Quality Account
2014-2015
Promoting hope
and wellbeing
together
Contents
Page
Part 1: Statement on quality from the chief executive, Steve Shrubb3
Part 2: Priorities for improvement 4
Looking back – our quality priorities 2014/15 4
Looking forward – our quality priorities 2015/16 21
Review of Clinical Governance - recommendations26
Statements of assurance from the board
27
1.
Review of services 27
2.
Participation in clinical audit 27
3.
Internal audit reports
34
4.
Participation in clinical research
36
5. Commissioning for Quality and Innovation (CQUIN)36
6. Care Quality Commission (CQC) compliance40
7.
Quality indicators
8. Quality indicators – other indicators
41
47
Part 3: Other information - review of quality performance49
Message from the medical director, Dr Nick Broughton
49
What service users, carers and the public say – key messages and actions
51
1. From complaints
51
2. Action taken in response to incidents and serious incidents56
3. Safeguarding children and adults at risk62
Other quality and improvement initiatives67
Initiatives and improvements in West London Forensic Services77
Initiatives and improvements in Ealing Forensic Services
78
Initiatives and improvements in High Secure Services
79
Comments from Meridian
82
Annex 1: NHS Ealing CCG Statement for WLMHT 83
Quality Account 2014-15
Annex 2: Statement of directors’ responsibilities89
Annex 3: How our services are structured 90
Annex 4: Internal Governance Structure91
Annex 5: Independent auditors’ limited assurance report 93
Annex 6: Criteria applied for the measurement of the indicators tested by PricewaterhouseCoopers LLP 97
2
Annual Report I 2014/2015
Part 1: Statement on quality from the
chief executive, Steve Shrubb
Welcome to our Quality Account for 2014-15.
Within this report we describe the work we
are doing to improve patient safety, clinical
effectiveness and the experiences of people
using our services.
Quality improvement work at the trust is guided
by our quality strategy which is based on the
principles of: service users at the heart of all we
do; a focus on measurable clinical outcomes;
and informed, engaged and staff empowered to
innovate and drive forward service improvements.
We are also guided by our feedback from service
users and carers including complaints, the learning
from incidents, regular audits of our services and
national priorities. We know that we are a low
reporter of incidents at the trust compared to
other similar organisations, and in developing a
learning culture, which is safe for patients we are
focusing our efforts on encouraging staff to report
all incidents so we can discuss them openly across
our organisation and learn from them.
Staff are key to the success of any organisation,
which is why we have continued to prioritise
our staff engagement programme of work this
year. The 2014 NHS staff survey shows that
although we are seeing some improvement,
we still have a great deal to do to improve staff
engagement as it is fundamental to delivering
excellent quality patient care.
We have strengthened our senior leadership
team this year with the appointment of a
permanent director of nursing and patient
experience. Beverley Murphy is an experienced
senior leader and her portfolio will also include
managing our estate which makes an important
contribution to a positive patient experience.
We have further developed the West London
Mental Health NHS Trust’s leadership model
this year to give clinicians key leadership roles
in delivering services. We know from other
healthcare trusts that strong clinical leadership
improves the quality of decision making, patient
care and staff engagement and we’re now
embedding our new service lines, each led by a
senior clinician, into our daily practice.
We’ve continued to develop ways to ensure
that patients have a voice in the trust, such as
through the West London Collaborative, an
independent organisation, funded by the trust
to promote user involvement. Their work is
described in the report.
Following last year’s publication of the
Department of Health’s investigation into Jimmy
Savile, including his connection with Broadmoor
Hospital, we commissioned a review of our
governance and safeguarding arrangements
in order to assure the public, service users and
their families, commissioners and partners,
and the organisation itself that its governance
systems are strong and effective.
You can read about the outcome of the
governance review within the quality account and
our resulting quality improvement plan, which
will be monitored by our corporate governance
team and fully implemented by May 2016.
This year we have seen significant progress in
the major redevelopments of St Bernard’s and
Broadmoor Hospital, which you can read about
in the report. Work is on track and will deliver not
only state of the art facilities but also centres for
new, recovery focused, clinical models of care.
We have also worked with clinical staff to agree
a two year plan of other building improvement
works which will help us to improve patient
safety and the patient experience across many
of our other sites.
We’re now preparing for a visit from the CQC
in June 2015, a key step in the journey to
becoming a Foundation Trust. I would like
to thank all of our staff for the work they are
doing to continually improve the quality of
our work to fulfil our new vision of being an
outstanding healthcare provider, committed to
improving quality and caring with compassion.
To the best of my knowledge the information
contained in this Quality Account is accurate.
3
Annual Report I 2014/2015
Part 2: Priorities for improvement
Looking back - our quality priorities 2014/15: What were they, how did we do?
High secure services
Patient safety
Improving medicines safety by ensuring consistency of medication error reporting and aim to reduce the
number of medication errors.
Why did we focus on this?
To improve medicine safety at ward and service line level. We knew that
the reporting of medication incidents at the trust was much lower than in
similar organisations.
What did we aim to do?
Increase medication error reporting and to learn from any medication
errors or near misses.
What did we expect to achieve?
Increase medication reporting and improve transparency with a view of
improving practice through learning from incidents.
How did we plan to
monitor and report?
Medication errors are reported electronically and collated and reviewed
through clinical governance. Run a pilot project to help us improve our
reporting of medication incidents.
Share findings at the lessons learned seminars.
How well did we do?
A trustwide initiative was launched where medication safety and learning
lessons workshops on the wards were implemented, focusing on those
areas where reporting was particularly low.
What we have found is that medication incident reporting has increased
significantly since the pilot project began. Of course the challenge for
us working here will be to keep up this good work, and so it was agreed
by the trust management team that we need to continue the project, by
continuing to support it financially.
Through workshops, study days and the Medicines Matters newsletter
work has been undertaken to promote a more open culture, where
colleagues have felt safe to report more frequently.
What next?
4
Annual Report I 2014/2015
To continue with focus on reporting medication errors and near
misses. To continue lessons learned seminars, including issues around
medication. To review training for staff in medication administration.
Reducing physical assaults on service users and staff
Why did we focus on this?
To provide a safe environment.
What did we aim to do?
Increase incident reporting so we can learn from them and have a better
understanding of any physical assaults on service users and staff. Pilot body worn cameras for staff.
What did we expect to achieve?
To reduce likelihood and impact of any physical assault/conflict. To work
in close collaboration with clinicians, the Police, CPS and court services to
ensure correct disposal.
How did we plan to
monitor and report?
Monthly reports to senior management team meetings and quarterly
reports to the trust board and commissioners.
How well did we do?
Improved awareness and increased reporting. Introduce restorative justice
programme and reviewed Prevention and Management of Violence and
Aggression training.
Opening of the new Violence Reduction Centre by the Minister for Health,
Norman Lamb in September 2014. The Centre is a new state of the art building
which provides a full range of training rooms that allow a range of scenarios to
be practiced. This includes a dedicated lecture theatre.
What next?
Focus on reducing restrictive practice and using restorative justice
programme. Introduce body worn cameras for staff.
Patient experience
Improved clinical supervision improves lessons learnt from incidents, complaints, improves team working,
patient experience and safety.
Why did we focus on this?
To ensure high uptake of clinical supervision and measure the quality of
clinical supervision and to improve emotional resilience.
What did we aim to do?
Ensure clinical supervision was in place and being utilised and revise
supervision policy.
What did we expect to achieve?
To have above 80% staff uptake on clinical supervision. To introduce a
measure of quality of clinical supervision.
How did we plan to
monitor and report?
Clinical supervision uptake is monitored via. Key performance indicator
reporting and through various governance forums.
How well did we do?
Clinical supervision uptake met the target. We completed a project/
development programme trustwide. This project demonstrated that we
met the target for efficacious supervision.
What next?
Improve training and clinical supervision. Implement revised policy.
Introduce measurement scale for quality of clinical supervision.
5
Annual Report I 2014/2015
To improve the service user experience of
engagement and communication with staff
Why did we focus on this?
To increase service user involvement in their care and to ensure a
collaborative approach to planning care.
What did we aim to do?
To review care programme approach policies and processes. Introduce
patient report (including wellness recovery action plan). Ensure user
involvement in their care and treatment.
What did we expect to achieve?
To audit patient uptake of submitting/providing a report at their care
programme approach. To monitor through patient direct feedback at
Recovery College, patients’ forum etc.
How did we plan to
monitor and report?
To audit patient uptake of submitting/providing a report at their care
programme approach. To monitor through patient direct feedback at
Recovery College, patients’ forum etc.
How well did we do?
New forms were introduced. Gradual increase in uptake of patients
providing a written report. Some patients prefer to give verbal feedback.
However, this is a positive initiative which will be continually promoted to
increase patient involvement in collaborative care planning. Working with
experts by experience to increase patient autonomy.
What next?
Patient self-advocacy course being developed within the Recovery College.
Course being developed by patients for patients in the Recovery College.
6
Annual Report I 2014/2015
Clinical effectiveness
Improve the detection and management of long term physical conditions.
Why did we focus on this?
Evidence has consistently shown that patients with mental illness have greater
physical health morbidity and mortality compared with the general population.
Many factors have been implicated and include a generally unhealthy lifestyle,
side effects of medication, and inadequate physical healthcare.
What did we aim to do?
Part 1 Screening process agreed for Diabetes, Chronic obstructive
pulmonary disease (COPD), Coronary Heart Disease (CHD), Hyper tension
Baseline International Classification of Diseases and Related Health
Problems (10th edition) (ICD10) report.
Part 2 Process for recording physical healthcare on RiO documents and
circulated to Clinical Governance Groups and Physical Health Care Groups.
What did we expect
to achieve?
To identify patients with a long term conditions, so that they could be offered
proactive care. To record these in the electronic health care records of RiO
and EMIS so that the information can be used to improve clinical care.
How did we plan to
monitor and report?
Use of QOF data to identify people with long term conditions. Audit of RiO records.
How well did we do?
