CentralandNorthWest LondonNHSFoundation Trusthealthwatchharrow.co.uk/sites/default/files/cnwl_provider_report.pdf · 3Central and North West London NHS Foundation Trust Quality Report

Core services inspected CQC registered location CQC location ID

Acute wards for adults of workingage and psychiatric intensive careunits (PICU) Stephenson House

Campbell CentreHillingdon Hospital Mental HealthCentreNorthwick Park Mental Health CentrePark Royal Centre for Mental HealthSt Charles Mental Health CentreThe Gordon Hospital

RV3Y1RV3ANRV383RV312RV320RV346

Wards for older people with mentalhealth problems

Beatrice PlaceHillingdon Hospital Mental HealthCentreNorthwick Park Mental Health CentreSt Charles Mental Health CentreTOPAS Waterhall Care Centre

RV329RV3ANRV383RV320RV3Y2

Wards for people with learningdisabilities or autism Kingswood Centre RV3CA

Community based services foradults of working age Stephenson House RV3EE

CentrCentralal andand NorthNorth WestWestLLondonondon NHSNHS FFoundationoundationTTrustrustQuality Report

Stephenson House75 Hampstead RoadKings CrossLondonNW1 2PLTel: 020 32145700Website: www.cnwl.nhs.uk

Date of inspection visit: October 2016 to May 2017Date of publication: This is auto-populated when thereport is published

1Central and North West London NHS Foundation Trust Quality Report This is auto-populated when the report is published

This report describes our judgement of the quality of care at this provider. It is based on a combination of what wefound when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us frompeople who use services, the public and other organisations.

Summary of findings


RatingsWe are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings willalways be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring dataand local information from the provider and other organisations. We will award them on a four-point scale: outstanding;good; requires improvement; or inadequate.

Overall rating for services at thisProvider Good –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and MentalCapacity Act/Deprivation of Liberty SafeguardsWe include our assessment of the provider’s compliancewith the Mental Health Act and Mental Capacity Act in ouroverall inspection of the core service.

We do not give a rating for Mental Health Act or MentalCapacity Act; however, we do use our findings todetermine the overall rating for the service.

Further information about findings in relation to theMental Health Act and Mental Capacity Act can be foundlater in this report.

Summary of findings


Contents

PageSummary of this inspectionOverall summary 5

The five questions we ask about the services and what we found 6

Our inspection team 11

Why we carried out this inspection 11

How we carried out this inspection 15

Information about the provider 16

What people who use the provider's services say 17

Good practice 17

Areas for improvement 18

Detailed findings from this inspectionMental Health Act responsibilities 22

Mental Capacity Act and Deprivation of Liberty Safeguards 22

Findings by main service 24

Action we have told the provider to take 51

Summary of findings


Overall summaryWhen aggregating ratings, our inspection teams follow aset of principles to ensure consistent decisions. Theprinciples will normally apply but will be balanced byinspection teams using their discretion and professionaljudgement in the light of all of the available evidence.

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

• Following the last inspection In February 2015, thetrust had implemented a comprehensiveimprovement plan.

• In February 2015, we rated one of the sixteen coreservice as inadequate and a further two of the sixteencore service as requires improvement. At thisinspection we found the trust had worked to makeimprovements and the trust had taken action to meetthe requirement notices issued following the February2015 inspection.

• In February 2015, we recommended the trust shouldtake a number of actions to improve services. At thisinspection we found that the majority ofrecommendations had been met and improvementshad been made.

• Following the this inspection, we have changed ratingsof the following key questions from inadequate torequires improvement:

• the safe key question for wards for adults of workingage and PICU

• Following the this inspection, we have changed ratingsof the following key questions from inadequate togood:

• the responsive key question for adults of working ageand PICU

• Following this inspection, we have changed ratings ofthe following key questions from requiresimprovement to good:

• the well led key question for wards for adults ofworking age and PICU

• the effective key question for wards for older peoplewith mental health problems

• the caring key question for wards for older people withmental health problems

• the responsive key question for wards for older peoplewith mental health problems

• Following this inspection we have changed the ratingsfor the following key questions from good tooutstanding:

• the effective key question for wards for people withlearning disabilities or autism

• the caring key question for wards for people withlearning disabilities or autism

• the responsive key question for wards for people withlearning disabilities or autism

• Following this inspection we have changed the ratingof one core service from inadequate to good. This isthe core service for wards for adults of working ageand PICU.

• Following this inspection we have changed the ratingof one core service from requires improvement togood. This is the wards for older people with mentalhealth problems.

• Following this inspection, we have changed the ratingfor one core service from good to outstanding. This isthe core service for wards for people with learningdisabilities and autism.

• Following this inspection the rating for one coreservice remains as requires improvement. This is thecore service for community services for adults ofworking age.

• We have not yet re-inspected the rehabilitation mentalhealth wards and crisis services and health basedplaces of safety. The requirement notices for theseservices will be checked at future inspections.

• We also carried out a ‘well led’ review and found thatthe trust had continued to strengthen its seniorleadership team and refine the trust governanceprocesses.

Summary of findings


The five questions we ask about the services and what we foundWe always ask the following five questions of the services.

Are services safe?We rated safe as requires improvement because:

• In February 2015, we rated two of the sixteen core services asrequires improvement and one core service as inadequate. Thisled us to rate the trust as requires improvement overall for thiskey question. At this inspection three of the core serviceremained requires improvement for safe.

• In February 2015, we identified that staff were not completingphysical health observations following administration of rapidtranquilisation medication on the acute wards for adults ofworking age and psychiatric intensive care units. At thisinspection we found some improvements had been madethough gaps and inconsistencies remained.

• The number of incidents of restraint taking place across theacute wards for adults of working age and PICU was significantand there were variation in the levels of restraint across hospitalsites. In addition, despite the training in restraint being updatedabout 70% of the restraints were still in the prone position.

• Incident records of physical restraint on acute wards for adultsof working age and wards for older people with mental healthproblems were not completed fully.

• Risk assessments for patients in the acute wards for adults ofworking age and PICU and community based mental healthservices for adults of working age were not always completedthoroughly to reflect current risks.

• Whilst staffing levels had improved, there were still areas ofhigh staff turnover and this was impacting on the consistency ofpatient care especially in community based mental healthservices for adults of working age.

• Milton Keynes CMHT did not have arrangements to supportstaff and patient safety such as access to alarms for staff to callfor assistance if needed.

• Mandatory basic life support for non-clinical staff and firetraining completion rates were low in some community mentalhealth teams.

However:

• At this inspection we have changed the rating for acute ward foradults of working age and PICU, from inadequate to requires

Requires improvement –––

Summary of findings


improvement. This is because the service had addressed theproblems with staffing levels, training for staff on safe restraint,seclusion recording and risk management of blind spots andligature points on wards.

• Across the services inspected there were sufficient numbers ofstaff to deliver care. A programme of staff recruitment andretention was being implemented in the trust to work towardsreducing staffing vacancies across services.

• The trust had made improvements to the safety of the wards forolder people with mental health problems including ensuringgender segregation on took place, emergency resuscitationequipment was safely accessible, medicines were securelystored and staff were able to monitor and track safeguardingreferrals.

• The trust had made improvements to the safety of thecommunity based mental health services for adults of workingage. These included ensuring that defibrillators andresuscitation equipment were checked and serviced across thecommunity mental health teams.

• Patients received care in clean and hygienic environments.

Are services effective?We rated effective as good because:

• In February 2015, we rated two of the sixteen core services asrequires improvement. This led us to rate the core service asgood overall for this key question.

• We have changed the rating for this key question for the wardsfor older people with mental health problems from requiresimprovement to good. This is because In February 2015, weidentified that physical health checks were not routinely beingcompleted. At this inspection we found this had improved andan early warning score system was being used to support earlyidentification of deterioration in physical wellbeing.

• Patients had comprehensive mental and physical healthassessments in place.

• Patients with mental health needs were receiving improvedsupport with their physical health.

• Staff understanding and application of the Mental Capacity Acthad shown improvement.

However:

• We have not changed the rating for this key question forcommunity services for adults of working age.

Good –––

Summary of findings


• Care plans were not always reflect the patients identified needsin some of the community based mental health services foradults of working age.

• Patients were often not able to access any or sufficientpsychology input which meant their treatment was not in linewith best practice. Whilst the trust was working to introducealternative arrangements for patients to access talkingtherapies, there was still more to do.

Are services caring?We rated caring as outstanding because:

• In February 2015 we rated the trust as outstanding for caringoverall. Many of the services that were previously outstandingfor caring at the last inspection were not inspected this timebut there is no new information to suggest those ratings havechanged.

• We have changed the rating for this key question for wards forolder people with mental health problems, from requiresimprovement to good. This is because improvements had beenmade to maintain the privacy and dignity of patients, increasepatient participation in care planning, and improve provision ofpersonal lockable space for patients.

• Patients were treated with kindness, compassion and respectacross the services we inspected.

• Patients and carers were supported to be involved in caredecisions and also in the wider operation of the trust.

• Patients and carers were encouraged to give feedback aboutthe services being delivered by the trust.

However:

• On the acute wards for adults of working and PICU andcommunity mental health services for adults of working agecare plans did not always include patient views and evidence oftheir involvement. The format and language used in care plansdid not always support patients’ involvement.

Outstanding –

Are services responsive to people's needs?We rated responsive as good because:

• In February 2015, we rated three one of the sixteen core servicesas requires improvement and on core service as inadequate forthis key question. This led to an overall trust rating of requiresimprovement for this key question.

Good –––

Summary of findings


• At this inspection we inspected the one core service previouslyrated as inadequate and one the core services previously ratedas requires improvement.

• We have changed the rating for this key question for acutewards for adults of working age and PICU from inadequate togood. This is because improvements had been made to ensurepatients had access to a bed when needed and patients couldreturn to a bed after going on leave from hospital.

• We have changed the rating for this key question for wards forolder people with mental health problems from requiresimprovement to good. This is because improvements had beenmade to the management of clinically inappropriateadmissions to the wards.

• In February 2015, we recommended that the areas used bypatients at Hillingdon West CMHT (Mead House) be refurbished.At this inspection, we found this had improved andrefurbishment had been completed.

However:

• Whilst there was clear information displayed throughout theservices visited to explain to patients and carers how to make acomplaint, informal verbal complaints were not being recordedand so it was not possible to ensure these had been addressedor to look at themes and areas for learning.

Are services well-led?We rated well led as good because:

• In February 2015, we rated all but one of one of the sixteen coreservices as good for well led. The exception was wards foradults of working age and psychiatric intensive care units(PICU); which we rated as requires improvement for this keyquestion. Following this most recent inspection, we changedthe rating of well led for acute wards for adults of working ageand PICU to good. This means that all seven community healthcore services and nine of the ten mental health core servicesare now rated as good for well led. The wards for people with alearning disability or autism are rated as outstanding for thiskey question.

• The trust had a skilled and experienced leadership team whowere committed to providing high quality services.

• There were clear strategies in place which put the patients andcarers at the centre of the work of the trust, whilst addressingthe financial challenges.

• The leadership team were cited on the risks facing the trust andhad robust action plans in place to address these areas.

Good –––

Summary of findings


• Patients, staff and external stakeholders were actively engagedin the trust. Further developments in carer engagement werebeing promoted.

• The trust welcomed innovation and was introducing asystematic approach to quality improvement.

Summary of findings


Our inspection teamTeam Leader: Our inspection team was led by Jane Ray,head of inspection, David Knivett, inspection manager andRekha Bhardwa, inspector.

Acute wards for adults of working age and psychiatricintensive care units (PICU)

The team that inspected this service comprised nine CQCinspectors, two CQC inspection managers, one head ofhospital inspection, two assistant inspectors, twopharmacy inspectors, three Mental Health Act reviewers,seven specialist advisors who had experience of working inacute and psychiatric intensive care units and three expertsby experience. An expert by experience is a person who haspersonal experience of using or caring for someone whouses similar mental health services.

Wards for older people with mental health problems

The team that inspected this service comprised fourinspectors, one CQC inspection manager, two pharmacyinspectors, one Mental Health Act reviewer, five specialistadvisors who had experience of working in wards for olderpeople with mental health problems and five experts byexperience. An expert by experience is a person who haspersonal experience of using or caring for someone whouses similar mental health services.

Wards for people with learning disabilities and autism

The team that inspected this service was comprised threeinspectors, one pharmacy inspector, two specialist advisorswho had experience of working in wards for people withlearning disabilities and one expert by experience. Anexpert by experience is a person who has personalexperience of using or caring for someone who uses similarmental health services.

Community services for adults of working age

The team that inspected this service comprised seveninspectors, two inspection managers, one pharmacyinspector, five specialist advisors two of whom wereconsultant psychiatrists and three nurses who hadexperience of working in community based mental healthservices for adults of working age.

Well Led Review

The team that completed a well led review comprised onehead of hospital inspection, a CQC inspection manager, aCQC inspector, a Mental Health Act reviewer and aspecialist advisor with experience of working at board levelwithin an NHS trust.

Why we carried out this inspectionFor this inspection we looked at the mental health coreservices which had been rated as inadequate or requiresimprovement at the last inspection. We also looked at onegood core service to see if standards had been maintained.We did not inspect the community health services providedby the trust.

We undertook this inspection to find out whether Centraland North West London NHS Foundation Trust had madeimprovements to their acute wards for adults of workingage and the psychiatric intensive care units; wards for olderpeople with mental health problems; wards for people withlearning disabilities or autism; and community based

services for adults of working age since our lastcomprehensive inspection of the trust, that we undertookin February 2015, where we rated the trust as requiresimprovement overall.

When we last inspected the trust In February 2015, we ratedthe acute wards for adults of working age and thepsychiatric intensive care units as inadequate overall.We rated the core service as inadequate for safe, good foreffective, good for caring, inadequate for responsive andrequires improvement for well-led.

Following that inspection, we told the trust it must makethe following improvements to the acute wards for adultsof working age and the psychiatric intensive care units:

Summary of findings


• The trust must address the blind spots in the wardenvironment of St Charles MHC, Park Royal MHC andthe Gordon Hospital to enable clearer lines of sightand reduced risks to patients and staff.

• The trust must ensure that staff working on the wardsare able to articulate how they are assessing andmanaging the potential risks from ligature points forthe patients using this service. The use of blanketrestrictions must be reviewed and risks from ligaturesmanaged to reflect the needs of the patients on theward.

• The trust must ensure that staffing levels are adjustedto reflect the actual numbers of patients on the wards.This number must include those patients spending theday on the ward even if they are sleeping on anotherward or at another hospital overnight

• The trust must implement the training of all staff innew restraint techniques to ensure that staff workingtogether on wards are all trained in the sametechniques and in line with current best practice onthe use of prone restraint, to prevent injury to staff andpatients.

• The trust must ensure that staff working on the wardsare able to articulate how they are assessing andmanaging the potential risks from ligature points forthe patients using this service. The use of blanketrestrictions must be reviewed and risks from ligaturesmanaged to reflect the needs of the patients on theward.

• The trust must take further steps at the GordonHospital and other sites where acute inpatient servicesare provided to ensure that risks to detained patientsfrom being absent without authorised leave areminimised

• The trust must ensure that records relating to theseclusion of patients provide a clear record of medicaland nursing reviews, to ensure that these are carriedout in accordance with the code of practice.

• The trust must take further steps at the GordonHospital and other sites where acute inpatient servicesare provided to ensure that risks to detained patientsfrom being absent without authorised leave areminimised.

• The trust must ensure that, on admission to a ward,patients have a designated bed that is within the wardoccupancy levels.

