employment. Whilst some carers recognised the opportunities for more involvement, there were others who still found it hard to engage with services.

Quality improvement had also become fully embedded in the work of the trust since the last inspection. People working for and associated with the trust talked about how the approach was widely used. This approach was being developed to address areas where the safety of care needed to improve, such as reducing falls and improving pressure ulcer care. Quality improvement projects had resulted in reductions in violence and aggression and in the use of restrictive interventions. A quality improvement approach was used to improve access to services, such as reviewing psychological therapy services and the assessment of young people with attention deficit hyperactivity disorder and autism spectrum disorder.

The trust made good use of data to inform decision making. They had access to management information and since the previous inspection had made widespread use of integrated performance reporting. There was improved access to ‘real time’ information and they were working towards automated dashboards. The quality of performance information was good and board members felt they had access to data that was reliable.

The trust embraced digital technology to improve services. One of the key developments had been the use of e-prescribing which was in place for inpatient services and being extended to home treatment teams. In pharmacy services patients could scan a QR code on their mobile devices which provided access to educational videos on high-risk medicines. Plans were underway to have further automation of human resources processes; increase the number of patients being able to order their prescriptions online; and develop technology to support patients managing their personal health record.

Partnership working had developed significantly since the previous well led review. Senior divisional leaders were actively participating and leading in the care systems where most trust services were located. The trust had many examples of where it was working in boroughs and neighbourhoods to meet the needs of communities. The trust led and actively participated in provider collaboratives. They also helped deliver national programmes such as the roll out of the Mpox vaccine.

The trust was committed to supporting staff to ‘speak up’ and since the previous inspection arrangements for the freedom to speak up guardian had been strengthened. Staff knew how to access this support, the guardian was visible and supported by speak up ambassadors.

Feedback from the guardian was collated into themes to promote organisational learning. The resources for the speak up function were under review to ensure there was sufficient capacity.

The trust had further developed equality, diversity and inclusion. The trust had seven staff networks (there were five at the previous well led review). These were the lesbian, gay, bisexual and transgender (LGBT+); Black, Asian and ethnic minority (BAME); carers; women; lived experience of mental health stigma transformation; and disability. All the networks had a non-executive director and executive director sponsor. The staff networks were participating in wider governance arrangements by attending key meetings and having input into policy development. The trust were proud to have remained in the Stonewall list of top 100 employers. There was a recognition that there was still much more to be done and the workforce race equality standards showed ongoing disparity in career progression. However, there was lots of positive feedback about the 21 Century leadership programme where at least 50% of the intake were BAME staff (135 staff so far). The trust was supporting career conversations to look at individual needs. The trust had a stated intention that there would be a representative from a BAME background on recruitment and disciplinary panels. This was monitored but not always achieved, and further training was needed for the representatives.

We found some good practice in relation to incident reporting, incident investigations and mortality review processes. The trust had a strong reporting culture for incidents. This was reflected in the data for the previous year which showed that 98.2% of all incidents were reported as resulting in no or low harm. The incident investigation reports were completed to a high standard. The trust monitored how long it took to complete investigations and was working to keep the timescales at an appropriate level. The trust looked at themes and this was linked to the quality improvement work on patient safety. The trust had effective and robust governance processes in place to investigate deaths within the trust and use the learning to make improvements. This included being sighted on the deaths of people using community services. They had found a backlog of action plans which needed to be completed by the divisions and this was being addressed. They also recognised that there could be more shared learning with system partners.

However:

Overall, we found that whilst there had been significant progress in some areas since the previous inspection there was more to do. The trust leadership was mostly aware of where further input was needed and had plans to continue this work. They were focusing on improving the experience of patients accessing and using their services.

The escalation and oversight of operational risk needed to be strengthened and work was underway. Our inspection found that an acute ward in Milton Keynes had been experiencing significant challenges when it was inspected in 2020. A follow up inspection in 2023 had found many of the similar challenges. Whilst risks in the service had been escalated there had not been a recognition that following a period of improvement the service had not sustained the changes. Following the latest inspection, the trust had appropriately identified the current level of risk in the service and was making the necessary changes. At the time of the well led assessment the trust was refreshing its processes for the escalation of operational risk so that trust board members could have greater assurance about appropriate levels of oversight by the executive board. The trust had also updated the board assurance framework and there were plans for board members to review this and consider risk appetite.

The trust had several assurance processes to identify services at risk of developing a closed culture, but these needed to be strengthened further. Our inspection found a rehabilitation service, Westfield House in Epsom, where some institutional practices had developed and where patients were not receiving the support needed to promote their rehabilitation. Among the findings were some restrictive practices that prevented patients from leading a more independent life, a lack of choices and respect of patients’ preferences including those associated with eating and drinking and insufficient discharge planning. Following the inspection, the trust closed the service. The trust made good use of data to identify services which were outliers including feedback from complaints and staff concerns. They also had several visits to services including board members, governors, peer visits and in some areas input from Healthwatch. However, this needed further review and strengthening to ensure unacceptable practice was identified.

The trust was experiencing major pressures on the mental health urgent care pathway. This was a national issue, but our inspection found the experiences of many people accessing these services was poor, for example people waiting for excessive periods of time in acute emergency departments and in health-based places of safety. The trust was working to try and address the challenges within the different systems where they had services. This included work to reduce lengths of stay, improve patient flow and avoid the use of out of area placements. In North West London they had plans to open additional acute mental health beds at Park Royal. They had also opened a mental health crisis assessment service at St Charles Hospital in North Kensington. Other assessment services aligned to acute emergency departments were operating at St Mary’s and Hillingdon hospitals. The trust was closely monitoring their performance, and benchmarking, for 12 hour breaches in waiting for a mental health bed. They were performing well in relation to other London trusts but recognised that there was more to do, particularly in partnership with acute providers.

The trust had a programme of work to improve the physical healthcare of patients with mental health needs, but this had to embed further. Our inspection of the forensic wards looked carefully at this as the patients usually have long term mental health conditions. There had also been a death on the ward where a deterioration in the patients’ physical health had not been identified. Here we found that despite measures being taken by the trust to improve physical health monitoring this was not happening thoroughly.

Further work was needed to embed the trust strategy and align other enabling strategies. The trust had carried out a refresh of its strategy. There were five clear strategic priorities which were easy for people to understand. However, the strategy was not yet embedded in governance arrangements. For example, board papers were not aligned to strategic priorities. The trust was working to refresh a range of other strategies such as estates and digital. It was not always clear how these pieces of strategic work aligned to each other and the trust governance processes. The work on a clinical strategy was at an early stage.

Staff supervision had progressed since the last inspection but there was more to do. The staff had developed an online tool so that supervision could be recorded and monitored. However, from focus groups it was evident that staff were often having very different experiences of supervision. We heard about a current quality improvement project looking at how the quality of supervision can be improved this was including updating the policy, auditing supervision practices, and developing training to take this work forward.

The failure of staff to carry out therapeutic observations appropriately continued to be a recurring theme in serious incidents. Work was underway but there was more to do. The trust was aware of this and was taking steps to make improvements through a task and finish group. This included the pilot of new digital equipment to record observations – although this would not yet work for intermittent observations. Training had been enhanced and observations was covered in staff induction and was an area included in the simulation training being rolled out across the sites by the education team. The trust was trying the use of a badge – so that staff would know when a colleague was carrying out observations. They were also looking at giving staff bum bags containing items which could be used to improve therapeutic interactions such as a pack of playing cards.

Staff recruitment and retention continued to be the most significant risk for the trust. This led to the use of temporary staff and the associated reduction in consistency of care. Safe staffing was monitored and mostly met, with outliers clearly identified. At the time of the inspection trust vacancies were 9.3% (medical 13% and nursing 18%) – lower than other London trusts. Turnover was 19.2% and high turnover in the first year was an area of particular concern. The trust was trying a number of measures including a 1:1 conversation with each new starter every 30 days to find out if they needed any support. This was an area of ongoing work.

How we carried out the inspection

The teams which carried out the inspections of core services comprised of 11 CQC inspectors, 4 CQC pharmacist inspectors, 3 CQC senior specialists, 6 external specialist advisors and 3 experts by experience who talked with patients and carers in person and on the telephone.

The team which carried out the well-led assessment comprised of 2 external executive reviewers, a financial governance assessor from NHSE, 2 CQC pharmacist inspectors, a Mental Health Act reviewer, 2 CQC inspectors, a CQC operations manager, a CQC senior specialist, and two CQC deputy directors of operations.

The full inspection of forensic inpatient and secure wards involved visits to Java House and Tasman ward both located at the Park Royal site.

The full inspection of the rehabilitation mental health wards included visits to 6 services. In North West London these were Roxbourne Lodge, Roxbourne House and Rosedale Court. In Epsom these were Ascot Villa, Westfield House and The Cottages. Following the inspection the trust closed Westfield House.

The focused inspection of child and adolescent mental health wards for young people aged 13 to 18 with a learning disability involved a visit to Crystal House at the Kingswood Centre in North West London.

The focused inspection of crisis services included visits to the health-based places of safety at St Charles and Hillingdon Hospitals; the psychiatric liaison teams at Hillingdon Hospital, Northwick Park Hospital and Milton Keynes Hospital; the mental health crisis assessment services at St Charles and Hillingdon Hospital.

During our inspection of the four core services and the well-led review, the inspection teams:

reviewed records held by the CQC relating to each service

spoke with 59 senior leaders during our inspections of services, including board members, divisional directors, service directors, service managers, operation managers, the lead psychologist, matrons, ward managers and lead nurses.

spoke with 109 other members of staff, including registered nurses, healthcare assistants, forensic social workers, student nurses, consultant psychiatrists, specialist doctors, ward doctors, occupational therapists, pharmacists, advocates, housekeeper and catering staff, ward administrators, a mental health administrator, activity coordinators, a gym instructor, a speech and language therapist, drug and alcohol specialists and staff from the corporate health and safety team.

interviewed 54 patients and 31 relatives or carers of patients face to face or on the phone

reviewed 90 patient care and treatment records

attended meetings on the wards and teams we visited, including 5 staff handover meetings, 2 safety huddle meetings, 2 ward rounds, 2 community meetings, 1 patient planning meeting, observed lunch service on 2 wards and attended a bed management meeting

carried out observations on 2 occasions using the short observational framework for inspection (SOFI) on the long stay/ reablement wards. This is a tool developed and used by inspection teams to capture the experiences of people who use services who may not be able to express this for themselves.

looked at a range of policies, procedures and other documents relating to the running of each service.

You can find further information about how we carry out our inspections on our website: 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 on the forensic wards was mostly positive. Patients told us they were listened to and felt safe. All patients reported that they were involved in their care and had access to activities within the service and the community. They told us they were supported to maintain contact with family members. Patients said staff treated them well and that the ward was much calmer and settled.