QOF data shows that we are providing at least as good care with
improved outcomes as an individual would expect in the community.
What next?
Continue to offer proactive care, and identify appropriate outcome
measures for this group of patients.
7
Annual Report I 2014/2015
In light of the NHS constitution – we propose that every patient receiving care
through WLMHT should be offered the chance to participate in any part of research
Why did we focus on this?
It is important that patients are offered the opportunity to contribute
to research that may result in significant findings related to their own
condition or experience.
What did we aim to do?
Offer the opportunity to participate in research to all patients who are
deemed to have capacity to do so.
What did we expect to achieve?
To engage patients in the research agenda.
How did we plan to
monitor and report?
Through the Forensic Research Domain (FRED)
How well did we do?
All patients who were deemed to have capacity were asked to participate
in research during the course of the year, e.g. an ADHD study involved all
capacious patients.
What next?
FRED will use momentum to try and further engage patients and clinical
teams in research opportunities and in the proposal of new research themes.
To support patients with a mental health condition to stop smoking
Why did we focus on this?
To improve physical healthcare
What did we aim to do?
To continue being a non-smoking hospital. To increase awareness of risks
of smoking. To offer smoke cessation programmes to patients.
What did we expect to achieve?
To continue to be smoke free.
How did we plan to
monitor and report?
Through clinical governance and physical healthcare groups.
How well did we do?
The hospital is non-smoking and has been for some time. However, it
worked with Public Health England and NHS England to produce smoke
cessation guidelines for the Commissioners for Secure Services. The hospital also shared its experience with other services.
What next?
To continue to remain smoke-free and improve patient physical healthcare.
8
Annual Report I 2014/2015
West London Forensic Services – Clinical Service Line
Patient safety
Improving medicines safety by ensuring consistency of medication error reporting and aim to reduce the
number of medication errors.
Why did we focus on this?
To improve medicine safety at ward and service line level. We knew that
the reporting of medication incidents at the trust was much lower than in
similar organisations
What did we aim to do?
Increase medication error reporting and to learn from any medication
errors or near misses.
What did we expect to achieve?
Increase medication reporting and improve transparency with a view of
improving practice through learning from incidents.
How did we plan to
monitor and report?
Medication errors are reported electronically and collated and reviewed
through clinical governance. Run a pilot project to help us improve our
reporting of medication incidents.
Share findings at the lessons learned seminars.
How well did we do?
A trustwide initiative was launched where medication safety and learning
lessons workshops on the wards were implemented, focusing on those
areas where reporting was particularly low.
What we have found is that medication incident reporting has increased
significantly since the pilot project began. Of course the challenge for
us working here will be to keep up this good work, and so it was agreed
by the trust management team that we need to continue the project, by
continuing to support it financially.
Through workshops, study days and the Medicines Matters newsletter
work has been undertaken to promote a more open culture, where
colleagues have felt safe to report more frequently.
What next?
To continue with focus on reporting medication errors and near
misses. To continue lessons learned seminars, including issues around
medication. To review training for staff in medication administration.
9
Annual Report I 2014/2015
Reducing physical assaults on service users and staff
Why did we focus on this?
To improve patient safety and experience. A constant concern expressed
by staff via the staff survey.
What did we aim to do?
To reduce violent incidents. To improve staff de-escalation strategies.
Development of safe wards.
What did we expect to achieve?
To promote a recovery culture with an emphasis on co-production of careplans and establish a model of collaborative risk assessment.
How did we plan to
monitor and report?
Through the Restrictive Interventions Reduction and Monitoring Group.
Implementation of lessons learnt from incident reviews.
How well did we do?
Increased reporting to the police. Safe Wards programme implemented as
a pilot project on seven wards.
75% all qualified MDT staff and 100% of all patients (able and willing) have
attended a ollaborative risk assessment training (co-delivered via the
Recovery College).
What next?
To extend the safe wards programme to all wards in the CSU. Closer communication and regular joint meetings with the Met police.
Implementation of Restorative Justice Programme.
Patient experience
Improved clinical supervision improves lessons learnt from incidents, complaints, improves team working,
patient experience and safety
Why did we focus on this?
To ensure that clinical supervision is available to all professional groups.
To increase uptake of clinical supervision.
What did we aim to do?
To improve patient experience via an improvement on staff resilience and
self-awareness. To ensure reflective practice is available to all wards.
What did we expect to achieve?
An increase on the rate of uptake of clinical supervision. To have a supportive
staff culture, to improve staff engagement and staff resilience.
How did we plan to
monitor and report?
Via performance reports, SMT and Governance forums.
How well did we do?
A marked increase of staff uptake of clinical supervision.
What next?
Having increase uptake during 15/16 we are undertaking a review “quality”
of clinical supervision.
10
Annual Report I 2014/2015
To improve the service user experience of
engagement and communication with staff
Why did we focus on this?
To ensure that the principles of recovery and Individualised Care Plans are
at the centre of the patient care.
What did we aim to do?
To ensure meaningful coproduction of care-plans, individual recovery plans
and collaborative risk assessment.
What did we expect to achieve?
Greater patient/staff engagement that would lead to the enhancement of a
therapeutic and safe patient experience and a reduction of incidents.
How did we plan to
monitor and report?
To monitor through direct patient feedback via the recovery team, Meridian
project, Recovery College, patients’ forum, care programme approach etc.
How well did we do?
75% all qualified MDT staff and 100% of all patients (able and willing) have
attended a collaborative risk assessment training (co-delivered via the
Recovery College).
Implementation of efficient service user forums that are well attended
and co-chaired by service users. Marked improvement on co-production
initiatives via the recovery team.
What next?
To continue to enhance the role of recovery team and increase the
number and quality of co-production activities.
11
Annual Report I 2014/2015
Clinical effectiveness
Improve the detection and management of long term physical conditions
Why did we focus on this?
Evidence has consistently shown that patients with mental illness have greater
physical health morbidity and mortality compared to the general population.
Many factors have been implicated and include a generally unhealthy lifestyle,
side effects of medication, and inadequate physical healthcare.
What did we aim to do?
The physical health national CQUIN sought to assess cardiovascular health/
monitoring for 100 in-patients. In-patients were randomly selected from all
in-patient wards and the following factors/parameters were audited:
Smoking status
Lifestyle (including exercise, diet, alcohol and drugs)
Body Mass Index
Blood pressure
Glucose regulation
Blood lipids
What did we expect to achieve?
To establish the baseline results and implement changes to improve physical
health of service users.
How did we plan to
monitor and report?
Through the CQUIN process. National audit.
How well did we do?
On reviewing data it appears that all patients had been assessed for
alcohol and substance misuse however the data had been entered in a
different database and not always in RiO.
What next?
To focus on work set out in 2015/16 by the Commissioning for Quality and
Innovation (CQUIN) framework.
“Improving physical healthcare to reduce premature mortality in people
with severe mental illness” monitoring progress from Q2 audit to
implement improvements and verify in the Q4 audit of changes.
12
Annual Report I 2014/2015
In light of the NHS constitution – we propose that every patient receiving care
through WLMHT should be offered the chance to participate in any part of research
Why did we focus on this?
It is essential that service users are aware of research projects that are
related to their condition.
What did we aim to do?
To offer the opportunity to participate in research to all service users.
What did we expect to achieve?
Greater engagement and awareness of research initiatives.
How did we plan to
monitor and report?
Through the FRED (Forensic Research Domain).
How well did we do?
No clear evidence that patients are routinely offered the opportunity.
What next?
Will audit available data. To ensure that research activities are reported
via Governance processes. To improve/increase WLFS presence and
involvement in FRED.
To support patients with a mental health condition to stop smoking
Why did we focus on this?
High prevalence of mental health patients who smoke.
Unequivocal evidence of lower life expectancy for patients with a severe
mental disorder and reduced further as a result of smoking.
To promote healthy living as an integral part of the recovery.
What did we aim to do?
To develop a smoking cessation program leading to having a smoke free
environment by January 2016.
To ensure that the smoking status of all patients is accurately and consistently
recorded in RiO and that all smokers are offered the opportunity of being
referred to a smoking cessation programme.
What did we expect to achieve?
To ensure that all service users who smoke had been offered the opportunity
of participating on a smoking cessation programme.
How did we plan to
monitor and report?
Smoking status and referral offering to be recorded on RiO.
How well did we do?
Unclear picture. Data incomplete and difficult to extract.
What next?
A smoke free environment multidisciplinary project group with service
user involvement is in place. Action plan being developed to ensure that
all service users have access and are encouraged to take part on smoking
cessation programmes.
Smoking cessation interventions were to be recorded RiO.
Training programme for staff to support service users in place.
13
Annual Report I 2014/2015
Local Services – Clinical Service Line
Patient safety
Improving medicines safety by ensuring consistency of medication error reporting and aim to reduce the
number of medication errors.
Why did we focus on this?
To improve medicine safety at ward and Service Line level. We knew that
the reporting of medication incidents at the trust was much lower than in
similar organisations.
What did we aim to do?
Increase medication error reporting and to learn from any medication
errors or near misses.
What did we expect to achieve?
Increase medication reporting and improve transparency with a view of
improving practice through learning from incidents.
How did we plan to
monitor and report?
Medication errors are reported electronically and collated and reviewed
through Clinical Governance.
Run a pilot project to help us improve our reporting of medication incidents.
Share findings at the lessons learned seminars.
How well did we do?
A trustwide initiative was launched where medication safety and learning
lessons workshops on the wards were implemented, focusing on those
areas where reporting was particularly low.
What we have found is that medication incident reporting has increased
significantly since the pilot project began. Of course the challenge for
us working here will be to keep up this good work, and so it was agreed
by the trust management team that we need to continue the project, by
continuing to support it financially.
Through workshops, study days and the Medicines Matters newsletter
work has been undertaken to promote a more open culture, where
colleagues have felt safe to report more frequently.
What next?
14
Annual Report I 2014/2015
To continue with focus on reporting medication errors and near
misses. To continue lessons learned seminars, including issues around
medication. To review training for staff in medication administration.