• The trust must ensure that staff always monitor andrecord physical vital signs in the event of the use ofrapid tranquilisation until the patient is alert. Theymust improve medical reviews of patients receivingrapid tranquilisation to ensure patients are not at risk.

• The trust must promote the privacy and dignity ofpatients. Patients must be able to make calls inprivate. At the Campbell Centre patients in sharedrooms must be able to attend to their personal careneeds with an adequate level of privacy and dignity

• The trust must ensure that, on admission to a ward,patients have a designated bed that is within the wardoccupancy levels.

• The trust must ensure that patients returning fromleave have a bed available on their return to the ward.The trust must take steps to reduce the number oftimes that patients are moved to other wards to sleepfor non-clinical reasons. Where it is unavoidable, staffmust ensure that a thorough handover takes place topromote continuity of care. Patients must only bemoved at reasonable times so that they are notadversely affected.

• The trust must ensure that information is available toinform patients how to make a complaint. They mustensure verbal complaints are addressed and, ifneeded, patients and carers have access to the formalcomplaints process.

• The trust must ensure that the acute wards for adultsof working age are well led by having contingencyplans in place for when the numbers of patientsneeding a bed increases above the beds available.

In addition we recommended the following actions:

• The trust should provide individual lockable space forpatients to keep their possessions safe

• The trust should ensure that maintenance issues atPark Royal MHC are resolved in a timely manner.

• The trust should ensure that patients are not confinedto bedrooms and that seclusion is implemented inaccordance with the code of practice: Mental HealthAct 1983.

Summary of findings


• The trust should address the sound of the alarms at StCharles MHC so that they are as least disruptive topatients as possible, and do not affect their wellbeing.

• The trust should improve the new multi-disciplinarycare planning system to ensure that all disciplinesrecord directly onto this. Nurses informed us that theymake entries for other professionals following reviewsof care. The expectation for nurses to do this is not inthe spirit of the system and could lead to inaccurateprofessional judgements being recorded.

• The trust should ensure that male staff are interactingappropriately with female patients on Pond wardfollowing a safeguarding investigation. Further supportshould be provided to staff to enable patients toapproach any member of staff for support.

• The trust should ensure that staff encourage allpatients to get involved in planning their care andtreatment. This involvement should be clearlyrecorded.

• The trust should ensure that staff incorporatedischarge planning into the care planning for patientsso that care and treatment is recovery focussed.

• The trust should monitor the impact of bedmanagement pressures and the ability of staff tofacilitate patients’ entitlement to take Section 17 leaveoff the ward.

• The trust should promote any staff and patientfeedback processes so that all people have anopportunity to be involved in the trust.

When we last inspected the trust In February 2015, we ratedthe wards for older people with mental healthproblems as requires improvement overall. We rated thecore service as requires improvement for safe, requiresimprovement for effective, requires improvement forcaring, requires improvement for responsive and good forwell-led.

Following that inspection, we told the trust it must makethe following improvements to the wards for older peoplewith mental health problems:

• The trust must ensure that Oak Tree ward and TOPAScomply with same sex accommodation guidelines topromote peoples safety, privacy and dignity.

• The trust must ensure that staff on Redwood ward atSt Charles do not leave medication unsupervised inreach of patients.

• The trust must ensure that on Redwood ward at StCharles staff keep medication used for emergencyresuscitation in one place so it is easily accessible in anemergency.

• The trust must ensure that at the TOPAS centre inMilton Keynes staff have access to a record ofsafeguarding alerts so they can know what action totake to keep people safe and learn from previousevents.

• The trust must ensure that on Redwood ward people’sphysical healthcare checks take place as regularly aseach patient needs to ensure their health is monitored.

• The trust must ensure that on Redwood ward primarilybut also on other wards for older people, patients aresupported to be dressed in a manner that preservestheir dignity, have access to a lockable space toprotect their possessions preferably their bedroom,have night time checks that are the least intrusive aspossible, be able to close their observation panels intheir door from inside their room and participate in thepreparation of their care plan and have a copy whereappropriate.

• The trust must ensure on Redwood ward that beds areonly made available for patients’ who are clinicallyappropriate for a service for older people.

• The trust must ensure that a bed is available forpatients who are on leave in case they need to returnto the ward.

In addition we recommended the following actions

• The trust should ensure staff working on wards forolder people can clearly articulate how they aresupporting patients to keep safe in terms of theligature risks on the ward.

• The trust should ensure that at St Charles chairs withsplit covers are repaired or replaced and enoughchairs are available so people can eat together.

• The trust should ensure that where actions are neededfollowing environmental risk assessments, these arefollowed through.

Summary of findings


• The trust should review the layout at Beatrice Place totry and provide gender separation in terms ofbathroom facilities.

• The trust should ensure on Redwood ward that riskassessments are updated following incidents.

• The trust should ensure staff have opportunities todiscuss and learn from incidents across the trust andnot just their site.

• The trust should ensure that Mental Health Actdocumentation is completed correctly for patients onTOPAS and Redwood ward to ensure people are beingsupported to understand their rights, their medicationis authorized and their leave is approved.

• The trust should ensure that staff have beensupported to have the training needed to supportpatients with their physical healthcare in line with thetraining provided at Beatrice Place.

• The trust should ensure that where patients aresubject to a deprivation of liberty safeguard that theauthorisations are kept under review and updated asneeded

When we last inspected the trust In February 2015, we ratedthe wards for people with learning disabilities or autism asgood overall. We rated the core service as good for safe,good for effective, good for caring, good for responsive andgood for well-led. We did not issue any requirement noticesto the core service.


• The trust should ensure the recruitment of staff towork in the services both nursing and other alliedprofessions continues to be a priority for the trust untilposts are filled.

• The trust should ensure that care planning processesare individualised. Care plans should be in a formatthat is meaningful to that person, there should be astrong recovery focus and the care plans should be putinto practice for each person.

• The trust should ensure that the service has accuratetraining records so that people’s training needs can beidentified and addressed.

• The trust should ensure that the service works withcommissioners to make arrangements for areplacement independent mental health advocacyservices at the Kingswood Centre and staff shouldknow who to contact when this service is needed.

• The trust should ensure that activities on people’sprogrammes happen in practice.

• The trust should ensure that patients receive thesupport they need to practice their faith if they wish todo so.

When we last inspected the trust In February 2015, we ratedthe community services for adults of working age asrequires improvement overall. We rated the core serviceas requires improvement for safe, requires improvementfor effective, good for caring, good for responsive and goodfor well-led.

Following that inspection, we told the trust it must makethe following improvements to the community services foradults of working age :

• The trust must ensure that where automated externaldefibrillators (AEDs) are provided because there is aclinical need for this equipment, for example atHillingdon community recovery team (PembrokeCentre), that they are maintained on a regular basis,accessible, and available for use. The provider mustensure that other teams also have resuscitationequipment if needed.

• The trust must ensure that all patient risk assessmentsin Harrow community recovery team arecomprehensive, detailed and thorough. They must bereviewed regularly and updated after incidents. Theremust be a personalised crisis plan in place for eachpatient.

• The trust must ensure there are sufficient staffavailable to work as care co-ordinators so that dutyworkers in some services are not holding largenumbers of patients which could potentially create arisk for the safety and welfare of patients.

• The trust must ensure that patients using communityservices are referred for regular physical health checks.


Summary of findings


• The trust should ensure that people using serviceshave crisis plans that reflect their individualcircumstances.

• The trust should support staff to learn about incidentsfrom services in other parts of the trust so they canapply the lessons learnt to their work.

• The trust should ensure that where people using theservice are being supported by a lead professionalclinician that their care plans should aim to be moreperson centred.

• The trust should ensure that psychological therapiesare available for patients using community basedmental health that reflect NICE guidance.

• The trust should focus recruitment to fill posts wherethe vacancies mean that a team does not have internalinput from a particular care professional.

• The trust should ensure that all staff in all services fullyunderstand the Mental Capacity Act and code ofpractice.

• The trust should address with staff at the Harrowcommunity recovery team how they approach andsupport patients with a personality disorder.

• The trust should ensure that the areas used bypatients at Mead House (Hillingdon CRT) arerefurbished so that it is a pleasant environment forpatients to use.

• The trust should ensure that risk registers in Harrowand Hillingdon community recovery teams reflect allrisks. Risk registers should be detailed, thorough andrisk rated.

We issued the trust with 24 requirement notices thataffected these four core services.

These related to the following regulations under the Healthand Social Care Act (Regulated Activities) Regulations 2014:

Regulation 12 Safe care and treatment

Regulation 17 Good governance

Regulation 18 Staffing

How we carried out this inspectionTo fully understand the experience of people who useservices, we always ask the following five questions ofevery service and provider

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

Before visiting, we reviewed a range of information we holdabout Central and North West London Foundation NHSTrust and asked other organisations for information. Wealso attended a board meeting on 10th May 2017. We gavethe trust one week notice prior to visiting core services.

We carried out a series of short notice announced visits tocore services on the following dates:

Acute wards for people of working age and psychiatricintensive units – 3rd to 6th October 2016

Wards for older people with mental health problems – 30thJanuary 2017 to 2nd February 2017

Wards for patients with learning disabilities or autism –27th March 2017 to 29th March 2017

Community based mental health services for adults ofworking age – 8th May 2017 to 15th May 2017

We looked at information provided to us on site andrequested additional information from the trust bothimmediately before and following the inspection visitrelating to the services.

We also contacted Healthwatch groups and clinicalcommissioning groups to gather feedback on progressmade since the last CQC inspection.

We also carried out a ‘well led review’ on the 15 and 18 May2017 to look at any changes that had taken place in theleadership and governance of the trust since the previousinspection. This also involved receiving feedback fromexternal stakeholders.

During the five inspection visits, the inspection team:

• visited 20 inpatient wards for adults of working ageand PICU across six hospital locations

Summary of findings


• visited all six of the wards at the hospital sites forwards for older people with mental health problems

• visited two wards for people with learning disabilitiesor autism

• visited eight community mental health teams foradults of working age and one early InterventionService in Brent, Hillingdon, Harrow, Westminster andMilton Keynes

• held a focus group with service directors and boroughdirectors

• spoke with the managers for each of the teams andwards visited

• attended 5 bed management meetings• accompanied eight home visits to see patients in their

home settings• spoke with 285 staff members; including doctors,

nurses, occupational therapists, health care assistants,recovery and support workers, psychologists and peersupport workers

• spoke with 45 carers or relatives of patients• spoke with one continuing care lead for the local

clinical commissioning group covering Beatrice Placein the wards for older people with mental healthproblems

• attended patient handover meeting and multi -disciplinary meeting

• spoke with 169 patients receiving care or treatment inservices inspected

• reviewed 27 comment cards• reviewed the arrangements for managerial supervision

of staff• looked at a range of policies, procedures and other

documents relating to the running of the services andteams

• checked the arrangements for transporting medicinesand recording stock medicines in the communityteams.

• reviewed 224 patient care and treatment records• reviewed 209 prescription charts• attended seven handover meetings, 14 multi-

disciplinary team meetings, four zoning meetings, 5activity groups, one quality meeting, two patientcommunity meetings

• interviewed members of the senior executive teamincluding the chief executive, chief operating officerand director of nursing

• spoke with service directors and borough directors inthe trust in a focus group meeting

The inspection looked at four mental health core servicesand we did not inspect the community health servicesprovided by the trust.

Information about the providerCentral and North West London NHS Foundation Trust(CNWL) provides integrated health and social care servicesto a population of around three million people living in theSouth-East of England including London, Milton Keynesand Buckinghamshire. The trust has an annual income of£439 million, employs nearly 6500 staff who provide about300 services from more than100 locations. Sixty per cent ofthe trusts services are provided in the community, inpeople’s homes, clinics and schools. The trust also hasspecialist inpatient services for people needing intensivetreatment. Services are provided to children and youngpeople, adults of working age and to older people. CNWLwas formed in 2002, following the merger of three mentalhealth trusts. It became a foundation trust in 2007. Over theyears additional contracts were awarded to the trust so itnow provides mental health and community healthservices.

The mental health services provided by the trust arelocated mainly in the five London boroughs of Westminster,Kensington and Chelsea, Brent, Harrow and Hillingdon aswell as Milton Keynes. The community services provided bythe trust are located mainly in Camden, Hillingdon andMilton Keynes. Other services are provided outside theseareas.

In addition the trust also provides health services in 17prisons, young offenders institutions and immigrationremoval centres. These services were not inspected duringthis inspection but will be inspected jointly with HMI ofprisons.

The trust works in a complex commissioning environment,with services commissioned on a local and national level.The trust has 28 locations registered with CQC.CNWL locations have been inspected on 33 occasions at 18of the locations

Summary of findings


The current inspection focussed on areas of non-compliance identified In February 2015. The most recent

inspection took place between October 2016 and June2017.We have re-rated the four core services that have beenthe subject of this most recent re-inspection andcompleted a ‘well led review.’

What people who use the provider's services sayOverall, patients we spoke with during the inspection ofservices said that staff were kind, patient, compassionateand caring.

On the acute wards for adults of working and age and PICU,some patients said they did not always feel involved in theircare planning. Patients told us they felt safe on the wardand there were enough staff present in ward environments.

On the wards or people with learning disabilities, patientswe spoke with said that staff were respectful andprofessional. Patients spoke highly of the support theyreceived from the advocate in making decisions aroundtheir care and treatment. Carers said staff fully involvedthem in decision-making, care planning and dischargeplanning.

On the wards for older people with mental healthproblems, The feedback from patients to tell us, familymembers and carers we received was overwhelminglypositive. They described staff as kind, caring, helpful andsupportive.

Carers told us they were welcomed and supported on thewards and could attend carers meetings.

Patients and carers told us that they had been providedwith a range of leaflets and other information and hadgood access to the recovery college and employmentadvisors.

Good practice• The positive attitude of staff was very evident

throughout the inspection. This was reflected in theirpride in working for the trust and their service, and intheir commitment to provide the highest standards ofcare to people using the service.

• The trust had recently implemented a qualityimprovement project (The Shine Project) to improveassessment and monitoring of physical health ofpatients receiving care and treatment in services. Apatient held record and single physical and mentalhealth assessment form were being rolled out acrossthe trust as part of the physical health implementationstrategy. The Shine project has been used as a casestudy of national best practice.

• On Oak Tree ward the consultant psychiatrist held aweekly open surgery which relatives and patientscould attend with an appointment to discuss theircare.

• The trust implemented a peer support workerprogramme, employing full time staff who had a lived

experience of using mental health services. Peersupport workers were employed in the wards for olderpeople mental health problems and the acute wardsfor adults of working age and PICU.

• At Beatrice Place, the staff delivered a sensorystimulation group programme called Namaste. Thisevidence based programme focused on meeting thephysical and emotional needs pf patients throughmeaningful activity which in turn decreases distressand resulting behavioural problems.

• On the wards for people with learning disabilities orautism, staff developed and used personalisedcommunication tools for each patient such as the useof photographs to put together booklets to supportpatients with different aspects of their care such asplanning for discharge and intensive interaction.

• On the wards for people with learning disabilities orautism, patient-led care programme approach

Summary of findings


meetings took place where people were involved inchairing their care programme approach meetings,and supported with their preferred communicationmethod.

• On the wards for people with learning disabilities orautism patients going out into the community were

provided with an easy read crisis card which could becarried in their pocket. This provided essentialinformation about them and details of people thatcould be contacted in the event of a crisis.

• The provider used the peer network through the RoyalCollege of Psychiatrists’ quality network for InpatientLearning Disability Services to drive improvements.Preston ward met 100 percent of the standards in theirannual peer review in February 2017.