The relatives and carers of patients with whom we spoke during our inspection of the forensic wards reported that their family members were safe and well looked after. They said they were involved in care programme approach meetings, ward rounds, discharge planning and Mental Health Act tribunals, in accordance with the wishes of their family member. However, all carers told us that they were not always kept updated and communication could be improved.

On the long stay and rehabilitation wards, patients mostly spoke positively about staff attitudes. Staff gave patients emotional support and advice when they needed it. Most patients enjoyed the activities on offer but said there was nothing for them to do at evenings or on weekends. Not all patients felt staff supported them to understand their own care and treatment, and some patients did not have regular one-to-one sessions with their named nurse.

Patients’ carers were very positive about staff on the rehabilitation wards and the care they provided. However, some carers expressed frustrations with not being invited to ward rounds despite their relatives having consented to their attendance. Most carers did not know how to complain but felt comfortable raising concerns with ward staff.

Young people on the child and adolescent mental health wards told us they felt safe on the ward and were appropriately supported by care staff. One young person told us that “it’s good being here, it’s good for me to be in a calm place, staff help me”.

Feedback from one young person showed that patients had enough to do to keep them stimulated. They told us that they rarely got bored on the ward and enjoyed activities such as boxing, drawing, cooking lessons, using the garden and going on community leave.

We spoke with three carers during our inspection, who were largely positive. A carer told us that their relative had improved whilst at Crystal House, and staff were very welcoming and kept them informed. This was confirmed by a young person who told us that since being at Crystal House “I’ve learnt to be kinder to myself and to love myself”.

In one health-based place of safety, one person gave us positive and complimentary feedback about the staff and told us they found the environment comfortable and accommodating. We also spoke with 4 patients who were former patients of the places of safety and their feedback was mostly positive. They told us they felt safe and cared for and had access to advocacy. One patient told us they did not get a choice of food.

The feedback from patients supported by the psychiatric liaison teams and in the crisis assessment centres was mostly positive. Patients told us they felt safe and found the environment comfortable for their stay. Most patients knew how to feedback or complain. However, 2 patients told us they had not been told how to give feedback. Most patients told us they valued the service and it had been helpful to them in a time of crisis.

Carers across the trust told us that they were pleased with the support they received in their roles. They also said that whilst the trust had many positive initiatives and QI projects, these were sometimes at a higher level and they did not always see the impact on the care of their relatives. For example, they told us about the Triangle of Care concept which the trust has adopted. They reported that they did not always see the application of the Triangle of Care at a more individual level for all patients or feel involved. The Triangle of Care is a partnership between professionals, the person being cared for, and their carers. It sets out how they should work together to support recovery, promote safety and maintain wellbeing.

This was an unannounced focused inspection of the two acute wards for adults of working age at the Campbell Centre, Milton Keynes. We carried out this inspection to follow up concerns raised following a serious incident in December 2022 when a patient died on Willow ward as a result of tying a ligature around their neck. This inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of patient risk on Willow ward. This inspection examined those risks.

This inspection has not been rated. This is because we only inspected two wards out of 17 acute or intensive care wards run by Central and North-West London NHS Trust. Hence, the findings from these two wards do not necessarily reflect the overall quality of acute and intensive care services provided by the trust.

Our last inspection of these wards was in November 2020. Following that inspection, we told the trust it must ensure that patients on Willow ward are protected from risks associated with inconsistent staffing and ensure that appropriate measures are in place to mitigate risks. During this inspection, we found that the trust had made some but not all of the required improvements.

We visited 2 wards during this inspection, both located at the Campbell Centre, Milton Keynes. Willow ward is an acute admission ward for up to 19 female patients. This is where the serious incident occurred. Hazel ward is an acute admission ward for up to 17 male patients.

The service is registered by the CQC to provide the following regulated activities:

Treatment of disease, disorder or injury
Assessment or medical treatment for persons detained under the Mental Health Act1983
Diagnostic and screening procedures.

Overall summary

We found the following areas the service needed to improve:

The nature and frequency of incidents on Willow ward indicated that the service was unable to ensure the safety of patients. The service had not addressed the concerns raised at the last inspection about the high number of safety incidents on Willow ward.
Staff did not carry out observations of high-risk patients on Willow ward in accordance with trust policy. One patient was involved in a ligature incident, despite being assigned to continuous observations. There were some gaps in observation records. Staff were required to carry out continuous observations of patients beyond the maximum period of time set out in the trust’s policy. Staff did not always maintain good professional standards whilst carrying out observations.
Staff did not discuss or sufficiently analyse risk incidents at multidisciplinary team meetings in order to understand the causes and mitigate the risk of such incidents reoccurring.
Staff did not manage the risks associated with prohibited items on Willow ward effectively. Staff did not carry out adequate searches when patients had been found with prohibited items that they had used to harm themselves.
Although staffing levels were consistent with national guidance, the staff were often not able to provide therapeutic care. Staff were not always able to respond to patients’ requests. Leave and activities were sometimes cancelled. Activities that were cancelled were sometimes replaced with an alternative activity.
Patients did not always have a regular 1:1 session with their named nurse. Staff were not pro-active in carrying out individual discussions with patients to understand their needs and monitor any changes in their level of risk.
The overall atmosphere on the wards, particularly on Willow ward, was not calm and therapeutic. Wards were often noisy. Wards could often become unsettled. Fights and disputes between patients were not uncommon. Staff were not pro-active in managing conflicts between patients.
Despite admitting high risk patients, staff on Willow ward did not always update risk assessments after safety incidents.
Staff and patients told us they did not always feel safe on the wards. Staff did not always respond when emergency alarms were activated.
Cleaning records were not available on Willow ward.
The trust did not provide training for staff in conditions presented by high-risk patients.
The service had high vacancy rates although there was active recruitment taking place..
Some staff found the electronic patient records difficult to use. It could be difficult for staff who were unfamiliar with the system to access information quickly.
Incident reports lack sufficient details of the circumstances surrounding the incident. The system for incident classification was not always able to reflect the seriousness of the matter.
Willow ward had not embedded some of the recommendations made in reports of investigations into serious incidents.
Handover meetings on Willow ward did not have robust discussions about risks or how to manage them, or provide a clear handover of tasks to manage patients’ risks.
Not all staff had completed and were up to date with emergency life support training although this was planned.
Staff were not having discussions with patients about their medicines and their potential side effects.
Staff morale on Willow ward was low. Staff struggled to cope with the pressure of their work. Many members of staff had been subjected to assaults from patients. The operational culture viewed this as part of the job. Staff felt the trust was not doing enough to address this.

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

Since our last inspection in 2020, the service had reduced the number of bank and agency staff working on the wards from over 50% to 20%.
The service had introduced specific training on observations for temporary staff.
The service had introduced monthly emergency scenario training for staff following a serious incident.
All wards were clean and well equipped. The wards complied with guidance in relation to mixed sex accommodation.
Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly.
Staff made attempts to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.
Patients told us they enjoyed the activities on the ward.
Almost all staff had completed safeguarding training and knew how to report safeguarding concerns.

Lavender walk is a children’s inpatient service provided by Central and North West London NHS Foundation Trust (CNWL). The ward offers assessment, management, and treatment on an inpatient and day basis for children and young people aged 13 up to their 18th birthday. The ward can accommodate up to 12 young people as inpatients and 4 as day patients.

The child and adolescent mental health wards core service was last inspected in 2015 with a rating of good across all domains and good overall. In 2020 we carried out a focussed inspection of a different child and adolescent ward within the trust and this inspection was not rated.

This was a focussed inspection where we looked at the domains of Safe, Caring and Well Led. Where we have found a breach of regulation, the rating for this domain is limited to requires improvement. Following this inspection, the ratings for Safe and Well Led were limited to requires improvement. The rating for Caring remained as Good, the same as the previous inspection.

The unit primarily accepts referrals for young people who are resident in or registered with a GP in any North West London borough.However, it also takes young people from London and surrounding counties if a bed is available. Providing care for young people with a primary diagnosis of mental illness and which does not exclude those with a mild learning disability, drug and alcohol problems or social care problems as secondary needs, some young people may require detention under the Mental Health Act. It does not accept referrals for young people with moderate to severe learning disability or those who require low or medium secure services.

The service is registered by the CQC to provide the following regulated activities:

Treatment of disease, disorder, or injury,

Assessment or medical treatment for persons detained under the 1983 Act

Diagnostic and screening procedures.

This unannounced inspection was prompted in part by notification of an incident following which a person using the service died. This inspection did not examine the circumstances of the incident.

However, the information shared with CQC about the incident indicated potential concerns about the management of risk of ligature. This inspection examined those risks.

At the time of the inspection the ward had reduced their inpatient numbers in response to this incident. During the first visit there were 7 young people and on the second visit there were 9 young people admitted to the ward.

We found several areas of good practice:

Staff had training in key skills and understood how to protect young people from abuse.
The ward was visibly clean and well maintained. Staff managed infection risk well.
The service used information from safety incidents to learn lessons and used information collected to improve the service.
Staff assessed risks to the young people and acted on them. They provided effective care and treatment and offered emotional support when young people needed it.
Most staff treated patients with compassion and respected their privacy and dignity. Staff provided emotional support to the young people, families, and carers.
Young people told us that they enjoyed the range of activities the ward offered including therapies and education.
Leaders were committed to running the ward well and using reliable information systems. All staff were committed to continually improving the service.
Staff we spoke to said they felt supported and valued.
The staff had improved their engagement with young people, families, and carers.

However:

The ward continued to have a high vacancy rate among nursing staff. Although this had reduced significantly, there was a continued reliance on agency and bank staff, particularly overnight. The service also had a higher turnover and sickness absence rate than the trust average. This meant nursing staff were not always familiar with the young people and their care and treatment needs.
The ward did not always manage risk well. We observed patient care and treatment records that were not always clear about a young person’s risk behaviour and how this should be safely managed.
Young people told us that they did not always feel safe on the ward and that some staff did not treat them with kindness and respect.
Governance processes related to medicines management on the ward were not always effective. On the first inspection visit we observed several areas of concern around medicines management. For example, there were several expired medicines in the clinic room.

What people who use the service say

Parents and carers told us they found the staff team very supportive, responsive, and helpful. They also said the staff were caring, polite and interested in the wellbeing of the young people. They told us staff supported them in their parenting role.

All the young people we spoke with said they were happy with the activities on the ward, and they had plenty of things to do even at the weekend. They told us they enjoyed working with the education and therapies team.

The young people said most staff treated them with dignity and kindness. However, all of them told us they felt less safe overnight with staff they were unfamiliar with, and some young people told of us staff who did not treat them with respect and kindness.