Reducing physical assaults on service users and staff
Why did we focus on this?
To reduce the incidents of assault and promote safer environments. Also
in relation to our staff survey results.
What did we aim to do?
Improve communication and engagement between staff and service
users. To promote therapeutic working and safer ward environments.
Coproduction events to generate thinking and joint initiatives.
What did we expect to achieve?
Joint learning and generation of enhanced de-escalation. Development of
individual contingency care planning to identify therapeutic inventions to
minimise aggression and risk of assault.
How did we plan to
monitor and report?
Security Steering Group implemented to monitor all incidents of safety
and security.
How well did we do?
Increased reporting to the Police and also an agreed joint capacity
assessment designed for Police use in promotion of criminal justice.
What next?
Ensure increased reporting of all incidents. Effective and consistent
practice of post incident de brief and support for staff and service
users. Further clinical training for teams to identify individual stressors
and pre cursors for service user aggression and apply service user led
interventions to prevent escalation.
15
Annual Report I 2014/2015
Patient experience
Improved clinical supervision improves lessons learnt from incidents, complaints, improves team working,
patient experience and safety
Why did we focus on this?
To ensure high uptake of clinical supervision and measure of the quality of
clinical supervision and to improve emotional resilience.
What did we aim to do?
To have 25% improvement on clinical supervision. To introduce a measure
of quality of clinical supervision.
What did we expect to achieve?
To have 25% improvement on clinical supervision. To introduce a measure of
quality of clinical supervision.
How did we plan to
monitor and report?
Clinical supervision uptake is monitored through reporting from the exchange.
How well did we do?
The Clinical Supervision Policy (S26) was reviewed and updated in early
2015. Clinical supervision uptake did not reach the target. However, local
services did achieve an overall 9.3% improvement during 2014/15.
What next?
We will highlight the importance of recording clinical supervision via the
exchange and will introduce a measurement scale for quality via key
performance indicator reporting through our governance structure.
To improve the service user experience of
engagement and communication with staff
Why did we focus on this?
To achieve better patient and staff engagement to enhance the patients
recovery and transition through our services.
What did we aim to do?
To ensure care plans are co-produced with individual recovery plans. Know
exactly what our patients really think about the health services we provide?
What did we expect to achieve?
Establish a baseline on service user experience on engagement and
communication with staff.
How did we plan to monitor and report?
To monitor through patient direct feedback, Meridian service user
feedback, FFT.
How well did we do?
From our Meridian feedback system 83% of our service users said their
experience of staff was caring and responsive.
What next?
To focus on co-production of care plans, recovery plans and risk assessments.
16
Annual Report I 2014/2015
Clinical effectiveness
Improve the detection and management of long term physical conditions
Why did we focus on this?
Evidence has consistently shown that patients with mental illness have greater
physical health morbidity and mortality compared to the general population.
Many factors have been implicated and include a generally unhealthy lifestyle,
side effects of medication, and inadequate physical healthcare.
What did we aim to do?
Part 1 Screening process agreed for Diabetes, Chronic obstructive
pulmonary disease (COPD), Coronary Heart Disease (CHD), Hyper tension
Baseline International Classification of Diseases and Related Health
Problems (10th edition) (ICD10) report.
Part 2 Process for recording physical healthcare on RiO documents and
circulated to Clinical Governance Groups and Physical HC Groups.
What did we expect to achieve?
1. 90% recording of physical healthcare diagnosis
How did we plan to
monitor and report?
Part 1 Screening process agreed for Diabetes, Chronic obstructive
pulmonary disease (COPD), Coronary Heart Disease (CHD), Hyper tension
Baseline ICD10 report.
2. Increase to 100% of individuals with physical healthcare diagnosis to have this recorded within RiO care plan.
Part 2 Process for recording physical healthcare on RiO documents and
circulated to Clinical Governance Groups and Physical HC Groups.
How well did we do?
1. Recording for inpatient services >90% during year.
2. Not audited during year.
What next?
Diagnosis recording will continue to be monitored during following year.
Focus for 15/16 will be for smoke free services.
17
Annual Report I 2014/2015
In light of the NHS constitution – we propose that every patient receiving care through
WLMHT should be offered the chance to participate in any part of research
Why did we focus on this?
The NHS Constitution, Section 3a, commits “to inform you of research
studies in which you may be eligible to participate (pledge)”
What did we aim to do?
Expand the offer of participation in research to all patients.
What did we expect to achieve?
As above
How did we plan to
monitor and report?
In the hiatus following the appointment of the previous R&D director to a
chair in Edinburgh, this commitment was not taken further.
How well did we do?
Currently we do not have robust metrics to give an accurate response. We
do know overall that 957 patients were recruited into studies in 2014-15,
a slight increase on 2013-14. We cannot state how many patients were
approached but declined to participate, not how many patients participated
more than once.
It may be possible to express this number as a fraction of the overall
number of different patients with whom the trust had contact last year, but
it cannot be assumed that here was a research study appropriate for every
patient with whom the trust has contact.
What next?
18
Annual Report I 2014/2015
The intention to appoint clinical research domain leads who are clinicians
involved in service delivery in each service line is intended to increase
research recruitment. We will work with our communications team
on how to communicate effectively the opportunities for research
participation to all patients as studies open for recruitment.
To support patients with a mental health condition to stop smoking
Why did we focus on this?
• High prevalence of mental health patients who smoke (need uncovered
by undertaking an audit in 2014).
• Smoking is one of the main causes of physical ill-health and focussing
on smoking cessation will increase life expectancy and improve mental
health symptoms.
• Translating the 2013/14 CQUIN into an integrated trust key
performance indicator.
• The trust has a duty of care to focus on physical health care and
affirming responsibility for holistic care.
What did we aim to do?
• Develop a smoking cessation pathway and then tailor an appropriate
smoking cessation intervention for patients with mental health conditions.
• Up-skill staff around the harms caused by smoking and the
effectiveness of smoking cessation interventions.
• Train staff to support the referral process whilst ensuring appropriate
recording of smoking status on RiO.
• Develop an education plan to enhance patients awareness of smoking
related issues.
• Deliver smoking cessation clinics for patients and staff across Forensic
and Local Services.
• Develop an evidence base of the effectiveness of smoking cessation
within the mental health setting in order to influence trustwide culture
and attitude to smoking cessation.
What did we expect to achieve?
To some extent we were very ambitious and actually expected to achieve
all of the above. Specifically we wanted to achieve points below:
• To create an in-house smoking cessation service this incorporated the
training of staff and patients, delivery of 1:1 clinics, whilst supporting
the trust’s physical health care agenda.
• We expected a positive attitude and buy-in from staff which would
involve behavioural change in that staff would record smoking status
and support the referral of patients to clinics.
• We expected patients who smoke to have a smoking cessation care plan.
• We expected to deliver a number of smoking quitters as defined by
DoH (4 week CO validated).
• Although aiming to adapt the existing trust culture we expected
strategic support for activity.
19
Annual Report I 2014/2015
How did we plan to
monitor and report?
• Smoking status and referral offering to be recorded on RiO.
• Smoking cessation interventions were to be recorded on our smoking
cessation database Quit Manager as well as Emis.
• Quitters recorded via Quit Manager.
• Effectiveness of training (frequency and numbers attending) was to be
recorded on our outreach & training log.
• Activity and information to influence local commissioner was to be
recorded on monthly reports.
How well did we do?
• All elements that we aimed to deliver as above were delivered.
• Pathway was developed and adopted.
• Clinics were established (4 clinics across forensic and local services).
• Training was delivered across all departments in forensic and local services.
• All patients within forensic (14-15) received a psycho-educational lesson
related to smoking and physical healthcare.
• Staff training was translated into e-Learning to help adoption and uptake.
• 59 mental health patients quit smoking (DoH 4 week quitter), 30% quit rate.
• Instigated the movement toward Smokefree site as NICE guidance (PH 48
recommendation).
• Obtained board approval to work towards a Smokefree site.
What next?
20
Annual Report I 2014/2015
Reinforce the work that has already been undertaken in the previous year.
To embed good practice and enhance quality of offering and smoking
cessation interventions. Implement the Smokefree site action plan.
Looking forward - our quality priorities for 2015/16: What they will be and how we will know if we have achieved them?
The trust has introduced a model of clinical
leadership based around seven service lines to
improve the engagement of clinical staff and
their teams in leadership roles to drive quality.
The changes will result in the development of a
leadership and management structure that makes
WLMHT more accountable to its stakeholders
including patients, carers, commissioners and
staff. The new arrangements will be designed to
make the organisation more efficient, leaner and
transparent. Overall the new structure will improve
the performance of the organisation, providing
a strong basis for growth and responsiveness
in an increasingly competitive and challenging
healthcare environment’
The trust has appointed clinical leaders to the each
of the following service lines:• High secure services
The trust continues to implement the quality
strategy 2013 - 2018 which provides an overarching
framework of how we deliver services, and for
2015/16 has agreed on five quality priorities which
will support this strategy and improve patient
safety, patient experience, care and treatment
provided, they are:
• To reduce the use of restrictive interventions,
including physical restraint, seclusion and long
term segregation.
• To ensure that there is a positive and open
culture of reporting incidents and implementing
and embedding the lessons that are learnt.
• To improve communication with service users by
providing them with timely information regarding
their care, including clearly identified people who
are working with them and collaborative risk
management planning.
• To ensure that our service users and patients are
treated in the best possible clinical environments
and these are at all times clean, safe and therapeutic.
• West London Forensic Services
• Access and urgent care
• Liaison and long term conditions
• Developmental services
• To improve the physical health of our service users,
patients and staff through the implementation of
smoke free services and improved physical health
monitoring and awareness.
(See Appendix 3 ‘West London Mental Health NHS
Trust services’ for a detailed view of which services
fit into each of the service Lines)
The priorities were identified in collaboration
with our service users and carers, managerial and
clinical staff from each service line.