Areas for improvementAction the provider MUST take to improve

Action the trust MUST take to improve the acutewards for adults of working age

• The trust must ensure that physical observationsfollowing rapid tranquilisation are consistently carriedout and recorded.

• The trust must take further action to reduce thenumber of incidents of prone restraint and the use ofrestraint across the service and also reduce thevariations in the use of restraint between different trustlocations

• The trust must ensure that risks to patients areidentified and the risk management plans mustcontain sufficient information on the risk and how therisks are managed. These risk management plansmust be easily accessible for staff.

• The trust must ensure that all records of physicalrestraint of patients comply with the policies andprocedures of the provider.

Action the trust MUST take to improve the wards forolder people with mental health problems

• The trust must ensure that all staff on wards for olderpeople with mental health problems have anunderstanding of the trust policy on reportingincidents and reporting restraint so that incidents arerecorded and the trust can monitor the levels ofrestraint to have an understanding of the quality ofcare.

Action the trust MUST take to improve communitybased mental health services for adults of workingage

• The trust must ensure that staff working in the MiltonKeynes CMHT have access to an appropriate alarmsystem.

• The trust must ensure that risk assessments arecomprehensively completed and reviewed.

• The trust must ensure that all non-clinical staffundertake basic life support training and all staffundertake fire safety mandatory training to enablethem to fulfil the requirements of their role.

• The trust must ensure that each patient has a careplan which is person-centred and that needs identifiedin the care plan are met or there is a clear indication ofwhy they cannot be met.

• The trust must ensure that patients in the service haveaccess to psychological therapies in line with bestpractice guidance.

• The trust must ensure that care co-ordinators regularlycontact patients on their caseloads.

Action the provider MUST take to improve the longstay / rehabilitation mental health wards for workingage adults which have not yet been re-inspected

• The trust must ensure in all the rehabilitation servicesthat information is available to inform patients how tomake a complaint. They must ensure verbalcomplaints are addressed and if needed have accessto the formal complaints process and that learningalso includes verbal as well as written complaints.

Action the provider MUST take to improve mentalhealth crisis services and health based places of safetywhich have not yet been re-inspected

Summary of findings


• The trust must ensure that when a person is assessedas requiring an inpatient bed that they are able toaccess a bed promptly.

• The trust must ensure that the access to the trust’splaces of safety promotes the patients’ dignity andprivacy by the provision of a separate entrance.

• The trust must ensure people’s private conversationscannot be overheard in adjoining interview rooms atSt Charles hospital.

Action the provider SHOULD take to improve

Action the trust SHOULD take to improve the acutewards for adults of working age

• The trust should ensure that ‘blanket’ restrictions arereviewed regularly on the acute wards to ensure wherepossible that patients had access to quiet rooms,outside spaces, snacks and hot drinks.

• The trust should collate information on the numbersof patients on the acute and PICU wards whereplanned escorted leave is postponed.

• The trust should ensure that information on incidentsand learning from incidents across the PICU wards isshared with all the hospital sites, so that thisinformation can be used to improve all the wards. Thetrust should ensure that the records of team meetingminutes on the PICU wards reflect the discussionsregarding incidents.

• The trust should ensure that staff complete theplanned mandatory training on fire safety andintermediate life support.

• The trust should ensure that patients are fully involvedin the planning of their care and that care plans arerecovery focused.

• The trust should ensure that where wards supportpatients who have a learning disability or autism thatstaff have received training on how to meet theirneeds.

• The trust should ensure that MEWS records aremonitored and appropriate action taken in responseto changes in patient’s physical health.

• The trust should ensure that handover information iscommunicated to the health care assistants working atthe Campbell Centre.

• The trust should ensure that staff treat patients withappropriate levels of dignity and respect, includingwhen staff wish to enter patients’ rooms.

• The trust should ensure that ward information leafletson Caspian ward provide accurate information aboutany restrictions that are in place.

• The trust should continue to monitor and reduce thenumber of patients waiting more than four hours foran inpatient bed especially out of hours.

• The trust should continue to monitor and ensure thatdischarges from acute and PICU services are plannedand the length of time for any delays for discharge isreduced.

• The trust should ensure that feedback provided bypatients is responded to in a timely manner.

• The trust should ensure that food provision meetspatients’ individual cultural, religious and dietaryneeds.

• The trust should ensure that all facilities meet theneeds of patients, including the provision of faithrooms and appropriately furnished and decoratedlounge areas.

• The trust should ensure that there are sufficientactivities available for patients to participate in atweekends to appropriately support their recovery.

• The trust should ensure that systems to records verbalcomplaints and any responses are implemented.

• The trust should ensure that the modified earlywarning score system is used to monitor the physicalhealth of patients in the acute services

Action the trust SHOULD take to improve the wardsfor older people with mental health problems

• The trust should ensure that the ligature riskassessment on TOPAS ward includes details of theligature points in the garden and the steps taken tomitigate these risks.

• The trust should ensure that an overall environmentalrisk assessment is completed on Redwood andKershaw wards.

• The trust should ensure that arrangements are inplace to share learning from incidents across all thewards to inform and improve practice.

Summary of findings


• The trust should consider the impact of usingmedicines charts which do not specify times onpeople whose medicines require exact dose timings orintervals and act accordingly.

• The trust should ensure that there is adequate staffingto enable staff members to take breaks withoutdisrupting the delivery of care and that patients haveregular one to one time with a staff member.

• The trust should continue to ensure that supervision isprovided regularly for staff in line with trust policy andthat the system for recording and monitoringsupervision is embedded across the service.

• The trust should ensure on TOPAS ward that there is asign on the door stating that informal patients canleave the ward.

• The trust should ensure that patients on Redwoodward and at Beatrice place have timely access topsychology input.

• The trust should ensure that care plan audits have anaction plan with timescales in place when shortfallsare identified.

• The trust should ensure that capacity assessments arecompleted fully and include details of the decision andthe discussion with patients to assess the level ofcapacity to make a specific decision.

• The trust should ensure that all relevant staff have anunderstanding of the deprivation of liberty safeguardsand ensure that the correct legal status of patients isreliably recorded in patient’s records.

• The trust should ensure that the ward environmentsare adapted to meet the needs of patients withdementia and cognitive impairment.

• The trust should ensure that care plans, menu andother information is provided in easy read andpictorial formats to support people with dementia andcognitive impairment.

• The trust should ensure that informal complaints arelogged and that a system is implemented to ensurethat relatives receive an update or feedback frominformal concerns or complaints raised.

Action the trust SHOULD take to improve the wardsfor people with learning disabilities:

• The trust should ensure that timescales are includedin the risk register for the replacement of woodenbeds.

• The trust should review how it records and monitors itstraining requirements relating to the Mental Health Act

Action the trust SHOULD take to improve communitybased mental health services for adults of workingage

• The trust should continue to ensure that lone workingpractices in the North Kensington and Chelsea andMilton Keynes CMHTs are followed.

• The trust should continue to focus recruitmentstrategies in the areas where there are the highestneed of permanent staff particularly for nurses andsocial workers to work towards a more stable staffteams especially in Brent and Hillingdon.

• The trust should support patients to have crisis plansand contact details that reflect their individual needs.

• The trust should ensure that safeguarding referrals inthe Milton Keynes CMHT are tracked so that progressof alerts, investigations and outcomes are known.

• The trust should ensure that locum staff and newpermanent staff, especially in Brent have promptaccess to essential patient record systems to performtheir roles.

• The trust should ensure that patient rights areexplained consistently when patients are on a CTO inaccordance with the MHA Code of Practice.

• The trust should ensure that privacy issues identifiedin the reception area at the East and West HarrowCMHTs are addressed.

• The trust should ensure that patient involvement isclearly recorded in the care records and each patientprovided with a copy of their care plan.

• The trust should continue to work at reducing theaverage referral to assessment time.

• The trust should ensure that all audits have an actionplans to address any shortfalls identified.

• The trust should ensure that agreements are in placewith local GPs in Brent so that patient discharges arenot delayed.

Summary of findings


• The trust should continue to ensure that patientswaiting for an assessment or their first appointmentare engaged with and monitored to support their riskmanagement.

• The trust should ensure that casework discussions aredetailed in staff supervision records.

Action the trust SHOULD take to improve the long stay/ rehabilitation mental health wards for working ageadults which have not been re-inspected

• The trust should ensure that maintenance issues areaddressed across the London services in a timelymanner.

• The trust should review the layout of Fairlight andColham Green to try and achieve the greatest level ofgender separation to promote people’s safety anddignity.

• The trust should keep blanket restrictions underreview such as levels of observation, access to hotdrinks and the impact of the front door at ColhamGreen being opened only by an electronic lockcontrolled from within the staff office to ensure theleast restrictive measures are in place that reflectpeoples’ individual needs.

• The trust should ensure that staff at Fairlight hadconsistent access to information necessary to providesupport and care for people through the electronicpatient record system.

• The London services should ensure that staff have anunderstanding of the role of independent mentalhealth advocates and general advocates within theservices so that patients can be supported to accessthe most appropriate service.

• The trust should ensure that where investigations areneeded as part of incident enquiries that these takeplace in a timely manner especially where staff aresuspended.

• The trust should look at the arrangements for patientsto have or replace keys for their rooms to ensure theycould lock their rooms without having to rely on staffdoing this for them.

• The trust should support staff to have an improvedknowledge of incidents across the trust from otherdivisions so the learning can be put into practice.

Action the provider SHOULD take to improve mentalhealth crisis services and health based places of safetywhich have not been re-inspected

• The trust should ensure the building work to make theGordon Hospital places of safety is completed.

• The trust should ensure people’s risk assessments areupdated on the trust’s electronic records system toaccurately reflect their changing risk.

• The trust should review arrangements for lone workingto ensure that all teams have robust systems in place.

• The trust should ensure that where appropriate, staffrecord when they have assessed a person’s capacity tomake a decision within the written records.

• The trust should ensure that teams consider ways tocollect regular feedback from people who have usedtheir services.

Summary of findings


Mental Health Actresponsibilities• The trust had clear structures and procedures for

monitoring the administration of the Mental Health Actadministration. Policies were reviewed and a range ofsub groups monitor the day to day functioning of MentalHealth Act activity.

• Despite the large size of the trust, the mental health lawteam were able to visit inpatient sites and also spendtime in community settings. The director of nursing isthe executive lead for mental health law and overseesthe work of the mental health law team.

• A yearly Mental Health Act performance report waspresented to the board by the mental health law group.This included an analysis of trends over the past year,but also recorded incidents of unlawful detentions,unlawful treatment, and problems with MHAassessments.

• Detention paperwork was generally filled in correctly,was up to date and was stored appropriately.

• There was a good adherence to consent to treatmentand capacity requirements and copies of consent totreatment forms were mostly attached to medicationcharts where applicable.

• Within all of the wards and teams visited we found thatpeople had access to Independent Mental Health

Advocacy (IMHA) services and information on IMHAservices was provided to patients. Patients and staffappeared clear on how to access IMHA servicesappropriately.

Mental Capacity Act andDeprivation of LibertySafeguards• The trust provided a statutory mental health law

training course all staff working in clinical settings. Thisincluded training on the Mental Capacity Act (MCA) andDeprivation of Liberty Safeguards.

• The trust had an up to date policy on the MentalCapacity Act and Deprivation of Liberty Safeguards(DoLS).

• There was a trust wide MCA lead and also leads indifferent services to support staff as needed.

• Adherence to the MCA was monitored through theMental Health Law group which provided a governanceprocess. This looked at the results of audits andconsidered new methodology as needed.

• The administration of Deprivation of Liberty Safeguardsunder the Mental Capacity Act was managed by thesafeguarding and Mental Capacity Act leads, whoreported to the head of social work and social care.

CentrCentralal andand NorthNorth WestWestLLondonondon NHSNHS FFoundationoundationTTrustrustDetailed findings


• Staff working in the wards for people with learningdisabilities or autism displayed an excellentunderstanding of the Mental Capacity Act. During the

inspection we consistently observed examples of staffunderstanding the needs for gaining consent andsupporting patients to make their own decision wherepossible.

Detailed findings


By safe, we mean that people are protected from abuse* and avoidable harm

* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatoryabuse

Summary of findingsWe rated safe as requires improvement because:

• In February 2015, we rated two of the sixteen coreservices as requires improvement and one coreservice as inadequate. This led us to rate the trust asrequires improvement overall for this key question.At this inspection three of the core service remainedrequires improvement for safe.

• In February 2015, we identified that staff were notcompleting physical health observations followingadministration of rapid tranquilisation medication onthe acute wards for adults of working age andpsychiatric intensive care units. At this inspection wefound some improvements had been made thoughgaps and inconsistencies remained.

• The number of incidents of restraint taking placeacross the acute wards for adults of working age andPICU was significant and there were variation in thelevels of restraint across hospital sites. In addition,despite the training in restraint being updated about70% of the restraints were still in the prone position.

• Incident records of physical restraint on acute wardsfor adults of working age and wards for older peoplewith mental health problems were not completedfully.

• Risk assessments for patients in the acute wards foradults of working age and PICU and communitybased mental health services for adults of workingage were not always completed thoroughly to reflectcurrent risks.

• Whilst staffing levels had improved, there were stillareas of high staff turnover and this was impactingon the consistency of patient care especially incommunity based mental health services for adultsof working age.

• Milton Keynes CMHT did not have arrangements tosupport staff and patient safety such as access toalarms for staff to call for assistance if needed.

• Mandatory basic life support and fire trainingcompletion rates were low in some communitymental health teams.

However:

• At this inspection we have changed the rating foracute ward for adults of working age and PICU, frominadequate to requires improvement. This is becausethe service had addressed the problems with staffinglevels, training for staff on safe restraint, seclusionrecording and risk management of blind spots andligature points on wards.

• Across the services inspected there were sufficientnumbers of staff to deliver care. A programme of staffrecruitment and retention was being implemented inthe trust to work towards reducing staffing vacanciesacross services.

• The trust had made improvements to the safety ofthe wards for older people with mental healthproblems including ensuring gender segregation ontook place, emergency resuscitation equipment wassafely accessible, medicines were securely storedand staff were able to monitor and tracksafeguarding referrals.

• The trust had made improvements to the safety ofthe community based mental health services foradults of working age. These included ensuring thatdefibrillators and resuscitation equipment werechecked and serviced across the community mentalhealth teams.

• Patients received care in clean and hygienicenvironments

Our findings• The environments were clean and well maintained

across the core services inspected. The services weinspected adhered to infection control procedures andmeasures were in place to minimise the spread ofinfection.

Are services safe?



• Across the environments used by community mentalhealth services for adults of working age there wereappropriate access arrangements with intercomsoperated by reception staff to keep the clinic areas safefor patients and staff.

• In February 2015, we identified that where automatedexternal defibrillators (AED’s) where provided, that theywere not always correctly maintained and checked. Thiswas a particular concern at the Pembroke Centre at theHillingdon community recovery team. At this inspectionwe found this had improved. All of the teams had anautomated external defibrillator which was servicedregularly.

• In February 2015, we recommended the trust shouldensure that maintenance issues at Park Royal MHC inthe acute wards for adults of working age were resolvedin a timely manner. At this inspection we found this hadimproved and response to maintenance issues wasprompt.

• In February 2015, we identified that there were anumber of blind spots in the wards in the acute wardsfor adults of working age. At St Charles Mental HealthCentre, Park Royal Mental Health Centre and the GordonHospital the wards did not have a clear line of sight tosafely observe patients. At this inspection we found thatimprovements had been made in this area. The trusthad improved the physical environments of the wards.Risks to patients and staff had been mitigated by theuse of mirrors, staff observations and individual riskmanagement of high risk patients. Some wards also hadCCTV installed in communal areas.