This was a focused inspection of 3 of the trust’s district nursing teams in the London Borough of Hillingdon. We looked at the safe domain only. This inspection was not rated as we did not look at any of the trust’s district nursing teams in the other boroughs in which it operates. We inspected this service because we knew of the pressures that all district nursing teams in London are under on account of the need to treat people at home whenever possible combined with district nursing staff shortages. We also received concerns about the management of pressure ulcers in the district nursing team.
The service had enough staff to care for patients and keep them safe. Flexible working had reduced staff vacancies. Staff we spoke to who had been recently recruited felt that flexible working made it attractive to work for the trust as it allowed them to practice alongside their domestic caring commitments.
Staff had training in key skills and understood how to protect patients from abuse. Mandatory training completion rates trust-wide for district nursing teams was 95%. The trust had an experienced nurse to support staff with induction, sign off on competencies, identify training gaps and liaise within the training department about staff training needs. Staff had a comprehensive district nursing induction pack for new staff.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Patient records were comprehensive; notes and care plans were clear and concise. Staff could consistently and readily access pertinent patient information in a timely way. Staff kept detailed records of patients’ care and treatment.
Staff assessed risks to patients and acted on them. Staff used recognised tools to assess the risk to patients and reviewed them after each visit. Staff reviewed all risk assessments every 12 weeks.
Staff considered patients’ needs holistically in handover meetings. Staff presented patient cases in handovers using situation, background, assessment, recommendation (SBAR). SBAR is a structured form of communication that enables information to be transferred accurately between individuals. We saw evidence of good interagency work, for example, with GPs, tissue viability and diabetic services.
Staff consistently recorded alerts in the patient record system and had up to date records for ‘Do Not Attempt Cardio-pulmonary Resuscitation’ (DNA CPR) where this was required. Records contained information about where to find a copy of the DNA CPR if this was needed. Immediate access to this information meant teams had the information needed to respect the wishes, and the comfort and dignity of patients.
Managers and staff carried out a programme of audits to check compliance with trust policies and improvement over time, such as a lone working audit; infection prevention and control audit environmental audit; and medicines audits. Medicines were managed safely. Infection prevention and control measures protected people and minimised the risk of infection. Staff kept equipment and their work area visibly clean.

However:

Although staff checked the defibrillators on a regular basis we found that the associated oxygen tube in the Oak Farm Team premises had expired in November 2019. We raised this issue with the staff who responded promptly and had a new defibrillator machine with up-to-date contents delivered during the inspection.
We highlighted to staff that there were no compressed gas signs for the oxygen cylinder kept at the Hayes and Harlington team. Again, staff responded promptly and added two compressed gas signs during the inspection.

How we carried out this inspection

This was a focused inspection of the trust’s district nursing services in the London Borough of Hillingdon. We visited 3 district nursing teams Hayes and Harlington team, Laurel Lodge and Oak Farm Team We did not look at their other district nursing teams.

We last inspected the trust in March 2015. The overall rating for community health services for adults was good. Community health services for adults had been rated good in safe, effective, caring, responsive and well led.

We inspected this service because we knew of the pressures that all district nursing teams in London are under on account of the need to treat people at home whenever possible combined with district nursing staff shortages. We also received concerns about management of pressure ulcers in the district nursing team. We did not inspect all areas of all key questions and the core service was not given an overall rating. We did not speak to patients or carers as we looked one key question:

• Is it safe?

Before the inspection visit, we reviewed information that we held about the location.

During the inspection visit, the inspection team:

spoke with 12 staff members including the clinical service manager, district nurses, community staff nurses; palliative link nurse, deputy district nurses
conducted a tour of the service environments
reviewed 5 incident records
reviewed 14 patient care records
observed 3 handover meetings
reviewed team allocation and daily diary
observed a district nurse home visit
looked at a range of policies, procedures and documents related to the services we visited.

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.

This was an announced focused inspection of the acute wards for adults of working age and psychiatric intensive care units core service. We carried out this inspection to follow up on concerns raised about the safety and quality of the service being provided. We used CQC’s interim methodology for monitoring services during the COVID-19 Pandemic.

The acute wards for adults of working age and psychiatric intensive care units core service was last inspected in 2019 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. As this was a focused inspection, we did not inspect and rate against all key questions.

We visited four wards during this inspection. Crane ward is an acute admission ward for up to 18 female patients based within the Riverside Mental Health Centre, Hillingdon. Frays ward is an acute admission ward for up to 19 male patients based within the Riverside Mental Health Centre, Hillingdon. Eastlake ward is an acute admission ward with 21 beds for male and female patients separated into different areas. This ward is located within the Northwick Park Mental health Centre, Harrow. Willow ward is an acute admission ward for up to 18 female patients based at the Campbell Centre, Milton Keynes.

The service is registered by the CQC to provide the regulated activities: Treatment of disease, disorder or injury, Assessment or medical treatment for persons detained under the 1983 Act and Diagnostic and screening procedures.

We found the following areas of good practice:

All wards were clean, well equipped, well furnished, well maintained and fit for purpose. The wards complied with guidance in relation to mixed sex accommodation.
Staff followed infection control protocols, all staff wore face coverings and measures were in place to cohort new admissions awaiting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test results. Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly.
Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident.
Staff made attempts to avoid using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe.
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
Staff assessed the physical and mental health of all patients on admission. When patients were first admitted to the ward, they were seen by a doctor who completed a full assessment and recorded this in the patient’s notes. This was reviewed by the multidisciplinary team at a ward round within the first few days of admission.
Staff on Frays, Crane and Willow Wards participated in quality improvement initiatives. As a result of learning from incidents on Crane Ward in 2019, the Riverside improvement programme had been introduced.
Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.
Patients on all wards told us that permanent staff treated them with kindness dignity and respect. We observed positive interactions between staff and patients which demonstrated that respect and understanding of individual patient needs.
Staff managed beds well. A bed was available when needed and that patients were not moved between wards unless this was for their benefit. Frays ward and recently reduced their number of beds from 23 beds to 19 beds. Eastlake ward had reduced their number of beds from 23 to 21 with an aim of reducing these further. This was in line with best practice guidance for acute adult inpatient wards.
Leaders had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff.

However, we also found the following areas the service needed to improve:

We saw that Willow ward was an outlier in that high staff turnover and patient acuity had led to high levels of bank and agency usage which had led to inconsistent care. We also saw that staff on Willow ward were not receiving regular support through supervision or team meetings. Some staff on this ward told us that they did not feel able to speak about their concerns.
Whilst the trust had taken action to ensure that care on Willow ward was safe and effective after incident data showed the ward was an outlier, this action had not been timely or robust enough. During the inspection we raised concerns with the trust that led to a voluntary pause on admissions to the ward whilst additional assurance was obtained and additional measures were put in place by the trust.
Planned building works to remove dormitory accommodation at Willow ward had been delayed by the pandemic and were scheduled to commence shortly after our inspection.
We saw that on Eastlake ward, the trust had learnt from a recent medicines incident. Some new systems had been introduced to ensure that medicines were managed and administered safely.
Patients on Crane and Frays Wards who received intramuscular rapid tranquilisation injections did not always have adequate physical health checks. Actions to improve this were being considered at the time of this inspection.
Some patients on Willow ward, did not have their assessed needs addressed by a comprehensive care plan. Detained and informal patients on this ward were not aware of their legal rights.

How we carried out the inspection

During the inspection, the inspection team:

observed four handover meetings, one on each ward
conducted a tour of the environment on each ward
spoke with two occupational therapists, seven registered nurses and four unregistered nurses over the four wards
spoke with the discharge coordinator at the Riverside Mental Health Unit
spoke with a peer support worker from Crane ward
spoke with the Frays ward activities co-ordinator
spoke with a pharmacy technician, a pharmacist and a medication safety officer on Eastlake ward as well as the deputy chief pharmacist for the trust
spoke with three ward managers, the trust director of Hillingdon services, three matrons and three consultant psychiatrists
spoke with 16 patients over the four wards
spoke with two sets of relatives of people who were using the service
looked at 17 patient care and treatment records and six patient observation records
reviewed documents relating to the running of the service including records of incidents on the ward.

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

Most of the patients we spoke with told us that staff treated them with kindness, dignity and respect. Patients told us that staff were compassionate and kind and understanding towards their needs.

All patients we spoke to said that they felt safe on the ward and most patients said that they felt involved in their care and treatment plan. Patients told us that they received one to one nursing interventions and staff supported their needs.

Patients on Willow ward told us that agency staff did not always treat them well or behave kindly towards them.

Patients told us that they could feedback on the service that they received and knew how to make a complaint if they wished to.

This was an announced focused inspection of the Collingham Child and Family Centre, part of the child and adolescent mental health wards core service. We carried out this inspection to follow up on concerns raised about the safety and quality of the service being provided. We used CQC’s interim methodology for monitoring services during the COVID-19 Pandemic.

The child and adolescent mental health wards core service was last inspected in 2015 with a rating of good across all domains and good overall. As this was a focused inspection, we did not inspect and rate against all key questions. The ratings from the previous inspection remain in place.

Collingham Children and Family Centre is a children’s inpatient service provided by Central and North West London NHS Foundation Trust (CNWL). The centre offers assessment, management and treatment for children up to the age of 13 who present with severe and complex mental health problems. The centre is able to accommodate up to 12 children as inpatients or day patients. Many of the children admitted for inpatient care have home leave over the weekend.

The service is registered by the CQC to provide the regulated activities: Treatment of disease, disorder or injury, Assessment or medical treatment for persons detained under the 1983 Act and Diagnostic and screening procedures.

We found the following areas of good practice:

The ward was clean, well equipped and mostly well furnished. Children had been involved in painting murals on the wall and had access to fresh air via a playground and a garden.
Staff did a risk assessment of every child on admission and updated them regularly. Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe.
Staff assessed the mental health of all children on admission. They developed individual care plans, which were reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected the assessed needs, were personalised, holistic and recovery-oriented.
Staff were observed to be interacting well with the children. Their interactions seemed kind and age appropriate. The children appeared to enjoy being around staff. Staff involved children in care planning and actively sought their feedback on the quality of care provided. They ensured that children had easy access to independent advocates.
Staff informed and involved families and carers appropriately and provided them with support when needed.
Staff from different disciplines worked together as a team to benefit the children. They said they felt able to raise concerns without fear of retribution.
The service treated concerns and complaints seriously. They investigated them and learned lessons from the results. Parents and carers were encouraged to provide feedback on the service.
Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the services they managed. They were visible in the service and approachable for children and staff.
Staff actively engaged in local and national quality improvement activities.