• Primary and planned mental health care
• Cognitive, impairment & dementia
“
“
Very much needed service (IAPT) people need to be made aware of
this service to be more accessible
because it’s really very helpful.
Once identified the priorities were then processed
through our internal governance structure
presented at service user forums, service line
SMT’s, Clinical Effectiveness and Compliance
Committee, Quality Assurance Committee and
agreed by the board. (Internal reporting structures
can be found in Annex 4).
The Quality Assurance Committee has delegated
responsibility to monitor the implementation
and progress made by each area in achieving
their selected milestones and targets to ensure
successful completion.
21
Annual Report I 2014/2015
In the tables below you will see how we set out to work on the quality priorities set for 2015/16.
Patient safety
Priority
Key
milestones
Q1
Key
milestones
Q2
Key
milestones
Q3
Key
milestones
Q4
Key
milestones
Q5
To reduce the use of restrictive interventions including:
Physical
restraints
Agree accurate
data source and
methodology.
Review data for 201415 as baseline. Outline
and introduce restraint
reduction plan.
Report against
benchmarks
(measures).
Greater use
of physical
(tertiary)
restraint as
compared with
Q2 2014.
Report against
benchmarks
(measures).
Greater use
of physical
(tertiary)
restraint as
compared with
Q3 2014.
Report against
benchmarks
(measures).
Target to be
greater of the
mean use of
tertiary over the
12 months of
2014-15
Audit report
produced
resulting in
a reduction
in each
comparable
quarter
Seclusion
Agree accurate
data source and
methodology for the
Seclusion Monitoring
and Review Group.
Review data for 201415 as baseline. Outline
Short Term Seclusion
(STS) reduction plan.
Report against
benchmarks
(measures).
Greater use
of STS as
compared with
Q2 2014.
Report against
benchmarks
(measures).
Greater use
of STS as
compared with
Q2 2014.
Report against
benchmarks
(measures).
Target to be
greater than
the mean use
of STS over the
12 months of
2014-15.
Audit report
produced
resulting in
a reduction
in each
comparable
quarter
Long term
segregation
Agree accurate
data source and
methodology. Review
data for 2014-15 as
baseline. Outline and
introduce Long Term
Segregation (LTS)
reduction plan. Work
with other organisations
on best practice
guidance on LTS.
Implement LTS
reduction plan
and benchmark
against data
from Q2 201415.
Report against
benchmarks
(measures).
Less use of LTS
compared with
Q3 2014.
Report against
benchmarks
(measures).
Target to be
that mean use
of LTS over the
12 months of
2014-15.
Audit report
produced
resulting in
a reduction
in each
comparable
quarter.
To ensure
that the is a
positive and
open culture
of reporting
incidents and
implementing
and embedding
the lessons that
are learnt
Benchmark incident
reporting for 2014/15.
Provide learning lessons
information to teams.
Increase in
reporting in
medication
errors reporting
(excluding
refusals). Audit
of feedback
of value of
learning lessons
event.
Increase in
reporting in
medication
errors reporting
(excluding
refusals). Audit
of feedback of
value of learning
lessons event.
Increase
in incident
reporting from
baseline. Audit
of feedback
of value of
learning lessons
event.
Audit report
including
benchmark
data of
Medication
Incidents.
To establish a
communications
strategy that would
ensure that information
from Incident Review
Group is summarised
and communicated
to all ward base staff
via ward Clinical
Improvement Group’s
(CIG) and staff meetings.
22
Annual Report I 2014/2015
Implementation
of the strategy.
Audit of ward
CIG minutes to
ensure effective
communication.
Ward CIG
minute audit
report.
Patient experience
Priority
Key
milestones
Q1
Key
milestones
Q2
Key
milestones
Q3
Key
milestones
Q4
Key
milestones
Q5
To improve communication with service users by providing them with timely information regarding their care including:
Clearly
identified
people who
are working
with them
Collaborative
risk
management
planning
Establish baseline
in compliance
with frequency of
lead professional
1:1 meeting with
patient.
Review welcome
letter to service/
ward to ensure
that it includes:
Details of care
team and contact
details.
Establish
baseline with
providing patient
with reviewed
welcome letter to
service including
the details of the
care team and
contact details.
Introduce HCR20
V3 training
(specialist risk
assessment
training for
Forensic Services).
Continue with
HCR20 V3 training.
Evidence at Care
Programme
Approach of user
involvement.
Benchmarking
audit for Q1 with
focus on time
to completion
from admission
and service user
involvement.
Team action plan
development with
standard based
on benchmarking
results.
10% increase of
compliance from
baseline of the
frequency of lead
professional 1:1
meeting with
patient.
10% increase
of compliance
from Q3 of the
frequency of lead
professional 1:1
meeting with
patient.
20% overall
improvement in
clearly identifying
professionals
working with the
service user.
10% increase
in compliance
from baseline
in providing the
patient with
the reviewed
welcome letter to
service including
the details of the
care team and
contact details.
10% increase in
compliance from
Q3 of providing
patient with
the reviewed
welcome letter
to the service
including the
details of the care
team and contact
details.
Audit Care
Programme
Approach user
involvement and
risk planning.
Audit Care
Programme
Approach user
involvement and
risk planning.
Training
established
and running,
training record as
evidence.
Agreed increase
in performance
against
benchmark.
10% increase
in performance
against Q3
performance.
10% increase in
performance of
collaborative risk
planning
20% overall
improvement
in compliance
of sending the
reviewed welcome
letter including the
details of the care
team and contact
details included.
I just wanted to say thank you for
your help, advice and support during
my CBT sessions with you. I feel the
process has been very helpful, and has
provided me with very useful tools and
techniques that I can apply to many
life situations. I’m steadily progressing
through the homework/resources that
you provided, which I feel have aided
me. Thank you for your time.
“
“
Agree standards
for 1:1 sessions
for the lead
professional
meeting with
patients.
Implement agreed
standards.
23
Annual Report I 2014/2015
Priority
Key
milestones
Q1
Key
milestones
Q2
Key
milestones
Q3
Key
milestones
Q4
Key
milestones
Q5
To ensure that our service users and patients are treated in the best possible clinical environments and
these are at all times:
Clean
Safe
Achieve above
85% on all areas
on 49 elements.
Agree method of
patient feedback on
cleanliness.
Achieve above
85% on all areas
on 49 elements.
Agree method of
patient feedback
on cleanliness.
Provide effective and
accurate infection
control standard
outcomes via
nursing governance
structure.
Provide effective and
accurate infection
control standard
outcomes via
nursing governance
structure.
Ligature anchor
point audit (LAP)
completed. Agree
method of patient
feedback on safety.
LAP audit update
and on update
Risk Register.
Benchmark
measure of patient
feedback on safety.
Target above 70%.
Key Performance
Indicator on
Central Alert
System (CAS) alerts.
Patients feeling
safe on wards is
Key Performance
Indicator on
Monthly Information
Return (MIR).
Therapeutic
Measure patients
experience using
satisfaction tool
(qualitative and
quantitative).
Monitor results and
action plan.
24
Annual Report I 2014/2015
Key Performance
Indicator on CAS
alerts. Patients
feeling safe on
wards is a Key
Performance
Indicator on MIR.
Action plan
implementation
based on
measurement’s in
Q1.
Q2 review other
measures of
satisfaction.
Achieve above
85% on all areas
on 49 elements.
Measure and
report of patient
feedback on
cleanliness.
(above 70%
satisfaction)
Achieve above
85% on all areas
on 49 elements.
Measure and
report of patient
feedback on
cleanliness (above
70% satisfaction).
Above 85%
compliance
with the 49
elements
audit.
LAP audit
update and on
Risk Register.
Measure of patient
feedback on safety
= Above 70%.
LAP audit
update and on
Risk Register.
Measure of
patient feedback
on safety =
Above 70%.
Reporting
outcomes on
LAP.
Key Performance
Indicator on CAS
alerts. Patients
feeling safe on
wards is a Key
Performance
Indicator on MIR.
Measure patients
experience using
satisfaction tool.
Monitor results
and actions.
Key Performance
Indicator on CAS
alerts. Patients
feeling safe on
wards is a Key
Performance
Indicator on MIR.
Action plan
implementation
based on
measurement in
Q1 & Q3.
Feedback
report
to senior
management
team
meeting
on patient
experience.
Clinical effectiveness
Priority
Key
milestones
Q1
Key
milestones
Q2
Key
milestones
Q3
Key
milestones
Q4
To improve the
physical health
of our service
users, patients
and staff
through the
implementation
of smoke free
services
Continue to
deliver smoking
cessation training
& establish the
baseline.
Review numbers
of staff trained
from the central
records and
measure the
increase from
Q1.
Review numbers
of staff trained
from the central
records and
measure the
increase from Q1.
Review numbers
of staff trained
from the central
records and
measure the
increase from
Q1.
Review Key
Performance
Indicator
information.
Promote
developed
pathway.
Ensure all areas
have smoking
cessation
information
clearly displayed.
Improved
physical health
monitoring and
awareness
To ensure that
all patients have
appropriate
investigations
at assessment.
Training
programme for
staff around
physical health.
Commence
CQUIN Target Improving Physical
Healthcare to
Reduce Premature
Mortality in People
with Severe
Mental Illness:
Measure
the amount
of patients
that have
quit smoking
through the help
and support
provided.
Implement the
Smokefree site
action plan.
Measure the
amount of
patients that have
quit smoking
through the help
and support
provided.
Continue to
implement the
Smokefree site
action plan.
Deliver training
programme for
staff around
physical health.
Deliver training
programme for
staff around
physical health.
CQUIN Audit:
Cardiometabolic
Assessment and
Treatment for
Patients.
Share CQUIN
Audit results
with the Clinical
Improvement
Groups.
CQUIN Audit:
Physical
Healthcare
Communication
with General
Practitioner’s.
Re-audit
CQUIN Audit:
Cardiometabolic
Assessment and
Treatment for
Patients.
Measure
the amount
of patients
that have
quit smoking
through the help
and support
provided.