• In February 2015, we found that although numerousligature risks had been identified. On the acute wards foradults of working age and wards for older people withmental health problems staff were not able to articulatethe measures being taken to manage these risks for thepatients using the service. At this inspection, we foundthat improvements had been made. The trust hadimplemented a ligature competency assessment, whichstaff completed annually. This provided annual updatesfor staff on the awareness and management of ligaturerisks. This competency assessment was also completedby bank and agency staff, ensuring consistency oftraining across all staff groups.

• In addition, the trust had carried out extensive work toreduce the number of ligature points on the wards. OnPond and Shore wards maps indicating the position ofpotential risks were placed in the staff office to remindstaff of their location, including temporary staff whowere less familiar with the environment. Work to reducethe presence of ligature risks within the wards for olderpeople with mental health problems had also beenundertaken since the last inspection.

• In February 2015, we recommended the trust improvethe environment on the wards for older people withmental health problems. In particular the chairs whichwere split and broken should be repaired or replaced,and enough chairs should be available so people caneat together. At this inspection we found this hadimproved and the furnishings had been replaced andwere suitable for use. In addition the seatingarrangements allowed patients to eat together.

• The wards for people with learning disabilities or autismwere clean, well-furnished and welcoming. The trustwas completing a programme of renovation of thewards. The ward risk register had identified two woodenbeds which required replacing. However there was notimescale or action plan for this work to be completed.This identified risk was not being sufficiently mitigatedwith a plan for replacement furniture.

• Environmental risk assessments were not completedfully on some of the wards for older people with mentalhealth problems. On Redwood and Kershaw wardsdespite mirrors being installed some blind spotsremained on the ward. In addition on Kershaw wardrisks associated with bin liners had not been identifiedon environmental audits. On TOPAS ward, the riskassessment of the garden was insufficient. It statedthere were various ligature points identified butcontained no subsequent actions. There was no overallenvironmental risk assessment for TOPAS

• In February 2015, we identified on the wards for olderpeople with mental health problems that Oak Tree andTOPAS wards did not comply with the guidance on samesex accommodation. At this inspection we found thatimprovements had been made. At Oak Tree ward therewas gender separation for five single bedrooms. OnTOPAS ward, we found that, as far as possible, men andwomen had bedrooms on separate corridors. Also atBeatrice Place the trust was managing admissions to

Are services safe?



the unit to ensure that male and female patients wereseparated. At Beatrice Place male patients wereaccommodated on the ground floor and female patientsaccommodated on the first floor.

• Personal alarm systems and nurse call alarm systemswere accessible across most of the core services whichwere re inspected. However in the community basedmental health services for adults of working age, MiltonKeynes CMHT did not have a personal alarm system forstaff to use. There were no fixed wall alarm system inrooms which patients would meet with staff. This poseda risk to the safety of staff and patients, who would findit hard to call for help in an emergency.

Safe Staffing

• The trust continued to face ongoing challenges in therecruitment and retention of staff. The trust had anactive recruitment and retention strategy. This includedimproving how it attracted potential staff throughtargeted recruitment schemes. Ideas being put intopractice were working with the universities to attractnursing students, engaging with local communities toattract staff and national & international recruitment.The trust was also introducing financial assistanceincluding ‘golden hellos’ and help for staff who wererelocating. The trust also attracted staff through offeringopportunities for learning and development. Forexample nurses were being offered the opportunity torotate between different roles to develop theirexperience and there were 175 nurses on thisprogramme. They were also supporting non-qualifiedstaff to develop skills and competencies to assumeexpand and diversify roles in care delivery withinservices.

• The services used bank and agency staff to cover vacantposts. Where temporary staff were used, the trust triedto use regular staff who had received an induction tomaintain the consistency of care as much as possible.

• In February 2015, we identified that staffing levels on theacute wards for adults of working age needed to beadjusted to reflect the actual numbers of patients on thewards including patients spending the day on the ward,even if they were sleeping elsewhere overnight. At thisinspection we found that improvements had beenmade. Ward managers planned and reviewed thestaffing skill mix to ensure patients received safe care

and treatment. Each ward had a minimum of qualifiedand unqualified staff on duty. Staffing was determinedby the number of patients on the ward and theirassessed needs.

• In February 2015, we identified male staff were reluctantto interact with female patients on Pond ward, an acuteward, following a safeguarding investigation. InFebruary 2015, we recommended further supportshould be provided to staff to enable patients toapproach any member of staff for support. At thisinspection we found this had improved and staff werereceiving support when working in challengingsituations.

• In February 2015, we recommended that the trustshould monitor the impact of bed managementpressures on the cancellation of patient leave. At thisinspection we found this had partially improved. On theacute wards for adults of working age there wereenough staff to facilitate planned leave from the ward.Staff prioritised patient leave and if leave was cancelledit was recorded as an incident. However on the PICUwards we received feedback from patients and staff thatscheduled leave was often cancelled or postponed dueto staffing shortages. However on these wards data wasnot collated on the number of occasions this occurred.Further work was needed to monitor any cancellation ofplanned leave to support the identification of whereimprovements were needed.

• Across the wards for older people with mental healthproblems we identified ward managers could sourceadditional staff if there was an increase in patient needsor for increased levels of observations. However, thestaff we spoke to on the inspection told us that whenthe ward required additional staff it was often due tohigh levels of need and patient risk. When working inthese situations staff often did not have time to take abreak during their working hours. On Ellington ward staffreported that regular one to one session with patientsdid not happen as often as they would like due tostaffing pressures.

• In February 2015, we recommended in the wards forpeople with learning disabilities or autism that therecruitment of staff, both nursing and other alliedprofessions, should continue to be a priority for thetrust. At this inspection we found this had improved.

Are services safe?



The trust was ensuring sufficient numbers of staff werein post to deliver patient care in a way that was safe andeffective. There was an ongoing recruitment process tofill staff vacancies across the service.

• The trust had re-designed the community mental healthservices for adults of working age in March 2016. Staffingwas a challenge and there were high levels of vacanciesacross the service. At our inspection in February 2015 weidentified that there were insufficient staff available towork as care co-ordinators, which meant that dutyworkers in Harrow, Brent and Hillingdon CMHTs wereresponsible for supporting a significant number ofpatients. At this inspection we found that this was notthe case and duty workers did not have appointmentsor assessments with their regular patients when theywere on duty so that they could concentrate solely onurgent and duty enquiries.

• Staff in all the community mental health teams told usthat staff turnover was a particular challenge,particularly as some locum staff did not stay in the teamfor a long period, leading to increased disruption. Thissometimes impacted on care delivery. Some of thefeedback from staff in the Brent CMHTs includedconcerns for patients when there were a lot of changesin care co-ordinators. At the North and South BrentCMHTs we heard that this was impacting on theregularity of contact with patients. We asked the trust toprovide information about how many patients allocatedwithin the service had not had any contacts with theBrent CMHTs for over 4 months. In Brent, 19% ofpatients had had no contact with the team for over 4months and 62% of patients had their last contact withthe team between 1 and 3 months previously. A contactincluded visits for routine depot injections and medicalreview meetings as well as regular meetings with a carecoordinator. This meant that some patients had not hadregular contact with a care co-ordinator for a significantperiod of time. The Brent operational policy for adultcommunity mental health teams indicated that there isan expectation that all people being held either on CPAor with a lead professional, would be seen a minimumof once a month. This meant that for the majority ofpatients, this was not the case and people were at risk ofnot having their assessed needs met. Staff alsodescribed the difficulties of keeping records up to datedue to the volume of work.

• Across the acute wards for adults of working age andPICU the average completion rate for mandatorytraining was 85%. At this inspection we identified thattraining for intermediate life support (2 year training)was below 40% and inpatient fire safety training wasbelow 65%. These areas had been identified and werebeing monitored by the trust. Where staff had notattended mandatory training they had been booked forthe next available course. The trust operated anelectronic system to track and monitor trainingcompletion rates.

• In February 2015, we recommended that the wards forpeople with learning disabilities or autism should haveaccurate records of training so that people’s needs canbe identified and addressed. At this inspection we foundthis had improved. Staff were up to date with theirmandatory training. The overall compliance rate formandatory training for this core service was 97%

• Across the community based mental health services foradults of working age on the 1 May 2017, the mandatorytraining compliance was 89% against the trust target of95%. However we found that at North Kensington andChelsea, Hillingdon North and Harrow CMHT’s basic lifesupport training was below 75% which meant that therewas a risk that staff may be in situations where theyneed to provide immediate support and their trainingwould not be up to date.

Assessing and managing risks to patients and staff

• In February 2015, we identified that all staff requiredtraining in new restraint techniques to ensure that staffworking together on acute wards for adults of workingage and PICU were all trained in the same techniquesand in line with current best practice on the use ofprone restraint, to prevent injury to staff and patients. Atthis inspection we found that improvements had beenmade. Staff received training in restraint. The majority ofstaff on the wards had undertaken training in supinerestraint and de-escalation techniques with new staffbooked to undertake this. Staff we spoke with had agood understanding of the use of preventative strategiesand that physical intervention was a last resort.

• On the acute wards for adults of working age and PICUand the wards for older people with mental healthproblems there were inconsistencies in the recording ofphysical restraints. Physical restraint records were not

Are services safe?



always completed fully. This included information onthe numbers and identity of staff involved and thelength of restraint. Further work was required to ensurethat the recording of restraint was comprehensive, clear,detailed and reflected trust policy.

• The trust had introduced a restrictive practice workinggroup which continually reviewed the use of restrictionsand restraint across the trust. The trust recognised thatthere were significant variations in the use of restraintacross the trust and that there needed to be a particularfocus on the inpatient services with higher levels ofrestraint. The trust had set a target of reducing the useof prone restraint by 50% across all services by June2016. They had achieved a 30% reduction andrecognised there was more to do. A number of initiativeswere taking place including the ongoing updatedtraining, looking at alternative ways to administerinjected medication, ensuring debriefs took place afterthe use of restraint and reviewing the data on restraint.

• In February 2015, we identified that monitoring of vitalsigns was not always maintained until the patient wasalert following the use of rapid tranquilisation (RT) onthe wards for adults of working age and PICU. At thisinspection we found that some improvements had beenmade but there were still gaps in the recording of postRT physical observations. We identified inconsistenciesin completion and recording of physical healthmonitoring following rapid tranquilisation at St Charlesmental health centre and the Campbell Centre. Thismeant that the monitoring of physical healthobservations post rapid tranquilisation was still notsafely and consistently carried out across this service.This was a continuing breach of regulation.

• Between March 2016 and 27 September 2016, therewere 174 incidents of the use of seclusion across theacute ward for adults of working age. The highest use ofseclusion was on Pond, Pine and Shore wards at ParkRoyal MHC.

• In February 2015, we recommended in the acute wardsfor adults of working age, the trust should ensure thatpatients were not confined to bedrooms and thatseclusion was used in accordance with the code ofpractice: Mental Health Act 1983. At this inspection wefound this had improved. Staff were appropriatelyidentifying the seclusion of patients

• In February 2015, we identified on the acute wards foradults of working age and PICU that the monitoring andreviewing of secluded patients was not always takingplace. At this inspection we found this had improved.We reviewed seclusion records and found that overallstaff had appropriately monitored and reviewed thecare of secluded patients. Staff kept seclusion records ina secure and appropriate way.

• Between 27 March 2016 and 27 September 2016, therewere 2 incidents of the use of long-term segregationacross the acute wards for adults of working age. Thesewere both on Pond ward. Staff had completed thenecessary safeguards and checks during periods of longterm segregation.

• In February 2015, we identified a number of detainedpatients were absconding from acute wards for adult ofworking age and PICU. At this inspection we found thishad improved significantly and the number of patientsabsconding from the acute wards for adults of workingage and PICU had reduced. The trust had implementedmeasures to address this risk. For example, wards hadsigns reminding all people leaving the wards to lookbehind them before opening the door to the ward and,having passed through it to wait for it to sound closedproperly before moving away. At St Charles MHC, thetrust had implemented a lock down mechanism thatthat could be activated by ward staff. This enabled themain entrance doors to the unit to be locked down.Further work had been identified at the Riverside MHCas there had been an increase in the number of patientsleaving the wards without leave prior to this inspection.The trust was continuing to review and implementmeasures to minimise the absconding of patients fromthe acute inpatient wards.

• At this inspection we identified some use of blanketrestrictions on the acute wards for adults of working ageand PICU. The kitchen area at the Campbell Centre waslocked between midnight and 6am as potential ligaturerisks had been identified. This had the consequencethat patients were unable to make hot drinks duringthese times. Also on Caspian ward information leafletsprovided to patients about restricted items wereinaccurate and gave patient the wrong impressionabout which personal items were restricted.

• At this inspection personal alarm systems for staff to usewere in place across the core services inspected.

Are services safe?



However, in the community based mental healthservices for adults of working age, lone workingprotocols were not being robustly implemented. NorthKensington and Chelsea CMHT was not monitoring thedaily movements of staff conducting home visits. MiltonKeynes CMHT did not have a lone working protocol, andthere was no robust system to monitor staff movementsand provide any safeguard. Following the inspectionprompt actions were put in place ensuring the dutyteam monitored the movements and activities of staffon a daily basis. Further work was needed to improvethis area of safety in community based mental healthservices.

• At this inspection we looked at the availability andcontent of patient risk assessment across the fourservices inspected. There was variation in the quality ofrisk assessments across the services inspected. Forexample on the acute wards for adults of working agewe found occasions where risk management plans werevague and lacked important guidance following riskassessments.

• In February 2015, we identified the trust must ensure allpatient risk assessment in Harrow community recoveryteam were comprehensive, detailed and thorough. Inaddition they should be reviewed regularly. At thisinspection we found this had improved. However, inNorth Kensington and & Chelsea and Brent CMHTsfurther improvements were needed.

• In February 2015, we recommended risk assessmentsshould be updated following incidents on Redwoodward which is a ward for older people with mentalhealth problems. At this inspection we found that riskassessments were being updated regularly followingincidents across this core service risk was routinelydiscussed and reviewed during multidisciplinary teammeetings. Risk assessment where multifactorialincluding health and social care needs of older people.

• The trust had systems in place to safeguard patientsfrom abuse. Across the four services which wereinspected, staff were aware of how to escalate andreport safeguarding concerns, and were aware of localprocess in the service areas to raise safeguarding alerts.However, staff at the Milton Keynes CMHT did not havearrangements in place to track the number ofsafeguarding concerns raised with the local authority,the progress of alerts, investigations and outcomes.

• In February 2015, we found that staff at the TOPAScentre, in the wards for older people with mental healthproblems did not have access to a record ofsafeguarding alerts. At this inspection, we found thatimprovements had been made. The service hadintroduced a safeguarding log which clearly showed allthe incidents that had been reported, the progress ofany investigation and the outcome of completedinvestigations.

• The trust had robust pharmacy arrangements to ensureservice users were protected against the risksassociated with the inappropriate treatment ofmedicines. We found that care and treatment wasprovided in a safe way for service users and medicationwas stored safely.Medication incidents were reportedand the trust safe medication practice group produceda medication safety bulletin published quarterly withthe aim of increasing awareness and promoting learningfrom medicines incidents. The trust completed anannual safe handling of medicines audit across alllocations.

• In February 2015, we found on Redwood ward for olderpeople with mental health problems service, that themedicine trolley was left unlocked and medicines hadbeen left where a patient could have picked them up. Inaddition on Redwood ward drugs to be used foremergency resuscitation were not stored together. Atthis inspection, we found that improvements had beenmade.