However, we also found the following areas for improvement:

We had concerns about how the service met the complex needs of the young people and kept them safe. This included how young people could call for help when needed. The service had acquired alarms specifically designed for the young people which they could access based on their individual risk assessments but these had not been used in practice.
The service did not always have enough nursing staff available. An incident was noted when children were left unsupervised on the upper level of the ward whilst staff cared for patients in the de-escalation room on the lower level. The ward had recognised this and additional staff were now rostered on duty. Whilst feedback regarding staff was mostly positive some patients did comment that one or two staff were less supportive.
Staff reported restraint and seclusion was only used as a last resort. However, there was some confusion noted when speaking with staff as to when seclusion had begun and how these incidents should be documented.
When reviewing incident reports we noted that staff had not recorded all the necessary information about which staff were involved in the physical restraint of a child.
As the profile of patients referred to the unit changes, the service should keep under review the composition of the multidisciplinary team. For example, at the time of our inspection, a large proportion of patients were noted to have an eating disorder or to be limiting their dietary intake. Whilst a dietitian was part of the multidisciplinary team, they were only available on the ward one day each week, which may mean that they are not able to appropriately support each child who needs them.
At times the ward could become too hot and uncomfortable. Staff were aware of this concern and were working to resolve this. Staff completed incident reports on each occasion and had escalated this to senior managers.

How we carried out the inspection

During this inspection we:

spoke with six members of staff, including the ward manager, unit matron and consultant psychiatrist
spoke with five children
spoke with two children’s relatives or carers
looked at the care and treatment records of five children
reviewed five incident reports made by the ward
observed both the nursing handover and the multi-disciplinary team handover
conducted a tour of the ward environment and observed how staff communicated with the children
looked at a range of policies, procedures and documents related to 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

We spoke with five children and two carers.

Both carers were very positive about the service. They reported good communication from the ward, they felt staff were caring and they felt involved in their child’s treatment and care.

Children said staff were mostly caring, helpful and approachable. However, three children mentioned there were one or two staff members who they felt were not caring.

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

On this occasion, we inspected five key questions for three core services; a total of fifteen key questions. The rating improved for three key questions and worsened for one - from good to requires improvement. This meant that the overall pattern of ratings for the whole trust remained broadly the same. When these ratings were combined with the previous ratings from services not inspected this time, 15 core services are rated as good and two as outstanding.

We rated the trust as good for well-led. The trust had a highly experienced, skilled and respected executive leadership team. They were inspiring, committed and continuously challenged themselves to improve services to meet the needs of patients.

The trust had a high calibre board, with a wide range of appropriate skills and experience, who were open and determined to provide high quality care to their local communities and those in receipt of specialist services.

The trust had a strong, cohesive senior leadership team which had instilled a positive ‘can-do’ culture within the organisation. Senior leaders expected high standards of themselves and their colleagues, but most staff regarded them as kind and supportive when teams and individuals were facing challenges. The depth of knowledge held by senior leaders about each service and the people running them was phenomenal given the size of the trust.

The divisional structure and borough-based working for local services were fully embedded and there was evidence of strong partnership working, with good foundations to increase this much further. The trust was participating effectively in local care systems and with NHS partners to drive progress and develop new models of care, such as integrated community health services in Hillingdon.

The board had good oversight of operational issues across all divisions. The governance processes were robust and ensured that both achievements and concerns were escalated appropriately. Problem areas had largely been identified before we brought them up and work was, for the most part, underway to resolve matters. The trust was very responsive and took steps to increase the pace of improvement and the support available following our feedback.

The trust had a strong grip on its finances. It was on target to achieve its control target for 2018 -19. Its spending on agency staff had significantly reduced and it was working to drive it down further.
The trust was fully committed to working in partnership with patients and, increasingly, carers. There were many excellent examples of patient and carer involvement at many levels within the organisation, including well established peer support workers.

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. For example, the roll out of the safer leave project for both detained and informal patients on the mental health wards. The trust was just short of its target of 95% compliance with statutory and mandatory training, averaging 93% which was high for a trust of this size.

The trust had worked creatively to meet emerging needs. A large-scale example was their response to the Grenfell tragedy where they, alongside many partners, were seeking to try to meet mental health needs that had been triggered, or exacerbated, by the trauma. On a smaller scale, the Campbell Centre at Milton Keynes had developed a social recovery team to focus on resolving practical issues for patients which delayed discharge.

The trust was making good progress with their quality improvement (QI) work, and despite this approach only being used in practice for about 18 months, it was becoming established across the trust. The trust had received an award from the South of England QI collaborative for building capability and capacity. During the inspection many of the staff we met spoke about their involvement in QI projects. At the time of the well-led review there were 276 active projects and 32 completed projects. The trust had a QI microsite which was accessible on the trusts website. This live site enabled staff to access resources, sign up for training events and record progress with their own project. This enabled services to identify similar projects and learn from each other. The trust was working with patients and carers and they were actively involved in 26% of the projects.

All staff we spoke with acknowledged they were provided with good learning and development opportunities and, through the trust’s recovery and wellbeing college, patients who used mental health services and their carers benefited from access to a wide range of courses. Trust mental health staff and staff working in partnership with them could also access these courses. The trust had invested in the development of leadership skills and we noted the competency and confidence of most leaders at all levels of the organisation.

The trust was making good progress with promoting equality diversity and human rights throughout the organisation. They had stated a commitment to becoming one of the most inclusive employers in the NHS by 2020. The trust had three well-established staff networks in place to support staff and to promote equality and diversity; the Black, Asian and minority ethnic staff network, the disability equality network and the lesbian, gay, bisexual and transgender staff network. Stonewall ranked the trust equal 28th in its list of top employers for 2019 (only five healthcare employers were in the top 100).

The trust had developed robust and innovative ways of managing its estate of 150 sites in ways that were just starting to benefit staff, patients and its finances. With the exception of one site, where there were ongoing negotiations with commissioners, the trust had plans in place to eliminate all its dormitory bedroom accommodation.

The trust transferred most of its services to a new electronic patient record system during our inspection; possibly the biggest migration of its kind in the UK. Technically, it went well, although staff were still in the process of getting used to it and some areas needed more time and support than originally envisaged. The new system will enhance joined up work with primary care services.

Trust staff had access to a full range of accurate and clearly displayed data relevant to their work which could be viewed at numerous levels from trust-wide to individual team or ward. Clinicians were involved in digital developments to ensure they complemented clinical work.

The trust’s communications strategy was working extremely well and staff commented favourably about the high quality of communications and the relative ease of finding information, when needed, on the trust’s intranet site.

The trust’s public website had been developed with the needs of people with communication difficulties in mind with links to a growing library of easy-read information on every page. The intranet and microsites were developed to make it as easy as possible for staff to adjust the information to their needs in terms of colour and font.

However:

Our inspection did identify wards and teams where improvements were needed. The trust was already aware of where services were facing challenges and was providing additional leadership and support.

The inspection did find that some of the improvements recommended at the previous inspection had not taken place. This included ensuring patients on the wards for older people had access to specialist staff such as a dietician when needed, or that information was put into accessible formats for patients with dementia or other cognitive impairments.

Recruitment and retention of staff remained challenging for the trust; and they were working creatively to address this within the context of national shortages. Despite the use of temporary staff where needed, some teams were struggling to deliver consistently high-quality care.

Some staff were not receiving supervision at the frequency required by the trust’s own policy and neither this, nor the quality, was monitored in a systematic way by managers, unless individuals had set up their own systems. This had also been identified as an area for improvement at the previous inspection. During the inspection the trust was piloting an online system to address this, but this would need to be embedded.

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

Throughout the inspection we saw good practice, particularly at the Campbell Centre, Northwick Park, some individual wards on other sites and in the psychiatric intensive care units. The site where there were the most concerns was at the Gordon Hospital where there had been a serious safeguarding incident. The trust was aware that this service needed additional leadership support and had put this into place.
Wards had made progress in minimising the use of restrictive practices and followed good practice with respect to safeguarding.
Medicines were mostly managed safely, although at St Charles, the Campbell Centre and Northwick Park, ‘as required’ medicines were not reviewed regularly or when not used by the patients for whom they were prescribed for over 14 days.
The service 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, although there were some inconsistencies in both areas.
Ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards, although patients on the wards at St Charles had limited access to psychological therapies.
Managers ensured that ward staff received training 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 usually 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, whilst most wards had regular team meetings using a standard agenda to ensure all the necessary topics were covered, a few did not take place regularly or the record of the meeting read like a ‘to do list’.

However:

While most wards were safe, clean, well equipped, well furnished, well maintained and fit for purpose, a few were not. Bedrooms on two wards at the Gordon Hospital were too small for safe use by patients in distress. At the Gordon Hospital, rooms designed to offer flexible accommodation for male or female patients were breaching guidance to eliminate mixed gender accommodation. Pond Ward at Park Royal was not clean in some areas. By the end of the inspection the trust had addressed all these matters and, where needed, taken rooms out of use.
Whilst the trust was working to recruit and retain staff, and most wards had safe staffing levels, a few wards were struggling to maintain safe staffing. Some wards did not have enough medical cover and some nursing staff told us they felt unsafe at night, especially when they had to attend to patient admissions as well as those already on the ward. We also heard from staff who said that patient leave was sometimes cancelled or that they could not leave the ward to attend training
Staff on most wards developed holistic, recovery-oriented care plans informed by a comprehensive assessment, but there was room for improvement on other wards.
Whilst staff generally understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff did not always request an opinion from a second opinion appointed doctor (SOAD) in good time. There were discrepancies in the completion of patients’ capacity assessments.
Most staff told us that they received regular supervision and they were happy with the content, but records were patchy on some wards. The trust was introducing an online system to monitor supervision, but this was at an early stage.

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

Patients were looked after in a safe and clean environment by sufficient numbers of staff who were committed to meeting their needs. The service protected patients from the risk of abuse and avoidable harm. There were clear, open and transparent processes for reporting incidents.
The care and treatment for most patients was assessed, planned, delivered and reviewed regularly. Staff completed physical health checks and on-going healthcare investigations and healthcare monitoring. Staff participated in a wide range of clinical audits to monitor the effectiveness of the service, and they monitored the outcomes of patients’ care and treatment.
Patients and carers spoke positively about the care, support and treatment they received. They said staff treated patients with kindness, respect and compassion. Staff recognised and respected the totality of patients’ needs and they involved and supported patients, and those close to them, in decisions about their care and treatment.
Staff worked in collaboration with community teams within the trust and local social services to facilitate patient discharges.
The choice of food took account of special dietary requirements and religious or cultural needs.
Staff had a good understanding of the trust’s vision and values for the service and felt supported and valued by their managers. They described a positive culture and felt comfortable raising any issues to their managers. Staff were involved in quality improvement initiatives.
At the last inspection, not all staff received supervision, and the system for recording supervision was not robust. At this inspection, most staff had received supervision and the trust was implementing a system to check supervision took place regularly.
Most wards were in the process of applying for national accreditation (a quality assurance scheme) and Ellington Ward had achieved it.