Key
milestones
Q5
Smokefree
progress report
monitored
at Clinical
Effectiveness
and Compliance
Committee
Quarterly.
Continue to
implement the
Smokefree site
action plan.
Gain feedback
from staff on
the effectiveness
of the Physical
Health Training
Programme.
Share CQUIN
Audit results
with the Clinical
Improvement
Groups.
Feedback report
on Staff Physical
Health Training
Programme.
CQUIN Audit
Reports.
Devise action
plans.
25
Annual Report I 2014/2015
Review of Clinical Governance - recommendations
Following publication of the Savile investigation
report in June 2014, the trust reviewed its
governance and safeguarding arrangements in
order to assure the public, service users and their
families, commissioners and partners, and the
trust itself that its governance systems are strong
and effective.
The trust commissioned Professor Sue Hooton
OBE, Dr Stephen Colgan and Malcolm Rae
OBE to undertake the clinical governance and
safeguarding review.
The terms of reference were to review progress
in implementing the key quality, culture and
safeguarding recommendations from the Savile
investigation report and to assess whether services
meet the Care Quality Commission standards for
safety, effectiveness, caring, responsiveness and
good leadership.
8. Develop a shared understanding from the board
to frontline services of the trusts risks, who
owns them and how they are being addressed.
Make sure outcomes are reported at all levels.
9. Improve reviews of safeguarding referrals,
incident reporting and reviews and link
the nursing strategy to the overarching
safeguarding strategy.
The trust welcomes the report’s findings and
the independent scrutiny of our governance
arrangements as we seek to continuously improve
the quality of care we provide. In response to
the recommendations, the trust developed the
following quality improvement plan, which will
be monitored by our corporate governance team
and our Quality Assurance Committee and fully
implemented by May 2016:
The trust board received the final report in March
2015 which included the following recommendations:
1. Revise the trust’s quality strategy to focus on
quality improvement that reflects learning and
recommendations from the Francis, Berwick
and other recent publications.
1. Sustain on-going work to improve the culture of
the organisation.
2. Develop and implement trustwide quality
improvement as part of the quality strategy.
2. Ensure a cohesive approach to clinical and
managerial leadership development supported
by a range of initiatives to achieve improvement
3. Further develop clinical governance
arrangements to ensure information flows from
ward to board and provides proper assurances
on quality and risk management.
3. Expand staff engagement initiatives to include
senior management.
4. Improve the learning culture of the organisation
through more personalised clinical supervision,
reviewing outcomes of training and ensuring
lessons learnt from incidents are widely shared.
4. Provide clarity about the roles, responsibilities
and structures for the central clinical
governance team and the CSU-based
governance staff.
5. Ensure the quality strategy focuses on
continuous improvement.
5. Provide quality improvement information every month to drive positive change within
clinical teams.
6. Review the trust governance structures and
ensure service level and corporate governance
functions are integrated and that information
flows from ward to board.
7. Monitor progress at the Quality Assurance
Committee providing updates on all actions.
7. Prioritise key performance information to
ensure a better understanding from ward to
board of key safety, quality, effectiveness and
patient experience risks and mitigating actions.
26
Annual Report I 2014/2015
6. Develop personalised training, supervision and coaching packages on clinical governance.
Statements of assurance from the board
Review of services
During 2014/15 the West London Mental Health NHS Trust provided and/or sub-contracted 8 relevant
health services.
The West London Mental Health NHS Trust has reviewed all the data available to them on the quality of
care in 8 of these relevant health services.
The income generated by the relevant services reviewed in 2014/15 represents 100 per cent of the total
income generated from the provision of relevant health services by the West London Mental Health NHS
Trust for 2014/15.
Participation in clinical audits
During 2014/15, 4 national clinical audits and 1 national confidential enquiry covered relevant health services
that West London Mental Health NHS Trust provides.
During 2014/15 West London Mental Health NHS Trust participated in 100% national clinical audits and 100%
national confidential enquiries of the national clinical audits and national confidential enquiries which it was
eligible to participate in.
The national clinical audits and national confidential enquiry that West London Mental Health
NHS Trust was eligible to participate in during 2014/2015 were as follows:
National clinical audits
• Prescribing Observatory Mental Health-UK (POMH-UK): Prescribing in
mental health services
• National Audit of Schizophrenia (NAS)
National confidential
enquiries
• The National Confidential Inquiry into Suicide and Homicide for People with
Mental Health Illness (NCISH)
27
Annual Report I 2014/2015
National Clinical Audits
Prescribing Observatory Mental Health-UK (POMH-UK): prescribing in mental health services:
The trust commissioned Professor Sue Hooton OBE, Dr Stephen Colgan and Malcolm Rae OBE to
undertake the clinical governance and safeguarding review.
• POMH-UK Topic 9c - Antipsychotic prescribing for people with a learning disability.
• POMH-UK Topic 12b - Prescribing for people with personality disorder.
• POMH-UK Topic 14a - Prescribing for substance misuse: alcohol detoxification.
• National Audit of Schizophrenia (NAS).
The national clinical audits and national confidential inquiries that West London Mental Health NHS Trust
participated in, and for which data collection was completed during 2014/15, are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases
required by the terms of that audit or inquiry.
Name of National Clinical Audit
Number
Submitted
%
POMH-UK Topic 9c - Antipsychotic prescribing for people with a learning disability
10
100%
POMH-UK Topic 12b - Prescribing for people with personality disorder
86
100%
POMH-UK Topic 14a - Prescribing for substance misuse: alcohol detoxification
9
100%
Second round of the National Audit of Schizophrenia (NAS2) 2014
Audit of practice – 79
Patient – 35
Carer - 20
79%
35%
20%
Name of National Confidential Inquiry
Number submitted
%
7
54%
The Confidential Inquiry into Suicide and Homicide by People with Mental Illness (CISH)
The reports of 4 national clinical audits were reviewed by the provider in 2014/15 and West London Mental
Health NHS Trust intends to take the following actions to improve the quality of healthcare provided:
1. POMH-UK Topic 9c - Antipsychotic prescribing for people with a learning disability
Date collection: March 2015
Report Due: July 2015
Lead: Dr Nick Broughton
Re-audit: POMH to confirm date
Audit standards:
• The indication for treatment with antipsychotic medication should be clearly described in the healthcare records.
• The on-going need for antipsychotic medication should be reviewed at least once a year.
• A review of side effects should be conducted at least once a year, including measurement of blood
pressure, blood glucose and lipid profile.
Actions taken prior to re-audit:
• Report is being developed.
28
Annual Report I 2014/2015
2. POMH-UK Topic 12b - Prescribing for people with personality disorder
Date collection: October 2014
Report Due: January 2015
Lead: Dr Oliver Dale
Re-audit: POMH to confirm date
Audit standards:
• A clinician’s reasons for prescribing antipsychotic medication (i.e. target symptoms or behaviour) are
documented in the clinical records.
• There is a written crisis plan in the clinical records.
• There is evidence that the patient’s views have been sought in the development of the crisis plan.
Actions taken prior to re-audit:
• Recommendations to be agreed as report was delayed by the Royal College of Psychiatrists to March 2015.
• Further analysis of data to be undertaken on a larger sample of patients.
3. POMH-UK Topic 14a – Prescribing for substance misuse: alcohol detoxification
Date collection: March 2014
Report Due: August 2014
Lead: Dr Nick Broughton Re-audit: POMH to confirm date
This is the first cycle of this audit topic run by POMH-UK.
Audit standards
• The decision to undertake acute alcohol detoxification of an inpatient should be informed by:
o A documented assessment of drinking history and current daily alcohol intake.
o A physical examination, carried out on admission.
• Blood tests relevant to the identification of alcohol-related physical health problems (e.g. liver function tests
including GGT, albumin, full blood count, glucose and renal function tests) should be carried out during the admission
• Pharmacotherapy to treat the symptoms of acute alcohol withdrawal should be limited to a benzodiazepine,
carbamazepine or clomethiazole (derived from NICE CG 100, 1.1.3.1 and NICE CG115, 1.3.5.3).
• Phenytoin should not be prescribed to prevent or treat alcohol withdrawal seizures (NICE CG 100, 1.1.5.3
and BAP evidence-based guidelines for the pharmacological management of substance abuse, 2012)
• Thiamine should be prescribed parenterally for inpatients in acute alcohol withdrawal.
Actions taken prior to re-audit:
• Participate in the re-audit and encourage data collection of a larger sample.
• Local audit to be undertaken due to low sample.
• Obtain feedback from the services.
29
Annual Report I 2014/2015
4. Second round of the National Audit of Schizophrenia (NAS2) 2014
Date collection: October 2014
Report Due: November 2014
Lead: Professor Thomas Barnes
Re-audit: RCPSYCH to confirm date
Audit standards:
The broad aspects of care included in the standards are as below:
• Service users’ experience of care, treatment and outcomes.
• Carers’ satisfaction with the support and information they had received.
• Information and decision making about medication.
• Practice in the prescribing of antipsychotic medications.
• Availability and use of psychological therapies.
• The extent of monitoring and intervention for physical health problems.
• Care planning and crisis planning.
Actions taken prior to re-audit:
• Engage service users to obtain better understanding of the poor satisfaction scoring
• Set up co-production workshop
• Set up compassion workshop
• Use Meridian system to gain feedback
• Carers myth buster to be loaded onto the Exchange and WLMHT website
• During discussion with the service user the clinicians need to be clear and explicit to ensure that the
service user is aware what their care plan is.
• New formats for letters to service users ad GPs following CCG recommendations.
• Card with crisis information to be sent to service user with first out-patient appointment.
• Crisis plan and contingency plan to be completed with service user and carer.
The reports of 13 local clinical audits were reviewed by the provider in 2014/15 and West London Mental
Health NHS Trust intends to take the following actions to improve the quality of healthcare provided
(described in table below).