• Across the trust approximately 770 community patientswere prescribed clozapine. Each CMHT had a localclozapine clinic run by a community mental healthnurse. At these clinics there was a point of care testingwhich meant there were instant blood test results sopatients did not have to return for a second time tocollect their medication. Appropriate arrangementswere in place for the dispensing and collection ofclozapine across these services. Each CMHT also ranlocal depot medicines clinics. Since January 2017 theuse of electronic prescriptions had been fullyimplemented for these clinics. Each prescription wasvalid for 6 months and was clinically checked by apharmacist.

• However at this inspection we identified the trustmedicines prescription charts used on the wards forolder people with mental health problem did not

Are services safe?



specify times for medicines administration. This meantthat there was a potential risk that a patient couldreceive medications too close together and not withinprescribed frequency of administration.

• In February 2015, we recommended that risk registers inHarrow and Hillingdon community recovery teamsshould reflect all risks. Risk registers should be detailed,thorough and risk rated. At this inspection we found thishad improved. Risks were recorded, scored and ratedaccording to severity, and there was evidence of somereview of risks. Overall, team managers were familiarwith the local risk areas for their teams and risks werereviewed and monitored at a local level.

Reporting incidents and learning from when things gowrong

• Staff were aware of how to report incidents using thetrust incident reporting system. We found there was apositive incident reporting culture across the trust. Anexample of this was in the learning disability serviceswhere there were a high number of incidents due to thechallenges presented by the patients and the staffunderstood the importance of reporting and learningfrom the incidents.

• Lessons learned from incidents were shared with staffand led to improvements in the care and treatmentprovided. The trust communicated information aboutserious incidents and learning from incidents throughvariety of mechanisms. Staff received updates throughteam meetings, email bulletins and notifications on thetrust intranet.

• In most areas staff were able to describe changes inevery day practice following learning from incidents.However, we also found that learning was not alwaysshared across similar services in different geographical

areas such as across the PICUs and some wards forolder people with mental health problems. We alsofound that for community mental health services, thatwhere a patient died in a care home or was receivingcare from other providers, the sharing of theinvestigation work and learning across providers did notalways work well. This meant that opportunities foridentifying improvements to services could be missed.

• Staff had the opportunity to debrief after incidents. Onthe wards for people with learning disabilities or autismstaff were supported with debriefing following incidents.These debrief sessions also included patients who weresupported with debriefing using pictorial aids and assistwith communication. This demonstrated a positive,reflective culture towards learning from incidents.

• Within the community services for adults of working agethe teams had recently started to use ‘feedbackhuddles’ which were dedicated communications andmemos to feedback about incidents within teams andacross the service.

Duty of Candour

• Staff working across the four core services understoodtheir responsibilities in relation to duty of candour.

• Overall, we identified staff were open and transparentwith service users when something went wrong. Forexample, at North Kensington and Chelsea CMHT a faceto face meeting was arranged with a patient following amedicine error so that staff could provide anexplanation and apology for what had gone wrong. Atthe East and West Harrow CMHTs we saw that staff hadapologised in writing to patients who had their careplans or letters to GPs inadvertently sent to otherpatients.

Are services safe?



By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.

Summary of findingsWe rated effective as good because:

• In February 2015, we rated two of the sixteen coreservices as requires improvement. This led us to ratethe core service as good overall for this key question.

• We have changed the rating for this key question forthe wards for older people with mental healthproblems from requires improvement to good. This isbecause In February 2015, we identified that physicalhealth checks were not routinely being completed. Atthis inspection we found this had improved and anearly warning score system was being used tosupport early identification of deterioration inphysical wellbeing.

• Patients had comprehensive mental and physicalhealth assessments in place.

• Patients with mental health needs were receivingimproved support with their physical health.

• Staff understanding and application of the MentalCapacity Act had shown improvement.

However:

• We have not changed the rating for this key questionfor community services for adults of working age.

• Care plans were not always reflect the patientsidentified needs in some of the community basedmental health services for adults of working age.

• Patients were often not able to access any orsufficient psychology input which meant theirtreatment was not in line with best practice. Whilstthe trust was working to introduce alternativearrangements for patients to access talkingtherapies, there was still more to do.

Our findingsAssessment of needs and planning of care

• At this inspection we identified that services assessedpatient needs comprehensively. Patients received a

prompt assessment of their physical and mental healthneeds upon referral to services. Assessments wereholistic and thorough, incorporating a wide range healthand social needs. Care plans were then developed andin most cases these reflected the needs of the individualand included input from the multi-disciplinary team.However in the community mental health teams foradults of working age further work was needed toensure care plans reflected the current needs of thepatients being supported.

• On the acute wards for adults of working age and PICUpatients had a physical health check upon admission tothe service and staff regularly reviewed their physicalhealth using the modified early warning system (MEWS).The majority of records we looked at showed that staffappropriately responded to the physical health needs ofpatients using this system. However the accuracy of thecompletion of the MEWS charts needed further work.

• In February 2015, we found that patients’ physicalhealth needs were not being monitored on Redwoodward in the wards for older people with mental healthproblems. During this inspection, improvements hadbeen made and patient’s health needs were beingmonitored. Regular physical health observations werecarried out and staff used national early warning scoresto support early identification in deterioration inphysical health and wellbeing.

• In February 2015, we identified that patients usingcommunity based mental health for adults of workingage must be referred for regular physical health checks.In the Harrow community recovery team some patientshad not been referred for a physical health check. At thisinspection, we looked at 24 care records and found thatall patients except one had received physical healthchecks in the previous year.

• In February 2015, we recommended the care planningprocess should be more individualised on the wards forpeople with learning disabilities or autism. Care plans

Are services effective?

Good –––


should be in a format that is meaningful to that person,there should be a strong recovery focus and the careplans should be put into practice for each person. At thisinspection we found this had improved significantly.

• In February 2015, we recommended on the acute wardsfor adults of working age that discharge planning beincorporated into patient care plans, so that care andtreatment is recovery focussed. At this inspection wefound this had improved and across this core service themajority of care plans reviewed demonstratedconsideration of discharge planning.

• In February 2015, we recommended the trust improvesthe new multi-disciplinary care planning system onacute wards for adults of working age and thepsychiatric intensive care units, to ensure that alldisciplines record directly onto this. At this inspectionstaff from a range of disciplines were now able to recordonto the electronic care records system.

• In February 2015, we recommended that the trustensures that care plan in the community based servicesfor adults of working age are more person centred whenpatients are being supported by a lead clinician. InFebruary 2015, we found that in Harrow communityrecovery team care plans for patients supported by alead clinician usually consisted of a letter for thepatients’ GP, some of which had technical language.During this inspection, we found that patientssupported by a lead clinician had a care plan in theircare records, which included patients’ social needs andindividual goals and were easy to understand. However,three care records reviewed at North Kensington &Chelsea CMHT did not have a care plan, and three othercare plans were brief and not person centred. For onepatient at the Brent South CMHT we identified their careplan had not been updated following an inpatientadmission and that the care co-ordinator had notactioned the recommendations made by theoccupational therapist. Two other care plans we lookedat did not indicate any information about patients’physical health care needs and two other care plans didnot have clear discharge plans to explain how peoplewould move on from the team. This meant that therewas a risk that patients’ needs would not be met. Also atthe North Kensington and Chelsea CMHT some patientsor carers who we spoke with did not have a copy of acare plan.

• In February 2015, we recommended that in communitybased mental health service for adults of working age;the trust should ensure that people using services havecrisis plans that reflect their individual circumstances.We specifically identified that some crisis plans in theHarrow community recovery team were not alwaysspecific to the patient or their needs. At this inspectionwe found that patients care records at the East and WestHarrow CMHTS contained crisis plans which were co-produced with patients and their families. However inother community teams some crisis plans were verygeneric and did not reflect people’s individualcircumstances or needs.

Best practice in treatment and care

• The trust had implemented a smoke free policy on allhospital grounds since October 2016. Across the fourcore services we inspected we saw that the trust wassupporting patients to reduce or stop smoking andnicotine replacement therapy was being offered topatients. The trust had delivered training to staff onsmoking cessation to improve the capability of theworkforce to implement this change.

• Across the four core service inspected staff routinelyparticipated in clinical audits. However, on Oak Treeward, in the wards for older people with mental healthproblems, care plan audits did not detail the timescaleor action required to address improvements which hadbeen identified. Within the community based mentalhealth services for adults of working age, local audits ofcare plans, did not have specific action plans to ensurethat issues identified were remedied by the team.

• The trust was working to improve the physical health ofpatients with mental health needs. There was a physicalhealth group to focus on this work. They were in theprocess of appointing a physical health nurse lead.There was a focus on training mental health nurses inphysical healthcare and they had started delivering atwo day training course for all the nurses. The trustrecognised that they had made good progress forpatients in inpatient services, but more was needed forpatients receiving community mental health services.

• Across the community based mental services for adultsof working age staff supported patients to engage withthe GP practice regularly. The trust had recently startedto implement the SHINE quality improvement


Good –––


programme across the teams. The SHINE programmeaimed to improve routine assessment and detection ofphysical health problems and lifestyle risks in peoplewith long-term mental health conditions. A physicalhealth and wellbeing group was also led by the peersupport worker at the North Kensington & ChelseaCMHT. This provided psychosocial support for patientsto make healthy lifestyle choices and improvedunderstanding and importance of healthy eating.

• On the wards for people with learning disabilities orautism there was a strong focus on health promotionand healthy living. Patients had a health action plan inline with best practice guidance. Hospital passportswere in place for patients on the wards for people withlearning disabilities or autism, providing essentialinformation for other healthcare professionals to ensureeffective care and treatment and personalised careplanning. For example if patients needed to attend theaccident and emergency department.

• Patients on the wards for people with learningdisabilities or autism received a high standard ofphysical health care. Dependant on the patient’sindividual needs, this included dental care, physicalobservations, weight reduction programmes, food andfluid monitoring, bowel monitoring. Staff regularlyreviewed their physical health using the modified earlywarning system (MEWS). All patients had a cardiachealth check. Physical health monitoring was inaccordance with NICE guidance for patients prescribedantipsychotics and mood stabilisers.

• Whilst the trust provided access to psychologicaltherapies in most areas the level was variable. InFebruary 2015, we recommended that psychologicaltherapies be available for patients supported by thecommunity mental health teams for working age adultsto reflect NICE guidance. At this inspection, we foundlittle improvement in this area. For example, at theMilton Keynes CMHT a psychologist was not employedand none of the patients registered with the servicewere receiving a service from the psychologicaltherapies team. Fifteen members of staff we spoke withacross Brent North and South CMHTs, mentionedspecifically how the low level of psychology provisionhad impacted on service delivery and also how manypatients were having to wait long periods beforereceiving this input. Some of the teams were addressing

the lack of one to one therapy. For example, thepsychologists and psychology assistants at HillingdonWest CMHT were developing a group that people on thewaiting list could attend whilst they waited for one toone treatment. In addition the team at NorthKensington & Chelsea CMHT were working with the localpsychotherapy department to provide group basedservices for group therapies to support patients andreduce waiting times. This was in response to concernsraised by patients on the waiting list.

• Access to psychology services varied across the wardsfor older people with mental health problems. Overallwe found that patients and carers could accesspsychological support. However, on Redwood ward thepsychologist post was vacant and this meant patientscould not be referred for psychology input. At BeatricePlace and there was no dedicated psychology post orresource on the ward. If staff needed to make a referralfor a psychology assessment they were able to make areferral to a psychologist in the trust who had anagreement to conduct assessments. This meant that allpatients did not have access to specialist input from apsychologist available in a timely manner.

• In February 2015, we recommended staff working atHarrow community recovery team, part of thecommunity based mental health services for adults ofworking age, should improve how they approach andsupport patients with a personality disorder. At tisinspection we found this had improved. Staff spokeabout patients respectfully and demonstrated a goodunderstanding when describing the needs of individualpatients. The trust had provided specialist training forstaff at East and West Harrow CMHT to support peoplewith a personality disorder. The team had developed afocus to supporting staff to work with patients with adiagnosis of borderline personality. This had led toimproved feedback about the approach of staff, formpatients using the service.

Skilled staff to deliver care

• Staff received appropriate training, supervision,appraisal and professional development including bankand agency staff. Supervision and appraisal recordswere maintained on each ward.

• Across the wards for older people with mental healthproblems staff were receiving regular supervision to


Good –––


support them in their roles. Overall staff told us they feltwell supported in their teams and wards. The exceptionto this was at Beatrice Place where staff were notreceiving supervision regularly.

• The trust recognised that they needed to train staff to beable to support people with a learning disability and asession was now provided on the trust induction.However in some areas staff did not feel sufficientlytrained to meet the needs of the patients. For exampleat the Riverside mental health centre patients wereadmitted with a diagnosis of a learning disability orautism as well as a mental health diagnosis. Howeverstaff working on the unit had not received training towork with patients with a learning disability or autism.

Multi-disciplinary and inter-agency team work

• Within the acute wards for adults of working age andPICU, the recently introduced bed managementmeetings had fostered interagency working acrossteams and services in the local borough areas. Teamsand agencies were meeting regularly to review anddiscuss patient care, admissions, discharges andtreatment

• Within the wards for people with learning disabilities orautism the multi-disciplinary team (MDT) meetings werewell staffed and patient focussed. We saw excellentexamples of supportive practice, where patients wereempowered to lead their MDT meeting.

• At the Campbell Centre healthcare assistants (HCA) werenot attending the daily MDT handover meeting. Inaddition there was no established system for HCAs tofeedback information to the MDT meeting. This limitedinvolvement of HCAs in MDT working meant importantinformation might not be communicated.

Adherence to the Mental Health Act and the MentalHealth Act Code of Practice

• The trust’s systems supported the appropriateimplementation of the Mental Health Act and its Code ofPractice. Administrative support and legal advice wasavailable from the Mental Health Act lead in acentralised team within the trust, as well as MentalHealth Act law managers and Mental Health Actadministrators based at each hospital site.

• Training on the Mental Health Act and code of practicewas non mandatory. Training was provided to staff

centrally and within local teams. Role specific trainingwas given where required. Overall staff appeared tohave a good understanding of the Mental Health Act andcode of practice.

• In February 2015, we recommended that Mental HealthAct documentation was completed correctly for patientson TOPAS and Redwood ward in the wards for olderpeople with mental health problems. This wasrecommended to ensure people were being supportedto understand their rights, their medication isauthorized and their leave is approved. At thisinspection, we found this had improved. We looked atdetention records on the wards that we visited. Acrossthe core service mental health act documentation wascompleted correctly and stored appropriately.

• In February 2015, we recommended in the acute wardsfor adults of working age and PICU, staff at the GordonHospital should ensure copies of consent to treatmentforms were attached to medication charts. At thisinspection we found this had improved and consent totreatment forms were attached to medication charts.

• Across the four core services we found that patientswere having their rights under the MHA explainedroutinely initially, and during the course of admissionand treatment. However, at Milton Keynes CMHT in thecommunity based mental health services for adults ofworking age one patient was not routinely having rightsexplained consistently when periods of CTO were beingrenewed, changes in treatment were being considered,or when there was a care programme approach review.

• At this inspection we identified that TOPAS ward whichis one of wards for people with mental health problemsdid not have a sign on the door indicating the rights ofinformal patients to leave the ward. This meant that therights of informal patients were not being upheld, byactively informing patient they can leave the ward if theywish or need.