However:

Whilst there had been a number of improvements since our last inspection and there was a good standard of care across the service as a whole, there were inconsistencies that impacted on patients and staff on specific wards, which the trust needed to attend to.
Not all wards had timely access to specialists to meet the needs of older adults. For example, Kershaw and Redwood wards had not had regular access to a dietician since November 2018. Arrangements were put into place by the trust immediately after the inspection. Whilst access to psychological therapies had improved since our last inspection, patients at Beatrice Place were still experiencing delays.
Not all staff had received training in dementia despite the fact that a large majority of the patients had dementia or a cognitive impairment. This was not in line with National Institute for Health and Care Excellence (NICE) guidance, which states that people with dementia should receive care from staff appropriately trained in dementia care. Following our site visit, the trust arranged for relevant staff to complete dementia care training by 29 March 2019 and put arrangements in place to monitor attendance going forward.
The quality of staff supervision records was poor on Redwood Ward.
At the last inspection, information which was provided was not routinely available in an accessible format for patients with dementia or cognitive impairments; for example, information on notice boards, leaflets, activity schedules and menus. At this inspection, some progress had been made, but there was still further room for improvement.
The trust had some good practice in falls prevention such as non-slip socks, access to falls mats and adjustable bed heights. There had only been one serious incident reported in a year attributable to a fall. However, a few patients did not have a completed falls risk assessment on admission, which was not in line with the trust’s policy for prevention and management of falls.
The large size and layout of Kershaw Ward and Redwood Ward did not allow staff to observe all parts of the ward. Although staff had put mitigations in place, we observed during our inspection that staff were not always present in areas of the wards due to its large size, which left patients unattended. On Redwood Ward, the environmental risk assessment had not identified all of the potential blind spots on the wards. These blind spots made patient observation difficult. However, following our inspection, the trust installed mirrors for these blind spots.
At the last inspection, there was no tracking of informal complaints. At this inspection, most wards had made improvements but Kershaw Ward and Redwood wards did not keep a log of their informal complaints to identify any themes or learning.
At the last inspection, there was a lack of systems in place to learn from incidents across the divisional structure of the trust. At this inspection, although this had improved, we still found there were no formal arrangements in place for staff across the older adult wards to share learning and good practice. Some staff were unaware of incidents on other older adult wards, but knew about serious incidents that had occurred elsewhere.

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

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.
Patient risk was well-managed by most services and staff were aware of the key risks before visiting patients. Teams across the trust held regular meetings where clinical risk was explicitly discussed. However, some recorded risk assessments did not clearly state how the risk should be addressed, which could potentially mean that staff, especially if they were new to the team, might not know what steps to take.
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 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.
The service was well led and the governance processes ensured that that procedures relating to the work of the service ran smoothly.

However:

For some teams, assessments that were agreed to be less urgent did not take place in a timely manner.
Whilst systems were in place to protect staff who were lone working, some staff were not familiar with lone working procedures, particularly in Harrow and Brent. This could put staff at risk when working alone.
Some staff did not have a good understanding of the role of the freedom to speak up guardian so were unaware they could raise concerns through the guardian.

We rated the service as good because:

Improvements had been made following the serious incident that occurred in June 2018 in which a patient was injured after fixing a ligature. The window fixtures had all been replaced. Changes had been made to the admission process so that both a doctor and a nurse made a joint initial assessment of patients. Additional checks were made during each shift to ensure the alarm system was working.

Overall, the service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents. Staff and patients were debriefed and offered support following incidents.

The service provided care and treatment based on national guidance and evidence of its effectiveness. Comprehensive assessments were completed on admission to the service. Care plans were personalised, holistic, included the patient’s views and were regularly reviewed and updated. Staff monitored patients’ physical health and took appropriate action when needed. Outcome measures were used to measure the effectiveness of treatment programmes. Regular clinical audits were completed.

The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. There were always enough staff to safely deliver care and treatment.

The service made sure staff were skilled and competent for their roles. Managers appraised staff’s work performance and held regular supervision meetings with them. The service provided mandatory and specialist training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

The service assessed and managed individual patient risks appropriately. An individualised approach meant that patients were not subject to blanket restrictions.

Staff gave patients specialist care to ensure their nutrition and hydration needs were met safely and their health improved. They used special feeding and hydration techniques when necessary and staff were trained in these areas.

The service prescribed, gave, recorded and stored medicines safely. Patients received the right medicines at the right dose at the right time. A pharmacist visited the ward each week and completed a regular audit to check that medicines were managed and administered safely by staff.

Staff of different disciplines worked together as a team to benefit patients. The service also worked well with external teams and professionals.

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

Staff cared for patients with compassion. Patients were partners in their care. Staff worked hard to involve patients’ families and carers, despite some of them living far away.

People could access the service when they needed it. Most patients were admitted to and discharged from the unit to the outpatient part of the service. Staff planned effectively for patient discharge and worked well with other professionals and teams to ensure effective transfers of care.

The service had suitable premises and equipment and looked after them well. The service was clean and well maintained and staff followed infection, prevention and control procedures. The facilities promoted comfort, dignity and recovery.

The service took account of patients’ individual needs and staff worked hard to meet the diverse needs of the patient group. This included providing support to make LGBT+ patients feel welcome and protect their needs. Staff supported patients’ engagement with ongoing education opportunities and important relationships.

The service had managers at all levels with the right skills and abilities to run the service effectively. Staff also told us that senior leaders had been especially supportive following the serious incident that took place in June 2018. Managers across the service promoted a positive culture that supported and valued staff. Staff achievements were recognised by local leaders and through a trust wide annual awards ceremony.

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. The service treated concerns and complaints seriously. Staff understood their responsibilities regarding complaints and made sure information was available for patients.

However;

Whilst appropriate arrangements were in place to protect patients against the risks associated with ligature anchor points, the unit ligature risk assessment did not include some ligature anchor points and did not clearly state how staff should mitigate the risks that had been identified. This was escalated to the manager at the time of the inspection.

Whilst overall the service managed patient safety incidents well, further improvements were needed to ensure that lessons learnt were always consistently shared with the whole staff team.

The induction process for temporary staff was not formalised which meant there was no assurance that temporary staff could consistently meet the specific needs of the patient group.

A small number of patients said that some temporary staff had occasionally acted in an abrupt manner.

Staff we spoke with were not aware of who the trust’s freedom to speak up guardian was or how to contact them.

Following this inspection, we rated community-based mental health services for adults of working age provided by Central and North West London NHS Foundation Trust as requires improvement because:

During this most recent inspection, we found that the services had addressed most the issues that had caused us to rate safe and effective as requires improvement following the February 2015 inspection. However at this inspection we found areas where further improvement was required.

Since the last inspection in February 2015 improvements in risk assessment had been made in East and West Harrow CMHTs. At this inspection we identified that not all patients in the Brent and North Kensington and Chelsea teams had comprehensive risk assessments in place.

The teams had either no or little input from a clinical psychologist. Patients either had no access to specialised psychological therapy had to wait a long time. This meant they were not receiving care in line with best practice.

There was a large turnover of staff. The resulting high use of temporary staff meant there was a risk that patients’ identified needs were not met and they did not receive consistency in care. In the Brent CMHTs, this was impacting on the regularity that care co-ordinators met with patients.

Although staff had developed care plans for patients, many of these were not patient centred.

Whilst all patients had a crisis plan, further work was needed in some teams to make them reflect the needs of individual patients.

In some teams, less than 75% of staff had received recent training on basic life support (non-clinical staff) and fire safety training.

Protocols to support lone working and staff safety were not being consistently used across all teams. At Milton Keynes CMHT staff did not have access to an appropriate alarm system when seeing patients.

Staff did not always give patients who were subject to a Community Treatment Order an explanation of their rights.

However:

The trust had made a number of improvements following recommendations made at the previous inspection in February 2015.

The trust was reviewing service delivery and had employed peer support workers in teams to engage with patients and support access and discharge from CMHTs.

There were systems in place to ensure that patients consistently received their medicines safely and as prescribed.

Staff demonstrated a good understanding of how to recognise potential safeguarding issues and how to act on concerns. However the Milton Keynes team needed to to ensure they knew the outcomes of alerts and investigations.

Staff were well supported, appropriately trained and able to develop their roles. Multidisciplinary teams were consistently and proactively involved in patient care, support and treatment.

Most patients and carers spoke positively about the care and treatment received in all of the services. Staff actively involved people in developing and reviewing their care and maintained people’s confidentiality. Staff were kind and respectful to people using the services.

Morale of staff was good across the teams inspected despite staffing and recruitment challenges

The service supported patients with a range of diverse needs appropriately.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

After this most recent inspection we have changed the overall rating to good because:

Following the last inspection In February 2015, the trust had implemented a comprehensive improvement plan.

In February 2015, we rated one of the sixteen core service as inadequate and a further two of the sixteen core service as requires improvement. At this inspection we found the trust had worked to make improvements and the trust had taken action to meet the requirement notices issued following the February 2015 inspection.

In February 2015, we recommended the trust should take a number of actions to improve services. At this inspection we found that the majority of recommendations had been met and improvements had been made.

Following the this inspection, we have changed ratings of the following key questions from inadequate to requires improvement:

the safe key question for wards for adults of working age and PICU

Following the this inspection, we have changed ratings of the following key questions from inadequate to good:

the responsive key question for adults of working age and PICU

Following this inspection, we have changed ratings of the following key questions from requires improvement to good:

the well led key question for wards for adults of working age and PICU
the effective key question for wards for older people with mental health problems
the caring key question for wards for older people with mental health problems
the responsive key question for wards for older people with mental health problems

Following this inspection we have changed the ratings for the following key questions from good to outstanding:

the effective key question for wards for people with learning disabilities or autism
the caring key question for wards for people with learning disabilities or autism
the responsive key question for wards for people with learning disabilities or autism

Following this inspection we have changed the rating of one core service from inadequate to good. This is the core service for wards for adults of working age and PICU.

Following this inspection we have changed the rating of one core service from requires improvement to good. This is the wards for older people with mental health problems.

Following this inspection, we have changed the rating for one core service from good to outstanding. This is the core service for wards for people with learning disabilities and autism.

Following this inspection the rating for one core service remains as requires improvement. This is the core service for community services for adults of working age.

We have not yet re-inspected the rehabilitation mental health wards and crisis services and health based places of safety. The requirement notices for these services will be checked at future inspections.

We also carried out a ‘well led’ review and found that the trust had continued to strengthen its senior leadership team and refine the trust governance processes.

We rated wards for people with learning disabilities or autism as outstanding because:

Patients received an exemplary service that was tailored to meet their individual and diverse needs and preferences. There was a truly holistic approach to assessing, planning and delivering care and treatment to patients which focused on each patient’s strengths and needs. There was a strong focus on recovery. Staff engaged with patients in a positive way which promoted their well-being. There was an open and positive culture which focussed on patients.

Patients and others important to them were fully and actively involved in all aspects of the planning and delivery of their care and worked in partnership with the staff team. Staff delivered care in a way that ensured flexibility and individual choice. Patients told us they felt safe.