Audit
Patient Record
Audit
Lead
Medical director
Actions & Audit Frequency
-Review tool
Standards
Areas
Review of records
Inpatients
Enhanced Engagement &
Observation Policy O1
Trustwide
-Implement robust actions plans
for wards with regular questions
rating red/amber
Monthly
Observation
Audit of
Engagement
& Observation
Practice
Director of nursing
& patient experience
30
Annual Report I 2014/2015
Engagement & Observation info
available to all patients with a
copy of their engagement and
observation care plan
Monthly
Audit
Lead
Actions & Audit Frequency
NICE Infection
Control
Director of nursing &
patient experience +
infection control lead
Actions not yet available
Hand Hygiene
Director of nursing &
patient experience +
infection control lead
Actions not yet available
Self-assessment
checklist:
eliminating
mixed sex
accommodation
Director of nursing
& experience
Actions not yet available
NICE guideline
29 pressure
ulcer
Director of primary
care
Report not yet available
Clinical coding
Medical director
Action plan being devised
reflecting the recommendations
set out by the London Clinical
Coding Academy
Annual
Standards
Areas
NICE Clinical Guideline
139
Trustwide
10 Standards
Trustwide
Single sex
accommodation
checklist
Trustwide
NICE guideline 29
pressure ulcer
Trustwide
Primary & secondary
IC10 Coding
Inpatients
The standards within this
audit are derived from
National and trustwide
safety polices, guidelines
and procedures and local
ward operational polices.
Inpatients
ICP12 MRSA Policy
Section 7
Inpatients
NICE
Inpatients
Annual
Annual
Adhoc
Annual
Senior nurse
walkabout
checklist
Director of nursing
& experience
Local leads are to ensure that
the checklist is completed
monthly for each ward and
areas of concerned are acted
upon immediately.
Monthly
MRSA
Director of nursing &
patient experience +
infection control lead
Amendments to the tool to
include the routing of questions
Training on completion of audit
tool following discrepancies
within data submitted
Quarterly
Medicine
reconciliation
Medical director
Audit to be discussed in local
clinical governance and audit
groups and CSU action plans
developed and fed back to MMG
Trust policy M11
Every two years
Community
survey
Director of nursing
& experience
Quality improvement plan
complete
Survey
Community
services
Survey
Inpatient
services
MHA 2007
Local
services
Annual
Inpatient
survey
Director of nursing
& experience
Quality improvement plan
complete
Annual
Section 136 completion of
documentation
Medical director
Re-audit September-December
to gain further intelligence
31
Annual Report I 2014/2015
National Confidential Enquiries:
The National Confidential Inquiry into Suicide and Homicide for People with Mental Health Illness (NCISH).
As part of its core work the Inquiry examines suicide, and homicide committed by people who had been in
contact with secondary and specialist mental health services in the previous 12 months. It also examines
the deaths of psychiatric inpatients which were sudden and unexplained. It continues to provide definitive
figures for suicide and homicide related to mental health services in the UK.
This year we became a volunteer trust, providing feedback on their draft scorecard. The scorecard consists
of 6 indicators – suicide rate, homicide rate, rate of sudden unexplained death, patients under CPA, staff
turnover and NCISH questionnaire response.
Mental HealthTrust’s have been categorised into 5 equal groups (quintiles) and show the range of actual
results across trust’s in England in addition to our trust score. Due to the variation some of the quintiles have
a wider distribution of results than others though each quintile consists of the same number of trust’s.
Suicide rate
The suicide rate in your trust was 5.9 (per 10,000 mental health contacts*) between 2011-13 and in the low
quintile compared to other mental health providers in England.
Suicide rate
Lowest
Low
Suicides
Average
High
15.0
13.0
11.0
9.0
7.0
5.0
3.0
1.0
Highest
Your trust
Homicide rate
The homicide rate* between 2011-13 was 0.2 (per 10,000 mental health contacts) and in the average
quintile group compared to other mental health providers in England.
Homicide rate
Lowest
Homicide
Low
Average
High
32
Annual Report I 2014/2015
2.0
1.5
1.0
0.5
0.0
Highest
Your trust
Sudden unexplained deaths (SUD)
The SUD rate* was 1.8 and in the average quintile group compared to other mental health providers in England.
Sudden unexplained deaths (SDU)
Lowest
Low
SUD
Average
High
Your trust
12.0
10.0
8.0
6.0
4.0
2.0
Highest
% on Care Programme Approach (CPA)
The % of people on CPA was 23% and in the high quintile compared to the other mental health providers
in England.
% on Care Programme Approach (CPA)
Lowest
Low
CPA
Average
High
0%
20%
40%
60%
80%
100%
Highest
Your trust
Staff turnover
Non-medical staff turnover was 10.2% and in the high quintile in mental health providers across England.
Staff turnover
Lowest
Staff turnover
(non medical)
Low
Average
High
20%
15%
10%
5%
0%
Highest
Your trust
33
Annual Report I 2014/2015
Trust response rate
You have returned 97% of NCISH questionnaires in 2014. This is a high figure but below the national return rate.
Trust response rate
Trust response rate
Lowest
Highest
Your trust
Average
rate
Internal audit reports
What Baker Tilly, our internal auditors said:
The scope of all the audits was to evaluate the
adequacy of risk management and control within
the system and the extent to which controls have
been applied, with a view to providing an opinion.
Baker Tilly uses the following dashboard rating for
the outcomes of the audits:
Red: Taking account of the issues identified, the
board cannot take assurance that the controls
upon which the organisation relies to manage this
risk are suitably designed, consistently applied or
effective. Action needs to be taken to ensure this
risk is managed.
Amber 1: Taking account of the issues identified, the
board can take reasonable assurance that the controls
upon which the organisation relies to manage this
risk are suitably designed, consistently applied and
effective. However we have identified issues that, if not
addressed, increase the risk materialising.
Amber 2: Taking account of the issues identified,
whilst the board can take some assurance that
the controls upon which the organisation relies to
manage this risk are suitably designed, consistently
applied and effective, action need to be taken to
ensure this risk is managed.
Green: Taking account of the issues identified,
the board can take substantial assurance that the
controls upon which the organisation relies to
manage this risk are suitably designed, consistently
applied and effective.
34
Annual Report I 2014/2015
100%
95%
90%
85%
80%
75%
70%
65%
60%
National
Rate
Governance audit
The result from this audit produced an Amber/
Green status.
This audit focussed on a sample of committees
including QAC and its sub-committees and the 7
CSU groups reporting into the trust sub-committees.
Key recommendations were to streamline the
committees to enable timely information flow,
review terms of reference annually, ensure
committees provide an annual review of their
performance to QAC including a register of
attendance and ensure meetings are quorate
before commencing.
Taking account of the issues identified, the
board can take reasonable assurance that the
controls upon which the organisation relies on to
manage this particular risk are suitably designed,
consistently applied and effective. However we
have identified issues that, if not addressed,
increase the likelihood of the risk materialising.
In total there were eight recommendations, six
medium and two low.
These will all be completed by October 2015.
The result from this audit produced an Amber/
Green status.
The summary concluded that the trust was
performing quite well and the design of the control
framework was good however there were a number
of areas with required improvements; delays
between an incident occurring and it being recorded
on the Exchange were still evident, some action plans
did not have an identified co-ordinator, as required
by policy and in some cases there was no evidence
that unimplemented actions had been escalated and
recorded on the appropriate risk register.
In total there were seven recommendations, three
medium and four low.
The recommendations have now been implemented.
Compliance with mental health act audit
The result from this audit produced an Amber/
Green status.
Generally, systems were thought to be working
well but a number of areas for improvement had
been identified. The recommendations relate to the
application of the control framework – not its design
– and included recording on the Mental Health Act
register reasons for any doctor not having a S12
registration or Approved Clinician status, reconciling
the register with HR records of clinical staff working
within the trust, the undertaking of audit-based
activities to periodically test Mental Health Act
compliance and the establishment of a process to
ensure actions required in response to CQC Mental
Health Act Monitoring visits were completed and to
the standard required by the CQC.
“
“
Lessons learned and incident management audit
The service you have provided
me with have helped me to
get through the most difficult
time of my life. I am not sure
if I would have coped without
XX. She has been absolutely
fantastic. She helped me to
remain positive and helped
me to think aloud and helped
to deal with issues separately.
The service you provide is
excellent. Please keep up the
good work. I can’t say thank
you enough.
Service user feedback audit
The result from this audit produced an amber/
green status.
The weaknesses identified were in relation to how
the trust communicates the range of opportunities
for feedback and the importance it places on
feedback to service users and the public on a
regular basis. The recommendations included
developing a service user feedback operational
procedure, reporting to the board or committee
on the 2014 Learning Lessons conference and
developing a dedicated section on the trust website,
updated at least quarterly, that demonstrates the
trust’s approach to patient feedback.
In total there were 2 medium recommendations.
The recommendations have now been implemented.
The review was underway to examine all CQC visit
report responses from the last 12 to 18 months, to
ensure that actions had either been implemented
as required or, if not, that robust reasons for noncompliance were documented.
In total there were 4 medium recommendations.
The recommendations have now been implemented.
35
Annual Report I 2014/2015
Participation in clinical research
The number of patients receiving relevant health
services provided or sub-contracted by West
London Mental Health NHS Trust in 2014/15 that
were recruited during that period to participate in
research approved by a research ethics committee
was 957 (948 in 2013/14).
Throughout the year, the trust has been involved in
85 studies (132 in 2013/14); 63 were funded (83 in
2013/14) of which 8 were commercial trials (25 in
2013/14), and 22 were unfunded (49 in 2013-14). Over the past year researchers associated with the
trust have published 86 articles (77 in 2013/14) in
peer reviewed journals.
Commissioning for Quality and
Innovation (CQUIN)
CQUIN is a payment framework which enables our
commissioners to reward excellence, by linking
a proportion of our income to the achievement
of local quality improvement goals, securing
improvements in quality of services and better
outcomes for patients, whilst also maintaining
strong financial management.
Our commissioners plan challenging but realistic
CQUIN schemes which are set out in a standard
contract. There are also a number of national
CQUIN schemes and non-participation in any
should result in non-payment of that proportion of
CQUIN funding. Whilst the minimum requirements
for providers are set nationally, we will work with
our local commissioners to ensure that plans are
aligned with local commissioning strategies.