• Patients had access to an independent mental healthadvocate (IMHA) to support them whilst they weredetained. Patients were provided information about theIndependent Mental Health Advocacy (IMHA) Service.This information was displayed on a notice boardsacross the services we inspected.

• In February 2015, we recommended that the wards forpeople with learning disabilities or autism should work


Good –––


with commissioners to make arrangements for areplacement independent mental health advocacyservices at the Kingswood Centre and staff should knowwho to contact when this service is needed. At thisinspection we found this had improved. There wasaccess to an independent mental health advocate andan independent mental capacity advocate to supportpatients. Patients told us they knew who their advocatewas. The advocate supported patients when attendingMental Health Act tribunal hearings.

• Staff carried out regular audits to ensure the MentalHealth Act was being implemented correctly. The trustproduced a quarterly Mental Health Act PerformanceReport. A bi-monthly Mental Health Law group met toreview Mental Health Act performance and trends andprovided a governance structure.

Good practice in applying the Mental Capacity Act

• The trust did not include training on the Mental CapacityAct (MCA) as part of mandatory training. Despite this wefound that staff received training on the MCA which hadbeen organised within the core services.

• In February 2015, we recommended that staff in allservices fully understand the Mental Capacity Act 2005(MCA) and code of practice within the community basedmental health series for adults of working age. At thisinspection improvements had been made. Staff had agood understanding of the Mental Capacity Act. Staffassessed patients’ capacity when there was a reason todo so and involved family members in making decisionswhere appropriate when patients lacked capacity.

• On the wards for people with learning disabilities orautism, training on the MCA was part of induction for allnew staff and was incorporated into the trustsafeguarding training. 100% of staff had completed thistraining. Staff demonstrated an excellent understandingof the Mental Capacity Act (MCA) and Deprivation ofLiberty Safeguards (DoLS). Supporting patients to makedecisions was embedded throughout the service.

• As at January 2017, the overall rate of MCA training onthe wards for older people with mental health problemswas 75%. TOPAS had the lowest completion rate at 43%followed by Ellington ward (67%) and Beatrice Place(72%). Redwood ward had the highest rate at 100%.

• Overall across the core services, staff the understood theprinciples of capacity assessments and the five statutoryprinciples of the MCA. However, on the wards for olderpeople with mental health problems some staff onTOPAS ward staff were not able to articulate thestatutory principles of the MCA. However there wasawareness of the need to provide care in the leastrestrictive manner and the requirement to assume thatpatients have capacity unless it is established that theydo not. At Beatrice Place which is a ward in the wards forolder people with mental health problems, capacityassessment were completed however they weresometimes brief.

• On the wards for people with disabilities or autism wefound positive examples of staff supporting patients indecision making where capacity was impaired. Theassessment of capacity was embedded in allintervention and decision relating to patient care. Wefound that patients were routinely involved in decisionmaking and where required, staff proactively supportedpatients to make decisions about care.

• Between 01 January and 31 December 2016, across thewards for older people with mental health problems, 75Deprivation of Liberty Safeguards (DoLS) applicationswere made and 39 (52%) of these were approved. Withinthis core service applications were being made whenrequired and staff were working to protect the rights ofpatients.

• Overall staff working the core services had a goodunderstanding of DOLs. However in the wards for olderpeople with mental health problems staff did not alwayshave a robust understanding of which patients had aDOLs in place. For example on Kershaw three membersof staff understood a patient to be placed on a DoLswhen they were not currently subject to a DoLs. Thismeant that there was a risk that staff responsible forproviding care, were not aware of the current legalstatus of every patient on the ward.

• In February 2015, we recommended the trust shouldensure where patients are subject to DOLS there was aprocess to ensure that the authorisation are reviewedand followed up. At this inspection we saw good use of‘tracker’ documents at Beatrice Place, TOPAS andEllington wards, which tracked each application, when itwas authorised and the renewal dates.


Good –––


• Staff we spoke to in the wards for older people withmental health problems told us there were often delaysin response to DOLS applications from local authorities.This was impacted by the high number of applicationsthat local authorities were required to process.

• The trust had recently begun to train best interestassessors within the trust. This initiative aimed toincrease the response and accessibility of DOLSassessments and support the waiting list time for DoLSassessments experienced by the local authorities.


Good –––


By caring, we mean that staff involve and treat people with compassion, kindness,dignity and respect.

Summary of findingsWe rated caring as outstanding because:

• In February 2015 we rated the trust as outstandingfor caring overall. Many of the services that werepreviously outstanding for caring at the lastinspection were not inspected this time but there isno new information to suggest those ratings havechanged.

• We have changed the rating for this key question forwards for older people with mental health problems,from requires improvement to good. This is becauseimprovements had been made to maintain theprivacy and dignity of patients, increase patientparticipation in care planning, and improve provisionof personal lockable space for patients.

• Patients were treated with kindness, compassion andrespect across the services we inspected.

• Patients and carers were supported to be involved incare decisions and also in the wider operation of thetrust.

• Patients and carers were encouraged to givefeedback about the services being delivered by thetrust.

However:

• On the acute wards for adults of working and PICUand community mental health services for adults ofworking age care plans did not always includepatient views and evidence of their involvement. Theformat and language used in care plans did notalways support patients’ involvement.

Our findingsKindness, dignity, respect and support

• In February 2015 we found many examples ofoutstanding care, especially in the community healthservices. These services were not visited at thisinspection.

• In February 2015, we identified that patients on thewards for older people with mental health problems didnot always have their dignity maintained. In particularwe observed that female patients attended mealtimesin their nightwear and with no dressing gown. At thisinspection we found patients were appropriatelydressed and their dignity maintained.

• In February 2015, we identified that night time checkswere intrusive and patients were unable to close theobservation panel from inside of their bedroom. At thisinspection we saw that observation panels were keptshut on patient bedroom door to maintain dignity.

• Across all of the services we inspected we observed thatpatients were cared for and treated with dignity, respectand compassion. The staff we spoke to across the trustwere enthusiastic, passionate and demonstrated a clearcommitment to their work. Care was delivered by hardworking, caring and compassionate staff.

Involvement of people in the care they receive

• We saw that patients were actively encouraged to givefeedback on the services they received through a rangeof options including meetings and surveys. Servicesthought about how this feedback could be bestfacilitated. In most cases this was leading toimprovements but in some areas further work wasneeded. In February 2015, on the acute wards for adultsof working age and PICU we recommended the trustshould promote any staff and patient feedbackprocesses so that all people have an opportunity to beinvolved in the trust. At this inspection, patients wereable to give feedback about the service they receivedthrough a range of options. Community meetings anddaily planning meetings provided a forum for patients tocontribute to the planning of activities and the day today running of the ward. However, some patients wespoke with told us that there were no responses tosome of the requests which had been raised. Forexample, requests for bath plugs and a remote controlfor the television had not been responded to after beingraised at three consecutive community meetings.

• We saw many examples of patients and carers beingactively involved in the planning, development and

Are services caring?

Outstanding –


reviewing of their care plans. However, more progresswas needed in some areas. In February 2015, werecommended staff should encourage all patients to beinvolved in planning their care and treatment on theacute wards for adults of working age. This involvementshould be clearly recorded. Across the acute wards foradults of working age, we observed that patients wereinvolved in care planning and care reviews. However atSt Charles mental health centre we identified that whilstpatients were involved in care planning, this was notalways documented in care plan records. At theCampbell Centre most patients we spoke with said theywere not involved in their care planning. Further workwas required within this service to improve this are ofcare delivery. In February 2015, on the wards for olderpeople with mental health problems we identifiedpatients were not involved in their care planning. Inaddition patients were not being provided with a copyof their care plan. At this inspection we found this hadimproved. Patients and relatives or carers were includedin assessment planning and reviewing of care. Patientswere provided with copies of their care plans.

• There were variations in the presentation and content ofthe care plans and their overall accessibility. In February2015, on the wards for learning disabilities or autism we

recommended that care plans should be in a format thewas meaningful to the person, there should be a strongrecovery focus and care plans should be put in practicefor each person. At this inspection we found that therehad been significant improvements in this area. Careplanning documentation clearly reflected the patient’svoice and involvement. The care plans revieweddemonstrated and individualised, holistic approach tocare planning with an emphasis on recovery. On someof the acute and PICU wards and the community mentalhealth services some care plans used terminology whichwas focussed on diagnosis and treatment and did notreflect the patient goals, views or wishes in line withrecovery orientated practice. Further work was requiredto ensure care planning was person centred. Also onwards for older people with mental health problemsstaff were explaining and discussing care plans verballywith patients, though further work could improve thecare plan presentation for patients with dementia or acognitive impairment.

• Patients across the trust had access to advocacyservices. A particular area of positive practice was theinvolvement of advocates in the ward rounds and MDTreviews on the wards for people with learningdisabilities or autism.

Are services caring?

Outstanding –


By responsive, we mean that services are organised so that they meet people’sneeds.

Summary of findingsWe rated responsive as good because:

• In February 2015, we rated three one of the sixteencore services as requires improvement and on coreservice as inadequate for this key question. This ledto an overall trust rating of requires improvement forthis key question.

• At this inspection we inspected the one core servicepreviously rated as inadequate and one the coreservices previously rated as requires improvement.

• We have changed the rating for this key question foracute wards for adults of working age and PICU frominadequate to good. This is because improvementshad been made to ensure patients had access to abed when needed and patients could return to a bedafter going on leave from hospital.

• We have changed the rating for this key question forwards for older people with mental health problemsfrom requires improvement to good. This is becauseimprovements had been made to the managementof clinically inappropriate admissions to the wards.

• In February 2015, we recommended that the areasused by patients at Hillingdon West CMHT (MeadHouse) be refurbished. At this inspection, we foundthis had improved and refurbishment had beencompleted.

However:

• Whilst there was clear information displayedthroughout the services visited to explain to patientsand carers how to make a complaint, informal verbalcomplaints were not being recorded and so it wasnot possible to ensure these had been addressed orto look at themes and areas for learning.

Our findingsAccess and discharge

• The trust had undertaken a large piece of work toensure access to an inpatient bed on the acute wards

for adults of working age. Bed management across theinpatient sites had improved considerably since the lastinspection and was closely monitored by the trust.Further work was needed to improve the timelines ofdischarges and to reduce the number of patientswaiting more than four hours once they had beenclinically assessed as needing an inpatient bed,especially at weekends.

• In February 2015, we identified there were significantpressures and challenges on the acute admissionpathway. In addition we identified that improvementswere required to ensure patients had a designated bedwhen they were admitted and when they returned fromleave. At this inspection there had been significantchange and improvements to manage this process.Patients were no longer sleeping on couches. The trusthad introduced weekly bed management meetingsacross all boroughs to ensure that admissions,discharges, and bed capacity was regularly reviewedand discussed. These meetings included staff fromacute admissions wards, community recovery teams,homeless services, and primary care liaison nursingteams and early intervention in psychosis teams. Theseregular meetings meant that the admission, treatmentand discharge of patients was monitored and wherepossible patients were discharged promptly to ensurebeds were available.

• The trust had introduced single point of access service(SPA) service. This operated a one-stop entry point intoadult secondary community based mental health forpatients living in the North West London boroughs ofBrent, Harrow, Hillingdon, Kensington & Chelsea, andWestminster. The service received and triaged crisisreferrals and assessments and supported identificationof early assessment and prompt admission to acuteinpatient wards if required. As part of a redesign ofservices, the SPA referred patients to the hometreatment teams for assessment and gatekeeping ofinpatient admissions.

• The trust was reviewing each incident where a patientwaited more than four hours from the point at whichthey were clinically assessed as needing an inpatientbed. There were 22 breaches in July, 14 breaches in

Are services responsive topeople’s needs?

Good –––


August and 35 breaches in September 2016 all for adultpatients. Just under half of these breaches were at theweekend. Where the breach was over 12 hours therewas a common theme about the time taken to place thepatient in the independent sector. The trust reviewedthe learning from each case but recognised there wasstill more work to do to improve prompt access to aninpatient bed.

• Between 1 March 2016 and 30 August 2016 there were atotal of 145 delayed discharges from the acute wards foradults of working age and PICU service. The ward withthe highest number of delayed discharges was VincentWard with 30, followed by the Campbell Centre with 24.The trust was working to improve the discharge ofpatients. Each inpatient centre had a discharge co-ordinator although how they performed this role variedbetween geographical areas. Throughout the inspectionthere were many examples of ward staff working closelywith other trust teams and external organisations tofacilitate the discharge of patients. For example, theRiverside MHC had a dedicated staff member within thehousing department to ensure prompt patient referralsfrom the wards

• The trust was focusing on patients who had longerlengths of stay of over 60 and 100 days and were makingprogress with some individual patients. This wasmonitored at the bed management meeting and therewas still more work to do improve delayed discharges.

• In February 2015, we identified on the acute wards foradults of working age and PICU that the trust must takesteps to reduce the number of times that patients aremoved to other wards to sleep for non-clinical reasons.In addition, where it is unavoidable, staff must ensurethat a thorough handover takes place to promotecontinuity of care. Patients must only be moved atreasonable times so that they are not adverselyaffected. At this inspection we found this had improvedand this was not taking place, patients were no longerbeing moved to other wards to access a bed.

• In February 2015, we identified on the acute wards foradults of working age and PICU, that the trust mustensure that contingency plans were in place for whenthe numbers of patients needing a bed increases abovethe beds available. At this inspection we found this hadimproved.

• Within the PICU wards beds were available to provideintensive care if needed. The occupancy levels on thePICU wards between 1 March 2016 and 30 August 2016was below 90% with the exception of Colne ward whereit was 92%.

• In February 2015, we identified on the wards for olderpeople with mental health problems that Redwoodward must not provide beds for working age adults whowere not clinically appropriate for a service for olderpeople. At this inspection we found this had improved.Patients were not being admitted onto the wards forolder people when they were not clinically appropriate.Improvements in the bed management of the acutewards for adults of working age and PICU had preventedinappropriate admissions to these wards.

• Across the community based mental health services foradults of working age, urgent referrals were discussed atthe daily zoning meetings. Doctors within the teamscould review urgent referrals. All the teams had a dutysystem to enable the team to respond to urgenttelephone enquiries from health professionals and dealwith emergency situations. The duty worker was alsoable to see patients quickly if required.

• The trust was not meeting the agreed target of 28 daysfor routine referrals to assessments, although this wasimproving. From November 2016 to April 2017 averageroutine referral to assessment waiting times was 31 daysacross all services. The average number of days wasfluctuating between months. At the end of April 2017 theaverage waiting time was 31 days which was a dropfrom March 2017 where the average was 37 days. Acrossthe eight services, North Hillingdon CMHT had thehighest average waiting time over the six months at 47whilst North Brent CMHT had the lowest average of 25days. Breaches to the trust targets were monitored byeach team and reported on at service and divisionallevel.

• Each team monitored the referral to assessment waitingtimes, where shortfalls were identified in meeting targettimes action plans were in place. For example, in theEast and West Harrow CMHTs there was a managementplan in place to address non-compliance with the targettime by reviewing the teams’ management referralprocess, training administration staff and telephoningnew referrals before their appointment to confirmattendance. In the Brent CMHTs there had been an in-


Good –––


depth review of the non-compliance with the CCGurgent pathway targets. Improvements had been madein the North Kensington and Chelsea CMHT in thetimeliness of assessments and 81.8% of routine referralswere seen within 28 days in April 2017, an increase from25% in January 2017.

The facilities promote recovery, comfort, dignity andconfidentiality

• In February 2015, we recommended the trust shouldprovide individual lockable space for patients to keeptheir possessions safe on the acute wards for adults ofworking age. At this inspection we found this hadimproved. Patients had access to lockable spaces tostore individual possessions safely.