Risk management arrangements were robust and staff promoted a culture of positive risk taking. Patients were involved in managing risks to their care.

The service used every opportunity to learn from incidents to support the improvement of the service. Learning was based on a thorough investigation and analysis and was embedded throughout the service.

The standard of care provided was outstanding. Staff delivered a wide range of evidenced based, therapeutic treatment interventions which meant that patients received effective care, treatment and support. Patients and carers spoke very highly of the staff and the quality of the care they received.

Staff monitored and reviewed patients’ physical healthcare needs effectively.

Staff from different disciplines worked together professionally and with mutual respect to achieve the best possible outcomes for patients using the service. 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 and there was an embedded culture focussed on the delivery of holistic care.

Staff were supported by regular supervision and appraisals and had access to specialist training which was designed around the needs of the patient group. The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring and improving high quality care and support provided.

Staff were confident in managing behaviours which were challenging to the service with clarity and thoughtfulness. We saw exceptional use of positive behaviour support to effectively understand, anticipate and meet patients’ needs. Staff monitored and reviewed restrictive interventions robustly. Staff were committed to reducing the need for restrictive interventions such as restraint. Patients contributed to their own positive support plan using their preferred communication method.

Staff had an in-depth understanding of each patient. They supported patients to communicate effectively because staff had undertaken comprehensive communication assessments and used appropriate communication methods/styles to support people’s individual needs. We saw excellent examples of information that was presented to people in ways they could understand, such as the use of transition calendars, easy read leaflets for 35 psychotropic medicines and the use of photographs to put together booklets to support patients with different aspects of their care such as planning for discharge.

Consent practices and records were actively monitored and reviewed to improve how the patients using the service were involved in making decisions about their care and treatment. Staff demonstrated an excellent understanding of consent practices and how these supported patient’s rights.

We saw exemplary practice with the patient–led care programme approach meetings and ward reviews. Patients took a role in chairing their care programme approach meetings if they wished to. Staff in conjunction with the patients had developed new care programme approach documentation to support patients so that they could understand the process better and monitor their progress.

The service had an excellent advocacy service. Patients had their voice heard on issues that were important to them and all staff genuinely considered individual views and wishes when patients made decisions.

The service undertook numerous initiatives to ensure that patients were engaged and involved in the care they received. This included a focus on collaborative risk assessments, patient-led care programme approach meetings, staff recruitments and representation at the care quality meeting.

There was excellent use and implementation of ‘this is me’ life history documentation to provide person-centred care.

The provider used innovative and proactive methods to improve patient outcomes. Re-admission rates had reduced as the service had developed a comprehensive transition plan to support patients leaving the service. This included facilitating specific training for staff in the patient’s future service, reviewing the community provider’s risk assessment and risk management plan for the patient, to determine if the community provider could provide appropriate care and treatment.

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

Following this inspection, we rated wards for older people with mental health problems provided by Central and North West London NHS Foundation Trust as good because:

During this most recent inspection, we found that the services had addressed the issues that had caused us to rate effective, caring and responsive as requires improvement following the February 2015 inspection.The provider had made many improvements since the last inspection and had addressed all previous breaches of regulation and almost all of the previous recommendations.

The wards for older people with mental health problems were now meeting Regulations 9, 10, 12, and 13 of the Health and Social Care Act (Regulated Activities) Regulations 2014

Wards were clean and well maintained. The risks for individual patients were identified and managed to ensure that patients were safe.
Staffing levels supported the delivery of care. Escorted leave and activities were rarely cancelled due to staffing levels although some staff said they did not always manage to complete one to one sessions with patients or to take a break during their shift.

Patients’ needs were comprehensively assessed upon admission. Care records reflected patient’s individual needs, choices, preferences, and staff had the knowledge and skills to meet these.
Patients had good access to physical healthcare including access to specialists when needed.
Staff told us that they were supported with their work, training and professional development to effectively meet patients’ needs.

Patients described staff as caring and kind and told us they were treated with dignity and respect. Where patients were unable to tell us, we saw staff treat patients with kindness and compassion. Relatives and carers told us staff appropriately involved them in planning and reviewing patient care.

However:

However, there were findings at this most recent inspection that led to a continuation of rating safe as requires improvement.
Staff at St Charles MHC were not clear about the reporting of incidents of restraint when used to deliver personal care.
Environmental risks such as plastic bags and some blind spots had not been considered on Kershaw and Redwood wards. There was no overall environmental risk assessment and the ligature risk assessment for the garden at TOPAS ward was insufficient.
Staff at Beatrice Place did not receive clinical supervision in line with the trust policy.
Two capacity assessments at Beatrice Place contained very brief information, lacked detail about any assessment or discussions that had taken place. The legal status of one patient on Kershaw ward regarding their DoLS application had been incorrectly recorded.

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

In February 2015, staff on the wards were not properly managing ligature risks that they had identified. When we visited in October 2016, staff were taking appropriate steps to manage ligatures.
In February 2015, staff were not effectively managing blind spots on the wards and observing patients safely was difficult. When we re-visited in October 2016, staff were managing blind spots appropriately.
In February 2015 staff were not putting appropriate measures in place to help reduce the numbers of patients absconding from the wards. During this inspection we saw that measures had been put in place to reduce the numbers of patients absconding.

In February 2015, not all staff were trained in how to undertake the safe physical restraint of patients. During this inspection we found that staff had completed necessary restraint training.
In February 2015 the records completed by staff relating to the seclusion of inpatients did not provide clear evidence that staff had undertaken seclusion in accordance with the Mental Health Act Code of Practice. During this inspection we found that records overall showed that staff had secluded patients appropriately and monitored them when this had taken place.
In February 2015, 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 the wards had sufficient staff on duty to meet patients’ needs.
In February 2015 the wards were over-occupied and there were no plans to managed needs which impacted upon the experience of patients using the services. During this inspection we found that plans were in place to manage these issues more effectively.

Bed management across the inpatient sites had improved considerably since the last inspection and was closely monitored by the trust.

In February 2015, we saw that information had not been available to inform patients how to make a complaint on the PICUs. At this inspection, we saw that information about complaints was visible on all the wards we visited.
In February 2015 we found that patients were not always able to make phone calls in private. At this inspection we found that all patients were able to make private calls.
Patients told us that they felt safe on the wards. Wards across all sites were clean and well maintained.
Multidisciplinary teams were consistently and pro-actively involved in patient care, support and treatment.

However:

In February 2015 we found staff were not always attending adequately to patients’ physical health needs and monitoring of physical observations following administration of rapid tranquilisation RT tranquilisation (RT). At this inspection we found that some improvements had been made but there were still gaps in the recording of physical observations.
Staff did not always keep good records when physical restraint was used.

Further work was required to monitor and reduce the use of restraint and prone restraint across the service in line with national best practice guidance.

Systems to monitor patients physical health and to ensure that where the patient was deteriorating, appropriate help was made available were not being used consistently.

Overall rating for this core service - Good

Staff treated children and young people with respect and dignity and delivered care which was sympathetic and inclusive during clinics, school and home visits. Parents and children were involved in planning care. Feedback from parents and their children was consistently positive and they said they were treated with dignity and respect. Staff were dedicated, highly motivated and worked diligently in delivering a first class service.

Services for children and families were being adapted to make them more accessible and responsive to people using the services. The services were mindful of meeting the needs of children in vulnerable circumstances. The trust was able to provide interpreters and information in a range of formats to support staff in meeting the individual needs of children and their families in terms of their diversity. Staff were very sensitive to peoples culture, religion and beliefs.

The trust had a good track record on safety. Where concerns were found these were reported and addressed in a timely manner. The individual teams fostered a learning culture and the processes for responding to adverse incidents were robust. Infection control procedures were in place and were being monitored. Safeguarding processes were in place and child protection plans were reviewed and audited.

Staffing was very stretched especially for health visitors but work was prioritised based on risk. An active programme of recruitment was taking place particularly in Hillingdon. Staff were trained and appraised and there was a positive learning and sharing culture. The children and family services provided many examples of good multi-disciplinary and multi-agency work. Information was provided in a number of formats to help children and families understand and implement the treatment. Staff understood and applied the principles of consent in their work with the children, young people and families.

There was a strong culture of completing clinical audits to ensure care and treatment was delivered in line with best practice and providing positive outcomes for the children. Information about how to complain was available and complaints were addressed thoroughly with lessons learnt.

All staff were aware of the principles and values of the organisation. Some staff told us they felt inspired by the passion of the chief executive and felt innovation and originality in how services were provided was welcomed by the senior management team. Staff told us they felt confident with their immediate managers and staff worked together across all disciplines for the benefit of the children and families. Governance processes enabled information to be provided to services to support their monitoring and management.

We rated sexual health services as outstanding.

Patients were receiving safe care from appropriately trained, qualified and skilled staff. An extensive programme of training was in place. Staff confirmed that this prepared them for their roles and responsibilities.

All the patients we spoke with told us they were very satisfied with the care and treatment delivered to them, and felt included and involved in their care. The services were easily accessible and staff really focused on the individual needs of each patient.

Care and treatment provided to all patients were based on national guidelines, directives and research. The care and treatment was audited to monitor its quality and effectiveness, and where needed action had been taken to improve the service.

Managers were dynamic, inspiring and approachable and gave support daily not just when required.

The services were a centre for national and internation research and innovation. This meant that patients were benefitting from this work and receiving the latest treatment from staff who were committed to improving care and treatment for patients across the world.

We found that Central North West London NHS Foundation Trust was performing at a level which led to a judgement of requires improvement.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

The inspection of the trust was one of great contrast. The community health services were rated as good with the sexual health services rated as outstanding. The overall rating for caring was outstanding reflecting the individualised care provided in the community dental and sexual health services. The mental health services had three core services that required improvement. These were the acute wards for adults of working age, wards for older people with mental health problems and the community based mental health services for adults of working age.

The area of greatest concern related to safety and responsiveness on the acute wards for adults of working age which were rated as inadequate. There were however significant challenges being faced by the trust at the time of the inspection with pressures across the mental health acute care pathway.

We also found geographical differences, especially in London between the inner and outer London boroughs. The inner London boroughs were facing the greatest bed pressures for people needing acute mental health services. The outer London boroughs were facing challenges of demands for community services and difficulties in staff recruitment resulting in waiting lists. This was particularly notable in the London Borough of Hillingdon for mental health and community services.

There was much for the trust to be proud of. Most notably we found staff were very positive about the work of the trust and in most places care was delivered by hard working, caring and compassionate staff.

Two areas stood out as being very positive. The first were the opportunities given to staff for their personal development through strong support and access to training. 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. Secondly we heard many examples of where the trust embraced innovation and change. Staff told us how new ideas were welcomed and we saw many examples of service improvements taking place.