A proportion of West London Mental Health NHS
Trust income in 2014/15 was conditional upon
achieving quality improvement and innovation
goals agreed between West London Mental Health
NHS Trust and any person or body they entered
into a contract, agreement or arrangement with for
the provision of relevant health services, through
the Commissioning for Quality and Innovation
payment framework.
Further details of the agreed goals for 2014/15 and
for the following 12 month period from July 2015
will be available on our trust website, ongoing work
is taking place to ensure this information is readily
available: http://www.wlmht.nhs.uk/
36
Annual Report I 2014/2015
Local services
The following CQUIN targets were set for Local Services in 2014/15, including 3 national and 4 local CQUINs
and this is how they measured.
Local Services CSU
Q1
Q2
Q3
Q4
Patients
N/A
N/A
Met
Met
Met
N/A
N/A
N/A
Ealing, Hammersmith & Fulham and Hounslow
1. Friends and family test
Staff
2. Improving physical healthcare to reduce premature mortality
Cardio metabolic assessment for patients with schizophrenia
Met
N/A
Met
Met
Communications with GP’s
Met
Met
N/A
Met
Partially
met
Met
Met
Met
Met
Met
Met
Met
3. NHS safety thermometer (NST)
Shared care prescribing
4. Shared patient records and real time information systems
5. Mental health tariffs
Clustering data quality preparation for the introduction of local tariff from 2015/16
Met
Met
Met
Met
Develop integrated care pathways
Met
Met
Met
Met
Use of clinician rated outcome measures (CROM’s)
Met
Met
Met
Met
6. Children’s well-being
Safe transfer of care for all CAMHS patients as they reach their 18th birthday
Met
Met
Met
Met
Safe transfer of care for all CAMHS inpatients
Met
Met
Met
Met
Improving the quality of assessment and care planning for parents with mental health needs
Partially
met
Partially
met
Met
Met
7. Urgent access and assessment – safe transfer of care to integrated services, for all adults including dementia and learning disabilities
Improving and extending access to urgent/emergency secondary mental health assessment
Met
Met
Met
Met
Safe transfer of care – shared care communication
Met
Met
Met
Met
Enabling quality improvement and safe transfer of care through training
Met
Met
Met
Met
37
Annual Report I 2014/2015
West London Forensic Services
The following CQUIN targets were set for West London Forensic Services in 2014/15, including 2 national
and 5 local CQUINs and this is how they measured.
Forensic Service CSU
Q1
Q2
Q3
Q4
Patients
N/A
N/A
Met
At risk due
to poor
response
rate
Met
N/A
N/A
N/A
Met
Met
Met
Met
3. Improving care pathways in secure CAMHS
Met
Met
Met
Met
4. Enhancing family support in secure CAMHS
Met
Not met
Partially
met
Met
5. Collaborative risk assessments
Met
Met
N/A
Met
6. Needs formulation at transition
Met
Partially
met
Met
Met
7. Collaborative audit workshop HSS
Met
Met
Met
Met
1. Friends and family test
Staff
2. Improving physical healthcare to reduce premature mortality
Cardio metabolic assessment for patients with schizophrenia
38
Annual Report I 2014/2015
High Secure Services
The following CQUIN targets were set for High Secure Services in 2014/15, including 2 national and 7 local
CQUINs and this is how they measured.
High Secure CSU
Q1
Q2
Q3
Q4
Patients
N/A
N/A
Met
Met
Met
N/A
N/A
N/A
Met
Met
Met
Met
3. Changes in demand for high secure care
Met
Met
Met
Met
4. Best practice for LTS patients
Met
Met
Met
Met
5. Supporting observations
Met
Met
Met
Met
6. Better ways of involving carers
Met
Met
Met
Met
7. Recovery oriented practice
Met
Met
Met
Met
8. Social visits via video conferencing
Met
Met
Met
Met
9. Nutritional monitoring of the patients shop
N/A
N/A
Met
Met
1. Friends and family test
Staff
2. Improving physical healthcare to reduce premature mortality
Cardio metabolic assessment for patients with schizophrenia
39
Annual Report I 2014/2015
West London Mental Health NHS Trust is required
to register with the Care Quality Commission (CQC)
and its current registration status is ‘registered
without conditions.
The Care Quality Commission has not taken any
enforcement actions against West London Mental
Health Trust during 2014/15.
West London Mental Health NHS Trust has not
participated in any special reviews or investigations
by the Care Quality Commission during this
reporting period.
During 2014/15 the CQC inspectors visited 24 of
our service areas across the trust. Of these visits all
of them were unannounced.
• 12 Broadmoor Hospital
• 12 London Sites
The outcome of the inspections was successful,
with all of the areas found to be compliant with
both mental health act requirements and the
essential standards that they were assessed
against. There were areas where further
improvements could be made and full actions
plans were put in place to address these matters.
In November 2014 the CQC made an
unannounced visit to Broadmoor Hospital in
response to concerns regarding the staffing levels
which could be having an impact on the people
who use their services.
“
I am writing to you to compliment
all staff on care you provide to
your patient. I have known xxx
for many years, but the last
6-8 weeks showed me a “new
person”. I don’t remember xxx
looking so well, and what is more
important, behaving so well.
Whatever the staff is doing, is
something extraordinary.
“
Care Quality Commission (CQC) compliance
Five inspectors, a Mental Health Act Reviewer and a
Specialist Advisor (Consultant Forensic Psychiatrist)
visited 5 wards and the day services.
They spoke with service users, staff of all different
professions, reviewed patient records and any
relevant information provided by the trust to
inform their judgement.
CQC found that people were provided with care
and treatment from a skilled and committed
workforce and were very positive about the
support they received from staff. There were
programmes of therapeutic activity, with a
strong focus on recovery. Care plans and risk
assessments were comprehensive and up to date.
Staffing levels had been identified as an issue but
there were plans in place to address this which had
already made improvements, and they found that
staffing was being maintained at a safe level.
Their judgement was full compliance with the
standards assessed:• Care and welfare of people who use services.
• Staffing.
• Supporting workers.
40
Annual Report I 2014/2015
Quality indicators
The following section of the quality account describes how we have performed against a core set of
indicators as set out NHS (quality accounts) amendment regulations 2012 related to NHS outcomes
framework domains. We have reviewed these indicators and are pleased to provide you with our position
against all indicators relevant to our services for the last two reporting periods (years).
1. Care Programme Approach 7 Day Follow-Up: Percentage of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric in-patient care
during reporting period.
This measure enables us to ensure our service user’s needs are cared for and remain safe following
discharge from hospital to community care.
2014/15
2013/14
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
93.92%
95.20%
95.40%
96.70%
97.71%
96.01%
96.48%
95.14%
National average
*n/a
97.30%
97.30%
97.00%
97.41%
96.71%
97.47%
97.44%
Highest nationally
*n/a
100%
100%
100%
100%
100%
100%
100%
Lowest nationally
*n/a
90.00%
91.50%
93.00%
93.30%
77.22%
90.70%
94.10%
WLMHT
WLMHT annual outturn
Target
95.31%
96.34%
95%
95%
Data Source: http://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/
*n/a – data not available at date of publication ** taken from internal system as national data not available at date of publication
West London Mental Health NHS trust considers that this data is as described for the following reasons: the
data has been extracted from central department of health (DOH) repository and correlates with the data
submitted by West London Mental Health NHS Trust during the reporting periods.
West London Mental Health NHS Trust has taken the following actions to improve this percentage, and so
the quality of its services by:
• Further investigation and refinement of the Key Performance Indicator (KPI) definition in order to
ascertain classes of patients who should be included or excluded.
• Monitoring compliance routinely via the trust’s integrated performance report and the individual clinical
service unit (CSU) scorecards to identify clients discharged and followed up and/or requiring action.
• Continued monitoring of non-compliance using the trust’s business intelligence tools.
• Identifying any areas of underperformance and feeding back for service improvements. The indicator is
reviewed locally and via the trust governance framework (see annex 5).
• We will also be doing some work to gain knowledge of the quality of our seven day follow-up
appointments and our service users experience of the follow up appointment.
41
Annual Report I 2014/2015
2. Crisis Resolution Gate Keeping: Percentage of admissions to acute wards for which the Crisis
Resolution Home Treatment Team (CRHTT) acted as a gate keeper during the reporting Period.
The crisis resolution teams provide prompt and effective home treatment for people in mental health
crisis and quickly determine whether service users should be admitted to hospital or if suitable for home
treatment. It is important to our service users that they are treated effectively and promptly in the most
appropriate settings of care.
2014/15
2013/14
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
95.99%
96.80%
95.20%
98.00%
97.52%
99.37%
99.39%
99.42%
England average
*n/a
97.80%
98.50%
98.00%
98.20%
98.64%
98.67%
97.68%
England highest performer
*n/a
100%
100%
100%
100%
100%
100%
100%
England lowest performer
*n/a
73.00%
93.00%
33.30%
0.00%
85.48%
89.80%
74.50%
WLMHT
WLMHT annual outturn
Target
96.50%
98.93%
95%
95%
Data Source: http://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/
*n/a – data not available at date of publication ** taken from internal system as national data not available at date of publication
West London Mental Health NHS Trust considers that this data is as described for the following reasons:
the data has been extracted from central department of health repository and correlates with the
data submitted by West London Mental Health NHS Trust during the reporting periods. Compliance is
monitored routinely via the trusts business intelligence tool which identifies clients who were gate kept on
admission. This helps the service identify any areas where actions are required. Performance is monitored
through the trusts governance framework (see annex 5).
West London Mental Health NHS Trust has taken the following actions to improve this percentage, and so
the quality of its services by:
• Embedding consistent admission protocols across all trust sites where the same care specialities are delivered.
• Continue to monitor and report routinely to all relevant areas across the trust.