• In February 2015, we recommended the trust shouldaddress the sound of the alarms at St Charles MHC inthe acute wards for adults of working age. At thisinspection we found this had improved and patientswere not being disturbed by alarms sounding across thewards.

• On the wards for older people with mental healthproblems the environments were clean, comfortableand welcoming. However the wards did not consistentlyprovide a dementia friendly environment to supportpatients with cognitive impairment. The trust hadidentified further work could be done to improve theenvironment on these wards. An action plan had beenput in place to make improvements .This includedchanges to facilitate orientating patients to time andplace, sensory stimulation and more pictorial promptsand signs

• In February 2015, we recommended the rooms used tomeet patients at Mead House (Hillingdon CRT) wererefurbished so that it was a pleasant environment forpatients to use. At this inspection we found this hadimproved and the environment was pleasant andwelcoming. Overall the environments across all thecommunity teams we inspected were pleasant,welcoming and well furnished.

• At this inspection, all of the community mental healthteams we visited were welcoming, clean environments.There were adequate rooms and space for patients tomeet with staff to maintain privacy and dignity.However, some patients reported that there weredignity and privacy concerns in the reception area of the

building which housed the East and West HarrowCMHTs. Patients said that other patients could hearthem when they discussed confidential matters with thereceptionists, because there was not enough spacebetween the desk and the seating area. The receptionarea was small and meant that other people couldeasily hear patient information.

• In February 2015, we identified that the privacy anddignity of patients was not always promoted for patientsin a shared rooms at the Campbell Centre due tomeasures to manage ligature risks. At this inspection wefound that improvements had been made. The trusthad made improvements to the environments in theshared rooms and replaced curtains with doors. Thisaddressed the privacy and dignity of patients.

• Overall the trust worked to meet the dietary needs ofpatients on the acute wards for adults of working andPICU. However, patient feedback on the quality of foodwas mixed. Patients had access to a variety of menuoptions. Some patients we spoke with at Northwick ParkMHC said that the food provided did not meet theircultural and religious needs and at St Charles MHCsome patients commented the food was of poor quality.

• On the wards for older people with mental healthproblems patients were not effectively supported withinformation to make decisions about food choicesduring meal times On Redwood, Kershaw wards andBeatrice Place menus were available in small print only.Pictorial menu descriptions or easy read explanationswhich could help people with cognitive impairments tounderstand what was available were not provided.

• On the acute wards for adults of working age and PICU aprogramme of therapeutic activities was available forpatients to engage in throughout the week. Overallpatients spoke positively about the activities provided.However, the majority of patients we spoke with saidthere were few or no activities taking place at theweekends. Some action had taken place to provideactivities throughout the week. However further workwas required to improve access to activities atweekends for patients on the wards.

• In February 2015, we recommended the trust shouldensure that scheduled activities take place for patientsas planned. At this inspection we found this hadimproved. The service provided an extensive


Good –––


programme of activities which met the individual needsand preferences of patients. Each patient had anindividual activity schedule which involved one to oneand group activities within the service and in thecommunity. The activities programmes were personcentred, and took place regularly.

• On the wards for older people with mental healthproblems patients could access a range of activities andgroups to support their care and recovery. Theseincluded drama therapy, art therapy, exercise, cooking,music and reading groups on the ward. Activity co-coordinators and occupational therapy staff providedactivities. At Beatrice Place, we saw that patientsparticipated in a sensory stimulation group using musictherapy. TOPAS ward employed occupational therapiststo work at weekends. Weekend activities were alsoprovided for patients.

• On the wards for people with learning disabilities orautism patient extensive programme of activities whichmet the individual needs and preferences of patients.Each patient had an individual activity schedule whichinvolved one to one and group activities within theservice and in the community. Patients spoke positivelyof the activities that they took part in such as thecommunity leisure group, reading and writing groupand the social drop in group.

Meeting the needs of all people who use the service

• On the acute wards for adults of working age and PICUpatient’s religious and spiritual needs were supported.Local faith representatives visited the service or staffsupported patients to attend places of worship in thecommunity where appropriate. However, the faith roomat Park Royal MHC was bare and contained no materialssuch as religious or spiritual texts to support patients’spiritual needs.

• In February 2015, we recommended the wards forpeople with learning disabilities or autism shouldensure that patient should receive the support theyneed to practice their faith if they wish to do so. At thisinspection we found this had improved. Staff supportedpatients to practice their faith and requested faithleaders to meet with patients when required. Theservice had a multi-faith room and staff supportedpatients to meet their religious and cultural needs.

• In the community based mental health services foradults of working age staff were aware of communitygroups who could offer support to patients from diversebackgrounds. In the North Kensington and ChelseaCMHT we saw that staff referred BME patients to aspecific BME resource service at a local charity. In theBrent Early Intervention Service care records detailedthat written communication to a patient had beentranslated into their own language.

• On the wards for older people with mental healthproblems we saw positive practice at Beatrice Placewith staff proactively supporting patients from differentcultural and religious backgrounds. This included usingphrases and greetings in the person’s language. Thesewere developed in care plan with the support ofpatient’s relatives. Also the unit went the extra mile tosupport patients religious and faith needs.

• Across the services inspected we found that teams hadaccess to patient information leaflets in a wide range oflanguages. These could be printed off from the trustintranet.

• The trust had an excellent range of medicineinformation available to patients. There was acomprehensive range of patient information leaflets forall commonly prescribed medicines. These wereavailable in other languages, large print, Braille andaudio format on request.

• Staff were able to access interpreters to translate forpatients with different language needs. For example thiswas often used to explain patient rights followingdetention under the Mental Health Act

• All of the services provided disabled access for patientswith mobility needs.

Listening to and learning from concerns andcomplaints

• Information on how to complain was provided in theinpatient wards and in community services. In the teamswe inspected, this information was displayed clearly forpatients and relatives or carers.

• On the wards for people with learning disabilities orautism a complaints procedure was displayed on eachward and throughout the service. This was available inan easy read pictorial format. Patients could request


Good –––


advocacy support if they wanted to make a complaint.Complaints could be raised with the staff on the ward, atthe weekly patient group and during one to onesessions.

• In February 2015, we identified the trust must ensureinformation was available to inform patients how tomake a complaint across the wards for adults ofworking age and PICU. In particular the trust mustensure verbal complaints are addressed and, if needed,patients and carers have access to the formalcomplaints process. At this inspection we found this had

partially improved, and information on how to make acomplaint was available to patients. However, we foundthe system to collate and follow up on informal verbalcomplaints had not significantly improved on acutewards and wards for older people. Further work wasrequired to ensure that verbal complaints are followedup and the actions of verbal complaints collated andevidenced. This was a particular concern on the PICUwards in Brent following patients raising concerns incommunity meetings and informal complaints. This wasa continuing breach of regulation.


Good –––


By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.

Summary of findingsWe rated well led as good because:

• In February 2015, we rated all but one of one of thesixteen core services as good for well led. Theexception was wards for adults of working age andpsychiatric intensive care units (PICU); which werated as requires improvement for this key question.Following this most recent inspection, we changedthe rating of well led for acute wards for adults ofworking age and PICU to good. This means that allseven community health core services and nine ofthe ten mental health core services are now rated asgood for well led. The wards for people with alearning disability or autism are rated as outstandingfor this key question.

• The trust had a skilled and experienced leadershipteam who were committed to providing high qualityservices.

• There were clear strategies in place which put thepatients and carers at the centre of the work of thetrust, whilst addressing the financial challenges.

• The leadership team were cited on the risks facingthe trust and had robust action plans in place toaddress these areas.

• Patients, staff and external stakeholders wereactively engaged in the trust. Further developmentsin carer engagement were being promoted.

• The trust welcomed innovation and was introducinga systematic approach to quality improvement.

Our findingsLeadership capacity and capability

• The trust had a stable executive leadership team. Thechief executive had been in post for over 10 years. Themost recent appointment was the chief finance officerwho joined in 2016. The executive leadership team hada detailed knowledge of the trust.

• The chief executive was also the national mental healthdirector for NHS England. In dividing her time betweenthese roles she was very clear about what activities sheundertook for the trust that were essential. She was alsobased at the trust and was available when needed.

• The trust board was experiencing some change but thiswas being carefully managed. There were eight non-executive director posts including the chair. The chairhad been in post since January 2013. Two non-executive directors had been appointed for a secondterm to provide stability for the board. Two non-executives had just been appointed. There was onenon-executive board vacancy that was in the process ofbeing filled.

• The non-executives had a wide range of skills andexperience at a strategic level from careers in a range ofsectors. They did not include someone with a clinicalbackground, although there were members withexperience as a carer or other personal interests relatingto the services provided by the trust. The chair wasconscious that the composition of the board did notrepresent the diverse communities supported by thetrust and the need to try and increase the number ofdirectors from a BME background.

• A recently appointed non-executive director confirmedthey were receiving an in-depth induction to preparethem for their role. Non-executive directors had ongoingsupport to enable them to have the capability toundertake their role. This included pre-board seminars,separate meetings for non-executive directors with anannual overnight event and access to externalconferences.

• Non-executive directors demonstrated at the boardmeeting that they had a good knowledge of the trustand were well prepared for the meeting. They providedappropriate challenge where needed, although it wasrecognised that this will develop further once therecently appointed non-executive directors gainknowledge and confidence in their roles.

Are services well-led?

Good –––


• Succession planning had been carefully considered bythe chair and chief executive and senior staff had accessto bespoke plans for their development and careerprogression.

• The trust provided a range of leadership developmentopportunities. One was targeted at new front linemanagers to provide them with skills and a network ofsupport. Senior clinical leaders participated in theImperial leadership training course. The trust wasworking on pulling together all the initiatives to have amore robust talent management strategy to ensure theywere meeting everyone’s needs. Team and wardmanagers commented favourably about the access toleadership development opportunities. Divisional andborough directors described the range of opportunitiesthey had including mentoring and coaching, attendingconferences and more bespoke leadershipdevelopment courses.

• The Trust was in segment 2 of the NHS ImprovementSingle Oversight Framework linked to the rating ofrequires improvement from the last comprehensiveinspection.

Vision and strategy

• The trust had a clear vision and values. The vision was‘wellbeing for life for everyone’. The values were that weshould all experience and express every day,encompassing compassion, respect, empowerment andpartnership. These had been developed in partnershipwith patients, carers, staff and a wide range ofstakeholders.

• The vision and values were underpinned by clearstrategic objectives to provide high quality care and bestoutcomes for patients, and to be operationallysustainable and financially viable.

• The trust had a five year plan which provided thestrategic priorities for the trust and annual operationalplans.

• A trust clinical and quality strategy was just beingcompleted. This had been produced in consultationwith clinicians, patients and carers at an event withexternal stakeholders. It described how patients andcarers will be at the centre of the work carried out by thetrust in line with the trusts quality priorities.

• External stakeholders, governors, patients and carerswere also involved in the preparation of the annualquality account which agrees the quality priorities forthe year ahead and reviews progress with achieving thepriorities from the previous year.

• Staff were supported to understand the visions andvalues through the internal communication strategy.Information was available on the intranet, posters andwas the basis of trust communications.

• The visions and values of the trust were understood bystaff throughout the trust and they were able toarticulate how these related to their work within theorganisation and the care delivered to patients.

• Staff were aware of the need to deliver high quality carewhilst also delivering a very challenging savings plan.For the year 2016/17 the trust had achieved its end ofyear planned deficit of a £1.1m subject to this having anexternal audit review. The trust had also reduced thespend on agency staff in the last year by £10m. A savingstotal of £30m (6%) had been identified for 2017/18.

• At the time of the inspection the trust was working totransform services. Also divisions were identifyingfurther cost improvement schemes. These werepresented to the medical and nursing director and if theimpact on patient care was detrimental, the schemewould be refused.

• The trust was participating in a Lord Carter pilot reviewin some of its community services to look atcomparative costs, opportunities to save money andimprove care.

Culture of the organisation

• In the 2016/17 national NHS staff survey, the trust had astaff engagement score of 3.83 which was above averagewhen compared to other similar trusts. This was a verysimilar result to the previous year. There were five areaswhere further improvements were needed. Theseincluded staff working extra hours, recent experiences ofviolence, recent experiences of bullying andharassment, opportunities for flexible working andaccess to services for health and well-being. Seminarswere being arranged to discuss how improvementscould be made.


Good –––


• Staff who were interviewed during the inspection, weregenerally very positive about their experiences ofworking for the trust and said that the culture was veryopen and they felt able to raise concerns without fearsof retribution.

• The trust leaders placed a high priority on being visibleand approachable. This was a challenge as the trust wasvery large, geographically spread and provided a widerange of services. All the board members regularlyvisited services. The non-executive directors had aprogramme to ensure they went to a variety of servicesand they wrote up these visits and fed back anyconcerns to the board. They described how staff werevery open and willing to discuss any challenges theywere experiencing. They were also thoughtful abouthow to best speak to patients and get their feedbackduring these visits. Executive directors also undertookvisits including out of hours. This included a back to thefloor initiative where 50 senior staff each worked in 3areas and at the end came together to review thelessons learnt. Staff felt senior staff were accessible.

• A non-executive director was the trust lead ‘speak upguardian’. In addition five staff side representatives werealso ‘speak up guardians’. They had received someinitial training and guidance and wore a badge showingtheir role. This had been publicised throughout the trustusing the intranet and posters. It was too early to see ifthey were used much by staff.

• The trust also had a whistle-blowing process. In theprevious 12 months the trust had received andinvestigated 8 whistle-blowing concerns. These hadbeen raised in a number of ways, although the mostfrequent was to write to the chief executive. Followingan investigation, the lessons learnt had beenconsidered.

• External stakeholders had described the culture of thetrust as open and transparent.

• The trust worked closely with the trade unions withmeetings taking place every 4-6 weeks and joint policygroups in place including one to look at actions fromthe staff survey.

• Staff performance issues were addressed appropriately.In the last year there were two cases of staff dismissedfor bullying, which demonstrated the trustscommitment to address inappropriate behaviour.

• The trust recognised that they need to makeimprovements in terms of their workforce race equalitystandard (WRES). A WRES action group had been set upchaired by the chief operating officer. They werefocusing on four areas. These were to increase thepercentage of BME staff at band 8 posts and above;increase the likelihood of BME staff being appointedafter shortlisting; decrease the likelihood of BME staffentering formal disciplinary processes and increase BMEstaff believing the trust provides equality of opportunity.They were working on several developments includingthe roll out of unconscious bias training, having BMEstaff on interview panels, reviewing dismissals andpromoting BME role models and supporting BME staff tohave the confidence to apply for jobs. Much of this workwas still at an early stage.

• The trust had a number of networks promoting thediversity of staff. This included the BME network whichwas being supported to develop further. There were alsonetworks for LGBT staff, a disability network, staff whoare carers’ network and staff with lived experience.

• An occupational health service was available promotingthe health and well-being of staff. A new ‘staying well atwork service’ was being piloted to support staff whoneeded assistance with their mental well-being tosignposted them to appropriate services.

• The trust also provided a bursary to encourage staff tocome up with ideas to promote health at work. Lots ofteams had come up with ideas and a panel was beingconvened to decide which ideas to fund.

• The trust was aware of the challenges for staff basedlinked to staff vacancies. At the time of the inspectionthese were at 13.8% with turnover at 15.6%, sickness at3.2%. The completion of appraisals was at 86%. Thetrust was using initiatives such as golden handshakesfor new staff and relocation allowances to support therecruitment and retention of staff. A trust workforceboard had been established and was chaired by thechief executive to oversee this work and progress wascarefully monitored by the board. It was recognised thatfurther work was needed on retention. A rotationprogramme had been implemented for qualifiednursing staff to enable them to work across a number ofservices and develop their skills and experience. At thetime of the inspection 175 nurses were taking part in thisprogramme.