We found the trust was well led. There was a strong leadership team who had developed an open culture where the vision and values were known and were being put into practice. At the time of the inspection the trust was implementing a new divisional structure with a greater focus on local contact. Running through this will be a new accountability structure to ensure effective communication and learning. This will hopefully lead to more robust governance processes and to staff working at ward and team level receiving the information they need to know.

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

Services were found to be effective, caring, responsive and well led. There was a holistic approach to providing treatment and care to the patient which included involving their family members. Patients and their relatives reported they felt involved in the planning of their care and treatment. Support and training were provided to family members so they could provide safe and effective care and support when patients were discharged and returned home.

Services aimed to meet patients individual needs. It had been identified that high numbers of patients admitted to the wards were living with dementia. Some wards had been refurbished to promote a dementia friendly environment and work was on going at South Wing, St Pancras.

There was an embedded culture of reporting incidents. The trust had worked with staff to ensure risks would be reported in the correct manner, and to ensure incidents were fully investigated and action was taken to reduce the risk of similar incidents occurring.

Areas were clean and appropriate infection control practices were followed. Staffing levels met the planned staffing numbers through the use of agency staff. An active recruitment strategy was in place.

Medicines were managed to ensure the safety of patients. There were arrangements at all hospitals so patients had access to medical treatment in a timely and responsive manner. For patients at Hawthorn unit, Hillingdon the service was being improved with the introduction of seven day working for some therapists.

Staff reported they had access to training other than the required mandatory training. There was good multidisciplinary and integrated working between staff, who were respectful and caring.

There was good local leadership for staff and staff reported an open and supportive culture. Individual wards and departments had their own quality improvement plans. This allowed them to take ownership of their service and the changes they made to improve outcomes for patients.

We gave an overall rating for acute wards for working age adults and the psychiatric intensive care unit (PICU) of inadequate because:

Although the trust had a plan to reduce the number of ligature points on the wards, the work would take some time to complete. Until this was done, patients on the ward who were at high risk of suicide would be at increased risk. In response to this wards had prepared local management plans. When we looked at these documents and spoke to staff working on the acute wards they were still not able to clearly articulate how they would manage the ligature risks on the wards in terms of the support given to individual patients who were at high risk of suicide to keep them safe. In addition the privacy and dignity of patients was not always promoted as a result of measures to manage ligature risks that resulted in blanket restrictions.

Some of the ward environments at the St Charles MHC, Park Royal MHC and the Gordon Hospital did not have clear lines of sight. There was a lack of planning of how risks in the environment would be managed on a daily basis.

The failure to increase staffing to support increased numbers of patients on some wards put patients at risk of not having their needs met appropriately.

The training of staff in new restraint techniques had not yet been fully implemented. This meant that staff working together on wards were not all trained in the same techniques and in line with current best practice on the use of prone restraint. At the end of the last quarter there were about 75 incidents of prone restraint a month across the trust. Until this training is complete staff were using out of date interventions that could present a risk of injury to staff and patients.

In the event of the use of rapid tranquilisation, monitoring of physical vital signs was not always maintained until the patient was alert.

The records relating to the seclusion of patients at St Charles MHC did not provide a clear record of medical and nursing reviews, to ensure that these kept people safe and were carried out in accordance with the code of practice.

There were a significant number of detained patients absconding from acute wards especially from St Charles, Park Royal and the Gordon Hospital. In the 6 months prior to the inspection 82 detained patients absconded whilst receiving inpatient treatment and not when taking leave. In response to a serious incident, steps had been taken to address this at one hospital. Further review and actions were needed to reduce the risk of harm for patients using these services.

Despite work to mitigate this, the pressure on acute beds meant that wards were often over-occupied. There was not always a bed for patients and they slept on sofas or a temporary bed was used. Patients returning from leave could not always get a bed when needed and a bed was not always available in the PICU.

Patients were often transferred to different wards to sleep and returned to the ward during the day. This disrupted the continuity of their care and patients felt it affected their well-being.

Privacy and dignity of patients was not always promoted. Patients were not able to make calls in private. At the Campbell Centre patients in shared rooms were not able to attend to their personal care needs with an adequate level of privacy and dignity.

Information on how to make a complaint was not always available in the PICUs and verbal complaints were not always being recognised and addressed with access to the complaints process.

The service was not well run as contingency plans had not been in place to manage the increase in patients needing an acute hospital admission.

However the staff were kind and respectful to patients and had a good understanding of individual needs. Medicines were managed well across the sites. Multi-disciplinary teams worked effectively in the care and support of patients.

The wards were aware of the diverse needs of all the people who use the service and made positive attempts to facilitate conversations about this with patients.

Staff were committed to the vision and values of the organisation and felt connected to the trust. Staff morale was good and teams worked well together.

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

Oak Tree ward and TOPAS did not comply with the guidance on same sex accommodation.
On Redwood ward at St Charles the medication trolley was not locked when left at the nurse’s station. We saw medication had been left where it could have been picked up by patients which meant that they may not have been protected from avoidable harm.
On Redwood ward the drugs to be used for emergency resuscitation were not stored together which could make them harder to locate in an emergency.
At the TOPAS centre there was no record so staff knew about current safeguarding alerts and any actions that needed to take place to keep people safe.
On Redwood ward ongoing physical health checks were not always taking place which meant people’s physical health care needs might not be met.
On Redwood ward we saw that a number of the female patients attend the mealtime in their nightwear with no dressing gown and this did not preserve their dignity.
Patients were not always involved in their care planning across the wards nor did they have a copy of their care plans where appropriate.
On several wards patients did not have access to a lockable space in their rooms and were not able to lock their own bedroom doors.
People could not close their observation panel from inside their room to have privacy.
Redwood ward reported that they took patients from the adult wards in order to alleviate pressure on adult wards. Some of these patients were not clinically appropriate for the ward environment.
Most wards admitted patients to the beds of patients who were on leave. This meant that patients who were on leave, but not yet officially discharged, might not be able to return if they needed to.

This inspection highlighted that Redwood ward at St Charles had a number of areas for improvement. This was in contrast to many of the other services for older people which were providing a high standard of care. The improvements which had taken place at Beatrice Place were particularly positive. It was also good to see that the Butterworth centre was maintaining high standards of care even though the service was transferring to a new provider. This good practice needs to happen consistently across the services.

The commitment and care displayed by many of the staff was observed throughout the inspection. Most wards were well led and on Redwood ward alternative management arrangements had been implemented to start improving the service. Progress had been made in the management of falls and pressure ulcers. Risks were also being well managed.

Relatives and carers were mainly positive about being informed and involved in care decisions. Progress had been made in the use of the Mental Capacity Act.

There were many examples of good multi-disciplinary working and work between agencies to facilitate people being discharges.

We gave an overall rating for forensic/secure wards of good because:

Care was provided to people in a clean and safe environment. However the location of the seclusion room on a different floor could cause potential risks to the safety and dignity of patients when they need to use this facility.

Staff were competent and aware of how to report incidents and safeguarding concerns. Incidents were investigated and staff were aware of where learning could take place.

All admissions were assessed prior to admission and further assessments and management plans took place on admission. Risk plans were developed and updated as necessary. However some of the recording systems in place did not reflect the staff understanding of patients’ needs.

Staff were provided with regular supervision, annual appraisals and had access to mandatory and specialist training and training provided within the division.

Staff were confident about raising concerns and felt supported by their managers.

All admissions were planned and there was a very small waiting list for beds. The wards were part of a wider offender care pathway where support was provided by in-reach, outreach and inpatient services.

The service was sensitive to the differing needs of patient groups although there were some difficulties regarding disability access and outdoor access from Tasman ward.

There were strong clinical governance systems in place through the offender care pathway. However, as this was a small inpatient service within a larger division, there was a risk that learning from other inpatient wards and similar services such as the rehabilitation pathway within the trust were not strongly embedded.

We gave an overall rating for long stay/rehabilitation mental health wards for working age adults of good because:

Patients were provided with care in clean and safe environments. Environmental and ligature risk audits were undertaken regularly and mitigation plans were in place where necessary. Some services did not meet same sex accommodation guidelines.

There were some areas in the service, in particular at Horton, where there were high vacancy rates for nursing staff, however, managers had access to temporary staff, usually regular bank staff and the trust was taking action to actively recruit into vacant posts.

Staff had a good understanding safeguarding processes locally and were confident in reporting concerns. Incidents were reports and learning from incidents was disseminated through the service.

Risk assessments and care plans were up to date and regularly reviewed. There were strong multi-disciplinary teams based in the services who provided a wide range of support for patients on the wards. There were varying experiences of working with agencies external to the trust, depending on availability and coordination with services depending on their location. Staff had a good understanding of the Mental Health Act and the Mental Capacity Act.

Patients reported that they received good care and we observed kind and thoughtful interactions with staff. There were regular meetings on wards for patients to feedback information about the services. Availability of advocates varied but there was information on the wards about contacting advocates. Wards were well-equipped with rooms for activities although there were significant differences between the wards within this service.

Services were able to adapt to meet the needs of the local communities and there was access to interpreting services and food to meet cultural and religious needs.

The services had a strong recovery focus which staff embraced enthusiastically. The senior leadership within the service was visible and accessible. Staff told us that they felt confident in raising concerns. Information available at a ward level related to staff training and there is additional work being done to extend the amount of data available but currently this is monitored through ward managers. The service has participated in some research programmes and is working on a new online version of care planning to involve people more in their own care plan process.

We gave an overall rating for community based services for older people as good because:

The support provided by the older persons’ community mental health teams and the memory services was thoughtful, respectful and considered peoples individual needs. The teams also worked closely with carers and relatives.

The teams had appropriate staffing levels. Where there were recruitment challenges, there were plans in place to attract new staff. Bank and agency staff were used where needed. Staff had access to a range of training to perform their roles and felt well supported.

People using the service were assessed and had care plans and risk assessments in place. Further work should be done to ensure physical health needs are covered in all care plans and the care plan format is accessible to people using the service and their carers. The staff were making very good use of the Mental Capacity Act to support people to make complex decisions.

Waiting times from referral to assessment varied between teams, with people referred to services in Hillingdon experiencing longer waits. People who made the referrals were advised they could contact the team again if the person’s needs changed while they were waiting for an assessment. Services were delivered in a reliable and flexible manner to accommodate people’s individual circumstances.

The teams were able to follow best practice guidance and there were examples of innovative developments.

This service was not rated

Suitable numbers of staff were employed at each site, with appropriate arrangements in place to cover vacant posts with regular staff, ensuring consistency of care and treatment. All of the services we visited valued the contribution of volunteers and peer support workers who had previously received treatment. At all sites, staff were engaged in partnership working, in line with current best practice. Staff received appropriate training, supervision and professional development. There was effective multi disciplinary team (MDT) working taking place. Each of the services we visited had developed good working links with partners and external agencies, such as GPs, social services and mental health services.

