Central and North West London NHS Foundation Trust

Updated 22 February 2024

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

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

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

• Community-based mental health services for adults of working age

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

• Wards for older people with mental health problems

• Community-based mental health services for older adults

• Specialist community mental health services for children and young people

• Community mental health services for people with learning disabilities or autism

• Wards for people with learning disabilities or autism

• Specialist eating disorder services

• Substance misuse services

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

• Community health services for adults

• Community end of life care

• Community health services for children, young people and families

• Sexual health services

• Community health inpatient services

• Community dental services

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

However:

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

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

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

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

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

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

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

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

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

How we carried out the inspection

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

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

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

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

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

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

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

• reviewed records held by the CQC relating to each service

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

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

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

• reviewed 90 patient care and treatment records

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

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

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

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/ how-we-do-our-job/what-we-do-inspection.

What people who use the service say

Overall feedback from patients on the forensic wards was mostly positive. Patients told us they were listened to and felt safe. All patients reported that they were involved in their care and had access to activities within the service and the community. They told us they were supported to maintain contact with family members. Patients said staff treated them well and that the ward was much calmer and settled.

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

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

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

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

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

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

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

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

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

Updated 19 June 2015

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

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

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

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

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

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

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

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

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

Updated 19 June 2015

Overall rating for this core service - Good

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

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

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

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

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

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

Updated 19 June 2015

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

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

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

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

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

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

Updated 19 June 2015

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

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

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

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

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

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

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

Updated 19 June 2015

Overall rating for this core service Good

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

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

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

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

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

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

Updated 6 July 2023

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

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

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

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

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

Treatment of disease, disorder, or injury,

Assessment or medical treatment for persons detained under the 1983 Act

Diagnostic and screening procedures.

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

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

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

We found several areas of good practice:

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

However:

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

What people who use the service say

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

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

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

Updated 19 June 2015

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

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

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

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

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

• There was a commitment to continual improvement across the services.

Updated 19 June 2015

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

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

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

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

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

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

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

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

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

Updated 19 June 2015

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

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

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

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

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

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

Updated 19 June 2015

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

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

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

However in the responsive domain we found that:

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

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

Updated 14 June 2017

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

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

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

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

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

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

• Staff monitored and reviewed patients’ physical healthcare needs effectively.

• Staff from different disciplines worked together professionally and with mutual respect to achieve the best possible outcomes for patients using the service. There was a multi-disciplinary approach towards every aspect of the patient journey from admission to discharge. Staff were committed to partnership and collaborative working and there was an embedded culture focussed on the delivery of holistic care.

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

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

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

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

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

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

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

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

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

• The service had a positive, open and inclusive culture which centred on improving the quality of care patients received through empowerment and involvement. Throughout our inspection we saw that staff embedded the values of the trust in all aspects of their work and spoke about the patients being at the heart of the service.

Updated 22 February 2024

Updated 22 February 2024

Updated 4 June 2019

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

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

However:

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

Updated 4 June 2019

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

• Throughout the inspection we saw good practice, particularly at the Campbell Centre, Northwick Park, some individual wards on other sites and in the psychiatric intensive care units. The site where there were the most concerns was at the Gordon Hospital where there had been a serious safeguarding incident. The trust was aware that this service needed additional leadership support and had put this into place.
• Wards had made progress in minimising the use of restrictive practices and followed good practice with respect to safeguarding.
• Medicines were mostly managed safely, although at St Charles, the Campbell Centre and Northwick Park, ‘as required’ medicines were not reviewed regularly or when not used by the patients for whom they were prescribed for over 14 days.
• The service provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided, although there were some inconsistencies in both areas.
• Ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards, although patients on the wards at St Charles had limited access to psychological therapies.
• Managers ensured that ward staff received training and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service managed beds well so that a bed was usually available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
• The service was well led and the governance processes ensured that ward procedures ran smoothly. However, whilst most wards had regular team meetings using a standard agenda to ensure all the necessary topics were covered, a few did not take place regularly or the record of the meeting read like a ‘to do list’.

However:

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

Updated 19 June 2015

This service was not rated

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

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

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

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

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

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

Updated 4 June 2019

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

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly.
• Patient risk was well-managed by most services and staff were aware of the key risks before visiting patients. Teams across the trust held regular meetings where clinical risk was explicitly discussed. However, some recorded risk assessments did not clearly state how the risk should be addressed, which could potentially mean that staff, especially if they were new to the team, might not know what steps to take.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was well led and the governance processes ensured that that procedures relating to the work of the service ran smoothly.

However:

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