Good –––


• Staff success was recognised, with an annual staffawards ceremony and also monthly awards. The trustalso had long service awards for staff.

Governance and management

• The trust had robust governance structures in place.This meant that from ward to board there was a goodunderstanding of the challenges facing the trust. Areasfor improvement were recognised and work was done tomake these changes. An integrated dashboardmonitored key areas of performance and identifiedtrends across the three divisions and the trust as awhole. In the acute wards and PICUs we saw thatimprovements had been made to the oversight of bedmanagement across the trust which had been identifiedas an area for improvement at the previous inspectionin February 2015.

• The papers for the board and the quality andperformance committee were contained clearsummaries and detailed information.

• There were three divisions in the trust each with adivisional director and medical and nursing director.The three divisions each had responsibility for a numberof boroughs and other specialist services. This helped tofacilitate joint working with clinical commissioninggroups and local authorities.

• There was a clear accountability structure for eachdivision. At a directorate level assurance took placethrough a quarterly executive review meeting led bymembers of the senior executive team. These meetingsconsidered all aspects of the directorate’s operationalperformance and discussed plans for the directorategoing forward. A representative from the division alsoattended the quality and performance committee whichwas a sub-committee of the board. Divisions were clearabout issues which needed to be escalated to theexecutive team and other stakeholders when they arose.Similarly boroughs were accountable to the divisions.

• There was also effective sharing of information andlearning across the divisions. For example there wereregular meetings of divisional leads, a nurse forum andother clinical networks, peer reviews of services acrossdivisions and a learning disability network ofchampions.

• Where these systems identified services which neededadditional support, an improvement board was put inplace as was seen in the trusts offender care services.

• The non-executive directors were also clear about theirareas of responsibility. They chaired the board sub-committees. One or two non-executive directors werealigned to each division and the division informed thenon-executive director of key issues facing the division.

• At a ward and team level front line managers were alsoclear about their responsibilities and felt they weregiven sufficient autonomy and also support to performtheir roles.

• The trust recognised the importance of having a strongprogramme of quality assurance. This included clinicaland non-clinical audits, using feedback from patients todrive improvement, embedding learning from seriousincidents and complaints and assuring complianceagainst NICE clinical guidelines. These were seenworking well as part of the inspection.

• The trust has clear structures and procedures forensuring the implementation of the Mental Health Actand Mental Capacity Act reflected good practice. Despitethe size of the trust, the mental health law team had apresence on each inpatient site and also spent time incommunity settings. The director of nursing was theexecutive lead for mental health law and oversaw thework of the mental health law team. The use of bothacts were monitored and reported to the Mental HealthLaw committee.

• In February 2015, the trust had just brought in the fit andproper person policy and procedures. The records of sixdirectors were reviewed and a few checks were not yetin place, although we were assured these werecompleted after the inspection. This time we looked ateight records and they were all complete.

Management of risk and performance

• The trust had clear risk management processes in place,with risks collated and reviewed at different levels of theorganisation to ensure action plans were in place. Thesefed into the trust risk register which included the seventop risks, the assurance and action plans. These werereviewed by the quality and performance committeeand the board. The current concerns identified by the


Good –––


latest core service inspections such as staff vacancies, ITinfrastructure and varying quality of data at a team levelwere reflected in the risk register and actions to addressthem were in place.

• Following the publication of the Mazars review the trustestablished a central mortality review group. The groupmet monthly and was chaired by the medical directorand included clinical membership from all divisions.The group was also attended by an older adultpsychiatrist, end of life clinical network lead and clinicaldirector for learning disability services. Commissionerswere also represented at the meeting and a service usergovernor brought lived experience to the forum. Deathswere reviewed using the Confidential Enquiry intoStillbirths in Infancy (CESDI) Framework. This involved areview of the patient record, multi-disciplinary teamdiscussion and also allowed staff to take into accountfeedback from carers. The new process was beingapplied to all relevant deaths that had been reportedsince December 2016. A number of learning events hadtaken place across the trust which has included sessionsto front line clinical staff on the importance of this workand how to implement the framework. The initial focushad been on mental health and learning disabilityservices but this was being extended to communityservices using a sampling approach.

• The emergency planning & business continuity plan wasreviewed on an annual basis by the board. In the latestplan for 2016/17 the trust was compliant with 49 out ofthe 51 standards. For the remaining two, plans were inplace to increase training and exercising to test theplans.

Management of information

• At the time of the inspection the trust was experiencingdifficulties in the roll out of their IT infrastructure and asa result the delivery of a new patient record system. Thishad been highlighted on the risk register and clearactions were in place including extremely closemonitoring of the implementation of the contract withthe company providing this service. The inspectionfound there was some impact on patients and staff,although the trust had tried to minimize this as far aspossible. For example in one community team the newtelephones were not working well and it was notpossible to put through calls from the reception to othermembers of the team. This was causing problems with

patients having difficulty in getting through when theycalled the team. The trust was working to correct theseproblems and in the meantime had arranged foradditional staff to assist. Where the new patient recordsystem could not be implemented staff were continuingto use the old one. In areas where the IT changes hadtaken place staff were generally very positive and theyhad been provided with training and support to learnthe new systems.

• The trust was also implementing a new businessintelligence tool. Once this is fully implemented this willprovide information at a ward and team level to supportthe clinical delivery of the service. For example teamswill know on an individual named basis which patientsneed to have their care programme approach meetingor to be followed up within seven days of beingdischarged. It will also show how many patients eachcare co-ordinator has on their caseload. At the time ofthis inspection some team managers were not able toprovide this information with confidence, however thenew system when implemented will address this.

• The non-executive directors felt confident about thequality of the data at a board level. They said it wasreliable, accurate and timely. Divisions had a goodknowledge of services and could challenge data that didnot look correct.

• The information provided at the board meetingsprovided a holistic overview of performance andcovered clinical, operational and financial matters.

• The trust Integrated board performance reportcontained key data for divisions and the trust as a wholeand this was easy to follow and showed the trends inthe data, for example monitoring the reduction inrestraint and prone restraint.

Engagement and involvement

• The trust engaged well with staff, patients, carers and awide range of stakeholders. This was challenging due tothe size and complexity of the trust. The recoverycollege was universally praised and reflected the co-production work between all the engaged partiesleading to a range of highly valued learningopportunities.

• The trust engaged effectively with staff and had asophisticated communications strategy. Information


Good –––


was provided through a range of mediums including a‘three minute read’, newsletters, magazine, CEO blogand three key messages after the executive boardmeeting. Recent initiatives included the clinicalmessage of the week. The trust also used on-line forumsfor staff to discuss topics and share good practice.

• Individual divisions had responsibility for sharing keyinformation with staff through divisional and teammeetings. This included learning from incidents andcomplaints. Each division also had their owncommunication strategy and local leaders used a rangeof methods to communicate with staff including emails,social media and direct contact.

• Senior leaders were very visible and gave staff theopportunity to raise issues. Structured programmes ofvisits took place during the day and night. Meetings tookplace at a range of venues to allow staff to see differentparts of the organisation. Listening events took place atborough and team levels.

• Work took place with specific groups of staff, forexample listening events with junior doctors had led tosome improvements in rooms used by doctors whilstworking on – call..

• Governors felt very engaged in the work of the trust andwell supported. They had quarterly council of governorsmeetings, an annual away day with the board, tea withthe chair and learning sessions. Examples of their workincluded, helping to select the non-executive directors,participation in a range of advisory panels and visits toservices.

• The trust engaged well with patients. There was a trustwide patient reference group to oversee theengagement work. The trust also used the results of thefriends and family test to gain trust wide feedback.Healthwatch spoke positively about the engagementwork, although they said that opportunities forparticipating could be promoted more widely.

• Divisions had their own engagement strategies,reflecting the patients using their services. For examplein sexual health services, extensive feedback had beengathered and used to improve services throughfeedback cards completed after clinic appointments.

• Patients were involved in consultations on areas such asrevising care plans and reducing restrictive practices.They were also involved in consultations about servicetransformations.

• A patient or carer story was presented at each boardmeeting sharing positive and negative experiences.

• The trust was making excellent progress in therecruitment of peer support workers with over 40people in post. They carried out a wide range of rolessupporting patients and contributing to serviceimprovements.

• There were many examples of patient engagement inindividual services. For example in CAMHS the youngpeople helped co-produce the website and reviewoperational tools such as the leaflets and letters used bythe service. There were also mental health serviceswhere patients were co-producing art work inpartnership with local artists.

• The trust recognised that there was further work to bedone on involving carers. A carers council had beenestablished. The trust was starting to implement thetriangle of care. Healthwatch said more could be doneto ensure carers had a carer assessment.

• The trust had a list of patients and carers trained to helpwith staff interviews.

• There were a wide range of initiatives in place tosupport carers throughout the trust at a ward, team orborough level. For example in Harrow there was a carerssurgery to provide support for carers.

• The trust was engaged with a wide range ofstakeholders. For example staff were actively involved inthe work of three sustainability and transformationplans (STPs). This engagement took place at a directorlevel, divisional and borough level. The trust was alsoactively engaged in the development of accountablecare partnerships, such as the one in Hillingdon wherethey were working with the acute trusts, GP federationand third sector providers. External stakeholders spokepositively about the quality of this engagement work.

Learning improvement and innovation

• The trust participated in a range of research, thoughrecognised this could be developed further especiallyfor mental health services. A director of research had


Good –––


been appointed and a conference looking at researchhad been planned later in the year. The trust was linkedwith Imperial College London for some existing researchand also worked collaboratively with other trusts. Thetrust’s sexual health services were undertaking a rangeof research and acted as a host for research in othertrusts.

• The trust participated in a number of Royal College ofPsychiatrists’ accreditation schemes. This included theschemes for memory services (three teams accredited);psychiatric liaison services (three teams accredited oneas excellent); eating disorders (one team); learningdisability wards (one ward); working age adult wards

(two wards); ECT (two services accredited one asexcellent); perinatal inpatient and community (oneservice); inpatient CAMHS (one ward); rehabilitationwards (four wards).

• The trust had a director of improvement and wasfocussed ion continuous improvement and innovation.There was a culture where staff and patients felt able todevelop innovative schemes throughout the trust. Therewas also an innovation fund where teams could presentbids for funding for new ideas that would improvepatient care.

• The trust had recognised the need to implement asystematic approach to quality improvement and theyhad just signed up with a provider and the process wasstarting.


Good –––


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityAssessment or medical treatment for persons detained underthe Mental Health Act 1983

Treatment of disease, disorder or injury

Regulation 9 HSCA (RA) Regulations 2014 Person-centredcareCare and treatment was not provided in a way thatensured that assessments of needs and preferences ofthe service user were carried out and that these needswere met.

Community based mental health services foradults of working age

Care and treatment was not provided in a way thatensured that assessments of needs and preferences ofthe service user were carried out and that these needswere met.

Care plans were not person centred at North KensingtonCMHT.

At Brent CMHT, care and treatment was not carried out inaccordance with the care plan and care plans did notalways include identified needs.

Waiting lists for psychological therapies were very long.In some teams service users were waiting up to 24months to be seen.

Some patients in the North and South Brent CMHTs hadnot had regular contact with a care co-ordinator for asignificant period of time. This placed them at risk of nothaving their assessed needs met.

This was a breach of regulation 9(1)(2)(3)(a)(b)

Regulated activity

Regulation

Regulation

This section is primarily information for the provider

Requirement notices


Assessment or medical treatment for persons detained underthe Mental Health Act 1983


Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Acute wards for adults of working age andpsychiatric intensive care units

The trust had not ensured that patients were

appropriately assessed and that the welfare and safetyof patients was maintained.

The reasons for the administration ofrapid tranquilisation, and the reviews of patients’physical health, including vital signs, following rapidtranquilisation were not always demonstrated to ensurepatients were not at risk.

Whilst improvements had been made in this area, wefound gaps in the monitoring and recording of patientsphysical health following RT.

This requirement was stated in the last inspection InFebruary 2015, and is a continuing breach.

Risk assessments did not include details about risk andthere was no information in care records on how therisks were to be managed.

This was a breach of Regulation 12 (1)(2)(a)(b)(g)


Care and treatment was not provided in a safe way forservice users.

Risks were not always assessed, assessments lackeddetail and management plans did not address identifiedrisks.


Requirement notices


This was a breach of regulation 12 (1)(2)(a)(b)(c)(e)

Crisis services and health based places of safety

People were not being protected against the risks ofreceiving care or treatment that is inappropriate orunsafe. Delays in accessing inpatient beds whenrequired meant that people had to be supported inhealth based places of safety and bed managementlounges for extended periods of time.

This was a breach of regulation 12 (1)(2)(b)



Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment


The trust was not providing care or treatment in a waythat minimised acts which involved the use of control orrestraint.

The number of incidents of prone restraint and the use ofrestraint across the service were significant.

Further work was needed to reduce variations in the useof restraint between different trust inpatient services.

This was a breach of Regulation13(4)(b)



Regulation 15 HSCA 2008 (Regulated Activities) Regulations2010 Safety and suitability of premises

Regulation

Regulation


Requirement notices



Premises and equipment used by the service providerwere not suitable for the purpose for which they werebeing used.

Staff were at risk because the Milton Keynes CMHT didnot have an alarm system and staff did not carrypersonal alarms when seeing patients.

This was a breach of regulation 15(1)(c)

Crisis services and health based places of safety

People were not being protected against the risksassociated with unsafe or unsuitable premises.

People using the place of safety at the Gordon Hospitaland Park Royal had to pass through other parts of thehospital rather than accessing the service through aseparate entrance which could compromise their privacyand dignity.

Interview rooms at St Charles hospital did not maintainthe confidentiality of people using the service.

This was a breach of regulation 15(1)(c)(f)



Regulation 16 HSCA (RA) Regulations 2014 Receiving andacting on complaints

Long stay rehabilitation mental health wards

The trust did not have an effective system to informpeople of how to make a complaint.

Regulation


Requirement notices


There was a lack of information in some rehabilitationservices to inform people how to make a complaint.

There was not a central register of verbal complaints andit was possible that where patients wanted a formalresponse to their complaint this was not happening.

This was a breach of regulation 16(1)(2)



Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance


The trust was not ensuring that accurate,clear contemporaneous records of service users care andtreatment were being maintained.

Records of physical restraint of patients were not alwayscomplete and accurate.

This was a breach of Regulation 17(2)(c)

Wards for older people with mental healthproblems

The trust had not ensured that staff on Kershaw wardhad an understanding of the policy on reportingincidents and reporting restraint in relation to personalcare.

This was a breach of regulation 17 (2) (b)

Regulated activity

Regulation

Regulation


Requirement notices


Assessment or medical treatment for persons detained underthe Mental Health Act 1983


Regulation 18 HSCA (RA) Regulations 2014 Staffing


Staff were not receiving appropriate support, training,professional development, supervision and appraisal asis necessary to enable them to carry out the duties theyare employed to perform.

The trust must ensure that all non-clinical staffundertake basic life support training and all staffundertake fire safety mandatory training.

This was a breach of Regulation 18(2)(a)


Requirement notices


Documents

CentralandNorthWest LondonNHSFoundation Trusthealthwatchharrow.co.uk/sites/default/files/cnwl_provider_report.pdf · 3Central and North West London NHS Foundation Trust Quality Report