The premises that we visited were clean and free from clutter. Each had a suitably equipped clinical room. Appropriate arrangements were in place at each site to manage medicines and to dispose of sharps and clinical waste safely.

Initial patient assessments were completed in a timely manner and care and treatment was delivered in line with individual care plans. Overall, care plans were regularly reviewed and updated. The majority of patients were aware of their care plan and felt that they included their views. A standardised patient risk assessment was in use. We found that across all sites where potential risks had been identified there was not always a management plan to address these.

Patients received regular medical reviews with a doctor employed by the service.

At the time of our inspection no waiting lists were in operation at the services we visited. Patients were initially assessed on the day that they attended the service. Each of the services was able to offer a rapid medication pathway. The services that we visited had arrangements in place to follow up with patients who disengaged. Patients we spoke with knew how to complain and staff we spoke with knew about the complaints procedure and how to deal with complaints appropriately.

We found each service to be well-led. There was evidence of clear leadership at a local level. The culture of each service was open and encouraged staff to bring forward ideas for improving care. Staff we spoke with also told us that they felt supported by their service managers and felt that there was two way communication from “the board to the ward”. Each service had access to systems of governance that enabled them to monitor the quality of service provision and a range of measures were in place to gauge the performance of each site.

We gave an overall rating for wards for people with learning disabilities or autism as good because:

Patients received care in a clean and safe environment. There were enough staff of different disciplines working on the wards and the trust was recruiting to fill the vacant posts for qualified nurses. Staff had been trained and knew how to make safeguarding alerts. Staff managed medicines well.

We spent time observing how patients were treated and spoken to. We observed staff were kind and respectful to patients and recognised their individual needs. Staff were polite and softly spoken. All the patients we spoke with told us they liked the staff and were treated with respect.

Staff knew the vision and values of the organisation. Good governance processes identified where the services needed to improve. This had led to the improvement plans being put into place for the service. Staff morale was good and teams worked well together.

However the services would benefit from further work to ensure the care was person centred and really met the individual needs of each individual in terms of their day to day care and support provided to enable their recovery.

There was insufficient evidence to rate the Bent and Harrow Community Learning Disability teams:

Assessments were completed for each person referred to the team, based on their individual needs and the reason for their referral. Care plans had all been discussed and shared with the people using the service and their carers. Care plans covered all the areas of individual need for each person and were regularly updated. Staff monitored people’s medicines as part of a shared care with the person’s GP.

People who use the service had risk assessments that were updated on a regular basis to reflect the current individual needs of the person. People using the service all had individual crisis plans in place. People’s records showed that individual healthcare needs were clearly identified and closely monitored.

Both teams were multi-disciplinary and offered support based on the persons individual needs.

Staff members of the team worked closely where needed with primary care, colleagues in social services and a range of other care providers.

Staff talked about people in a way that demonstrated kindness, dignity and respect

People using the service were supported to be involved in their care planning and to attend meetings with their families and carers. Meetings often took place in the persons home or day service rather than at the team base.Team members worked closely with families and carers who knew the people using the service well.The service had recently piloted a survey of people using the service to get feedback on the quality of their support.

The number of people who did not attend appointments was generally low and people who missed appointments were contacted. We saw examples of two complaints. On both occasions lessons were learnt, staff received feedback and an apology was offered by the trust

Staff were aware of the service’s vision and values. Staff told us they felt valued and that managers were approachable and listen.

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

In general, the teams were well managed. Staff supported people with complex needs in a caring and supportive manner. Staff received mandatory training and were appraised and supervised, incidents were reported and investigated, staff participated in audits, and safeguarding and Mental Health Act procedures were followed. Staff knew about the whistle-blowing process.

Staff morale was high in most of the teams we visited. Many staff told us they were proud of the job they did and felt well supported in their roles.

However in the responsive domain we found that:

People who were assessed as requiring inpatient beds experienced long delays before being admitted. The delays in accessing inpatient beds meant that some people received care that did not meet their needs.
The places of safety at the Gordon hospital and Park Royal had no separate access.This meant that people had their privacy compromised as they arrived at the places of safety.
In the North Kensington team based at St Charles the interview rooms were divided by a door with a glass panel covered by a small curtain. Private conversations could easily be overheard in either room. This meant their privacy and dignity was not maintained.

At the Gordon Hospital the two place of safety rooms both contained ligature points. The toilet for use of people was also not ligature free. Although staff could manage risk through observation, the environment meant people could not be supported safely without compromising their privacy. The trust had agreed to the refurbishment of the place of safety and work was starting in April 2015.

We gave an overall rating for child and adolescent mental health wards as good because:

The service was well-staffed and staff felt well supported in the service.
The team worked together to formulate individual care plans and we saw good detail was provided within these.
NICE guidance was followed.
Children’s feedback was sought and used to inform service development.
Cultural and diversity needs were supported.
There was a culture of openness and transparency and staff felt listened to.
There was evidence of clear leadership at a local and service level.

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

Incident reporting and learning from incidents was apparent across teams. Staff had been trained and knew how to make safeguarding alerts. Staff managed medicines well.

Young people referred to teams were seen by a service that enabled the delivery of effective, accessible and holistic evidence-based care.

Staff demonstrated their commitment to ensuring young people received robust care by being proactive and committed to people using the service, despite the challenges they faced at times with limited resources.

There was strong leadership at a local level and service level across most of CAMHS that promoted a positive culture within teams.

There was a commitment to continual improvement across the services.

We gave an overall rating for community dental services of good because:

Overall we found dental services provided safe and effective care. Patients’ were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents were in place.

Dental services were focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practices within the service. There have been some difficulties recruiting staff to all posts however the service has been able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of the service.

The patients we spoke with, their relatives or representatives said they had very positive experiences of their care. We saw good examples of care being provided with compassion as well as sensitive and empathetic interactions between staff and patients. We found staff to be hard working and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At each of the clinics we visited the staff responded to patient’s needs. We found the service sought the views of patients using a variety of means. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs and at the right time. Through effective management of resources, delays to treatment are kept to reasonable limits.

The service was well-led. Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff were aware of the vision and way forward for the organisation and said that they generally felt well supported and that they could raise any concerns.

Overall rating for this core service Good

We gave an overall rating for end of life care good because :

The specialist palliative care teams were aware of the process for reporting any incidents. Staff we spoke with were able to explain what constituted a safeguarding concern and the steps required to report concerns. There were clear guidelines for medical staff to follow when prescribing anticipatory drugs to patients. A large percentage of staff had completed their mandatory training and that this was updated on a regular basis. We observed that patients’ needs were risk assessed and managed on an individual basis.

Clinical staff made a comprehensive assessment of patients when they were referred to the service. Multi-disciplinary meetings were arranged for patients who were approaching their end of life. These effectively arranged services in partnership with other health care professionals and GP’s involved in patients care. We looked at 12 DNACPR forms and found that in 5 cases patients had been involved in the discussions, and for the other cases where the patient had been identified as lacking mental capacity, a mental capacity assessment had been undertaken and a best interest decision made.

Throughout our inspection we saw patients being treated with compassion, dignity and respect by staff. We observed staff interactions with patients and families that were professional, sensitive and appropriate at all times. Staff ensured that privacy was maintained when they assisted patients with their needs. Patients told us their clinical nurse specialist would carefully explain pain control and involve them in their care plans.

Patients and families were able to access 24 hour 7 day per week palliative care services. Patients and relatives told us that they were very happy with the service they received and that had information on how to make a complaint. Staff were aware of the diverse needs of all the people who use the service and patients and relatives told us that they had been able to access interpreter services though the teams.

Staff knew the vision and values of the organisation. There was a good governance structure in place and the risk register was used to highlight any issues of immediate risk and these were reviewed on a monthly basis. Staff spoke positively about their team leaders and senior management. Staff felt supported and involved in the delivery of the service.

We gave an overall rating for community adult services of good because:

We directly observed staff treating patients with dignity and respect. All the patients we spoke with told us they had received good and compassionate care. Often telling us staff had been very flexible and had done more than was expected of them. Staff consistently involved patients and their families in their care. We observed staff giving patients detailed information about their treatment and discussing this with them. Staff we spoke with were aware of the importance of gaining patient’s consent and had an understanding of the Mental Capacity Act. Additional training was being provided in some areas.

Staff teams received equality and diversity training and consistently reported good access to interpreters. People using the services received information and care in a manner that met their individual needs in terms of their language, culture, religion and disability. Teams told us they had good access to patient equipment which was usually delivered in a timely way.

Leaflets had been given to patients on how to complain and where possible complaints were addressed quickly at a local level. Where formal complaints took place they were addressed thoroughly and staff learnt from the complaints.

Staff knew how to report incidents and there was learning from these events. The organisation was open when things went wrong and would keep the patient informed of the action they were taking. Safeguarding matters were correctly alerted and there was learning where needed. Medicine management varied between teams depending on local arrangements. In most cases infection control was managed well although this needed improvement in Hillingdon.

There were sufficient staff available to provide services, although this could at times be challenging and required ongoing monitoring. Staff said they had regular supervision, a recent appraisal and felt well supported within teams. We were consistently told that the trust supported and encouraged access to training. Arrangements were being made to monitor the frequency of supervision to ensure a consistent approach. There was good multi-disciplinary working and effective handover and multi-disciplinary team meetings. Staff consistently told us they had good links, and access to, a wide range of other services. Staff said they felt well supported by team leaders and most senior managers. Most staff felt valued and respected by the organisation.

We saw clear referral processes to teams often with duty staff to triage referrals received. Referral and transition process varied across the teams we visited and where there were challenges these were being reviewed.

A range of audits had been completed and improvements made to services in response to the findings. Teams were informed of changes to national guidance and practice had changed as a result of new guidance. There were good examples of innovation and close working with local clinical commissioning groups. We were told these innovations had been well supported by senior managers. The trust annual gem and team awards celebrate such developments.

Record keeping was generally good but needed more work to be of a consistency high standard.

We gave an overall rating for community based mental health services for adults of working age requires improvement because:

Not all services had properly maintained automated external defibrillators (AED) machines to be used in the event a person had a cardiac arrest.
The standard of some risk assessments was poor. They were out of date and lacked detail. Important information was not included.
There were insufficient staff available to work as care co-ordinators which meant that duty workers in some services were responsible for supporting a number of patients. This meant the safety and welfare of patients was potentially at risk.
Patients were not always referred for regular physical health checks when they should have been.

However, overall the quality of care and treatment was good. Staff were respectful, compassionate, caring and committed to their work. Learning from incidents and complaints led to improvements in care. Urgent referrals were prioritised and urgent assessments took place promptly. Most patients felt involved in their care. Services used a variety of strategies to meet the needs of a very diverse population particularly in Brent and North Westminster.

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.

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.

All Inspections

However:

How we carried out the inspection

What people who use the service say