West London Mental Health NHS Trust has reduced risk to patients but further progress is required, according to regulator
West London Mental Health NHS Trust (WLMHT) has made significant improvements
in risk management to protect patient safety, according to a recent report by
the Care Quality Commission (CQC).
The report examines the trust’s progress in implementing recommendations
made in July 2009 triggered by concerns about the trust's response to suicides
and other serious incidents. The original investigation highlighted delays in
investigating incidents and a failure to learn from common themes identified
and documented in action plans.
CQC completed its follow up inspection over five days (15 – 19 March
2010), interviewing service users, staff and board members and reviewing documented
evidence. It commended improvements in assessing service users’ physical
healthcare, risk management, the provision of primary care services and the
cleanliness of wards. Challenges remain in care planning, improving communication
between staff and service users and demonstrating that lessons learnt are shared
across the whole trust.
Colin Hough, regional director for CQC, said:
“ West London Mental Health NHS Trust faces real challenges in
caring for some of the most seriously unwell patients in the country. That
is why it is so important that its risk management processes are robust and
can protect these most vulnerable of service users.
will continue to monitor the trust through our tough new registration system,
which requires the NHS to meet essential standards of quality and safety.
WLMHT has been registered with compliance conditions relating to our original
recommendations and we have set out strict deadlines for improvement.
is no question that the trust has made significant progress, particularly
in the way it reports and investigates serious incidents and manages medicines
and pharmacy support. But there is more to do to improve service users’
experience of care through better care planning and more meaningful interaction
with staff. While the trust has already made changes to how lessons are shared
across the trust a sustained focus on this is very important.”
During the inspection, the trust provided evidence of its progress against
the majority of the nine recommendations made in July 2009. One area continues
to be a concern and one recommendation was not assessed in depth as it will
be addressed through a separate review of the trust’s Commissioners later
in 2010. CQC commended the progress made but said that some areas require improvement
and will continue to be monitored:
The nine (9) recommendations were:
- Improving management of risk through reporting, investigations
and the sharing of lessons learnt.
Concerns were initially raised that the right actions weren’t being
taken to prevent serious incidents being repeated. The trust has since reviewed
the management of risk in the organisation and the reporting of risks and
incidents now has a much higher profile. There is limited evidence of trust
wide shared learning and embedding this will continue in phase two of the
- Assessing the risks that service users pose to themselves or others
and reflecting them in risk management or treatment plans.
CQC is concerned that delays in addressing known ligature risks may not be
adequately highlighted in the risk register. Over 50% of service users interviewed
were not aware that they had a plan of care or knew what arrangements were
in place for their ongoing treatment. CQC would expect to have seen greater
progress in this area.
- Commissioners developing mechanisms for monitoring the reporting,
investigating and learning from incidents in the services they commission:
CQC will review the commissioning of services later in 2010 so this recommendation
was not assessed.
- Progressing the redevelopment plans for Broadmoor Hospital and
Many of the trust’s buildings are old and are not conducive to safe
and high quality care. The trust has now reconfigured the wards at Broadmoor
and is waiting for Department of Health approval to progress the site redevelopment.
An inspection by the CQC Health Care Associated Infection (HCAI) team found
no breaches of the Hygiene Code.
- Ensuring there are sufficient beds for patients.
Formerly, people slept on sofas or stayed too long on the intensive care unit
due to overcrowded wards. The trust has confirmed that all service users are
now admitted to an allocated bed.
- Ensuring sufficient numbers of staff with the right skills.
The trust has historically had problems maintaining adequate staffing levels.
Human Resource support and recruitment processes have been reviewed to reduce
the time taken to recruit new staff. Vacancies are now being filled more quickly
and the total number of vacancies is steadily reducing.
- Monitoring and reporting of staff attendance at mandatory training.
Poor attendance at mandatory training was a natural side effect of low staffing
levels. Staff attendance at training is now recognised as a key priority and
attendance is monitored locally by the ward and reported monthly to the trust
board. However, the inspection team is concerned that some service users report
that they do not speak regularly to a member of staff and that staff attitude
- Giving more priority to the physical healthcare of service users.
While the trust’s approach to users’ physical healthcare was slow
and fragmented in the past, they have now invested in the provision of primary
care services to ensure service users have access to GP services. Service
users in local units reported that their physical healthcare needs were addressed
- Prioritising medicines management and strengthening resources for
The original investigation uncovered variable pharmacy support across the
trust but the chief pharmacist has now confirmed that a medicines management
strategy has been implemented.
To see the full report into progress made at the trust, please visit CQC’s
website - see link below.