42
Annual Report I 2014/2015
3. Readmission Rate: The percentage of patients readmitted to a hospital which forms part of the
trust within 30 days of being discharged from a hospital which forms part of the trust during the
reporting period.
Readmission rates are monitored primarily to provide assurance that large numbers of service users are
not being readmitted to the hospital post discharge within a short period of time. It is important for us to
measure this, so we can monitor and review our clinical practice of safe discharge and as a reflection of
how effectively we manage our service users within our community services. We are pleased to report our
readmission rates within 30 days of discharge are below 10% target.
2014/15*
2013/14
2012/13
2011/12
0%
0%
0%
0%
15 years or over
7.04%
8.10%
8.10%
7.80%
Target
<10%
<10%
<10%
<10%
0 to 14 years
West London Mental Health NHS Trust considers that this data is as described for the following reasons: the
West London Mental Health NHS Trust figure is sourced locally from our clinical system (RiO). The percentage
is based on all readmissions within 30 days as a percentage of all discharges including local services and
specialist and forensic services. No comparable national benchmarking has been available.
West London Mental Health NHS Trust has taken the following actions to improve this percentage, and so
the quality of its services by:
• A full review of discharge and readmissions is being conducted.
43
Annual Report I 2014/2015
4. Staff recommendation of the trust as a place to work or receive treatment
Measure
Staff recommendation
of the trust as a place to
work or receive treatment
WLMHT
Performance
2014
WLMHT
Performance
2013
National
average for
MH trusts
Highest MH
trust score
Lowest MH
trust score
3.43/5
3.47/5
3.55/ 5
4.15/ 5
3.01/ 5
West London Mental Health NHS Trust considers that this data is as described for the following reasons:
The data is taken from the national NHS survey 2014 and is considered a reliable data source.
West London Mental Health NHS Trust has taken the following actions to improve this percentage, and so
the quality of its services by: a major initiative is being undertaken by WLMHT to improve staff engagement.
This includes a number of enablers and related actions to improve this percentage score, and so the quality
of its services by:
• Being clear and consistent about our vision and strategy so that staff understand what the trust is aiming
to achieve and how their role contributes.
• Engaging managers and empowering them to adopt a positive management style which encourages and
rewards staff rather than one which restricts and controls.
• Embedding our values from the top down – achieving culture change starts with the leadership of the
organisation.
• Promoting and improving staff health and wellbeing within the workplace.
• A number of initiatives are being undertaken by West London Mental Health NHS Trust to improve staff
engagement and motivation. These include:
- Monthly listening events held by the chief executive and other senior members of staff where concerns
and questions are received. Giving staff ‘a voice’ so they are listened to and know that their options
count and enabling them to express concerns openly.
- Trustwide learning lessons conferences look at specific incidents and how we can improve the way we
share learning. The conference also covers positive examples showcasing good practice is shared.
- Staff members were recruited as reporters to interview colleagues and report back to the board with
their findings resulting in an action plan and a number of projects to address concerns raised.
• This work is being led by our director of organisational development & workforce – Rachael Monech and
overseen by Staff Engagement Committee.
44
Annual Report I 2014/2015
5. The trust’s “patient experience of community mental health services” indicator score with
regard to a patient’s experience of contact with a health or social care worker during the
reporting period.
CQC National Community Mental Health Service user survey
2014
2013
Highest
Lowest
Did this person listen carefully to you?
8.3
8.7
8.9
7.7
Did this person take your views into account?
7.1
8.3
8.9
7.7
Did this person treat you with respect and dignity?
8.1
8.9
9.0
7.8
Were you given enough time to discuss your condition and treatment?
7.4
8.2
8.4
7.2
Overall, how would you rate the care you have received from NHS
Mental Health Services in the last 12 months?
6.5
7.0
8.7
7.3
Data source: http://www.cqc.org.uk/survey/mentalhealth/RKL Scores are based on marks out of 10
West London Mental Health NHS Trust considers that this data is as described for the following reasons:
The survey is used to gain a better understanding of what service users think about their care and
treatment provided by West London Mental Health NHS Trust. The data produced from this survey is
included in the quality and risk profile which contributes to our compliance with the essential standards of
quality and safety set by the government. The data is sourced from the CQC website.
West London Mental Health NHS Trust has taken the following actions to improve this percentage, and so
the quality of its services by:
• Undertaking a review of the current feedback mechanisms available to service users
• Inviting service users and carers to our annual learning lessons events
• Presenting our patient surveys at our board meetings
• Setting up and funding the West London Collaborative which is a community led consultancy working across
north west London to co-produce better and braver solutions to local health and social care challenges.
45
Annual Report I 2014/2015
6. The number and, where available, the rate of patient safety incidents reported within the trust
during the reporting period, and the number and percentage of such patient safety incidents
that resulted in severe harm or death.
The purpose of this indicator is to help monitor shifts in the risk of severe harm or death to patients and
to identify new emerging risks so that we are able to proactively identify potential impacts on patient care.
Trusts that have high reporting figures have a better safety culture.
Indicator
Performance
2014-15
Q3/Q4
2014-15
Q1/Q2
2013-14
Q3/Q4
2013-14
Q1/Q2
Severe
harm/death
WLMHT
0.5% (6) *
0.9% (8)*
1.1% (11)
1.3% (13)
National average
n/a **
1.0% (1361)
Not available
Not available
Highest MHT
n/a **
5.9% (65)
No data
No data
Lowest MHT
n/a **
0%
0%
0%
Data source: http://www.nrls.nhs.uk/resources/?entryid45=135195
* The figures in brackets represent the number of inpatient incidents reportable to the NPSA for severe harm or death to patient, as
recorded on our internal system.
** The data was not available from the data source above at time of publication.
West London Mental Health NHS Trust considers that this data is as described for the following reasons:
• The data for national figures is taken from the National Reporting and Learning System (NRLS)
feedback reports.
• Data has been verified by them up to and including 31 March 2015
• The national average and highest and lowest mental health trust was provided by the NRLS in their six
monthly feedback reports.
West London Mental Health NHS Trust has taken the following actions to improve the rate and so the
quality of its services by:
• Following up on the actions and recommendations from the review of the severe harm and death incidents.
• Holding regular learning lesson events.
• Improving system processes for quality checking and timeliness of reported date.
This has resulted in a sustainable improvement in our reporting rate and number of days taken to report
incidents to the NRLS.
We recently held a learning lessons event where reporting incidents was a key theme throughout the day.
At the date of publication no reports for 2014/15 were available from the NRLS, hence incidents reported
above have been taken from internal systems.
46
Annual Report I 2014/2015
Quality indicators – other indicators
Delayed transfers of care
This indicator measures the percentage of inpatients beds that are being used by service users who are
ready to move on from the hospital environment once they are safe to discharge.
We believe service users should receive the right care, in the right place, at the right time, and work closely
with partner agencies to minimise the length of hospital stay for users ready for discharge. In 2013/14 we
reduced our delayed discharges from 6.4% to 5.5%, remaining well within the target of 7.5%.
The table below shows our trustwide performance over the last four years:
% Delayed transfers of care
2014/15*
2013/14
2012/13
2011/12
Target
4.20%
5.75%
4.57%
4.66%
< 7.5%
*2014/15 is based on internal working as published data is not available yet (as of 16/04/15)
The trust recognises that good data quality is a key tool in ensuring the delivery of high quality and safe care,
and to help identify areas for improvements. Quality data is the foundation for provision of information and
intelligence that supports decision making and improvements in our care.
As a trust, we are continuously focusing on providing better and more accessible information to our staff who
are encouraged to access relevant information and tools to monitor and improve practices.
West London Mental Health NHS Trust will be taking the following actions to improve data quality:
• The data quality managers will ensure data is complete and correct by working closely with clinicians to
improve data recording processes and effective use of our clinical systems.
• There will be continued use of automated data quality reports to monitor data quality, and for staff to identify
and resolve specific data quality issues.
• There will be focus on Payment by Results (PbR) cluster information and use.
• There will be ongoing review of our information assurance framework which identifies gaps in controls or
assurance with subsequent action plans.
• There will be a review on our current clinical coding processes.
• We will continue to review and monitor our internal and external benchmarking data’.
Quality Improvement Map
The information in the Quality Improvement Map is used to inform the service area clinical improvement
groups to help them to identify any emerging themes, concerns or improvements required.
The information provided is displayed in the clinical areas on the quality notice boards.
It helps the teams to ask:
• How do I know that the service we are providing is safe, effective and of high quality?
• What are the next improvements we need to make?
• What support and/or risks do we need to escalate to the Clinical Service Unit (CSU) leadership team?
47
Annual Report I 2014/2015
NHS Number and General Medical
Practice Code Validity
West London Mental Health NHS Trust submitted
records during 2014/15 to the secondary uses
service for inclusion in the Hospital Episode Statistics
which are included in the latest published data. The percentage of records in the published data:
- which included the patient’s valid NHS Number was:
• 99.2% for admitted patient care;
In all cases the role of the management
responder is to:
• 99.7% for outpatient care; and
• Listen and offer advice.
• N/A for accident and emergency care.
• Record the information.
- which included the patient’s valid General
Medical Practice Code was:
• Not to make a judgement on the validity of the concern.
• 99.9% for admitted patient care;
• Not give a personal opinion.
• 99.9% for outpatient care; and
• Stay impartial at all times.
• N/A for accident and emergency care.
Quarterly reporter forums
West London Mental Health NHS Trust was not
subject to the Payment by Results clinical coding
audit during the reporting by the Audit Commission.
The trust continues to hold quarterly reporter
forums where staff attend act as a ‘speak up’
champions for the trust. They encourage staff to:
Improving staff engagement
• Raise concerns through the whistleblowing
policy, Speak up Friday initiative and external
whistleblowing support lines.
The trust continues to have quarterly staff
engagement committee which sits as a formal subcommittee of the board, monitoring the progress
and impact of the staff engagement action plan.
• Provide feedback on trust employment policies/initiatives.
Speak up Friday
We are currently recruiting more reporters to
ensure that the group is representative of our staff
professional groups across the trust sites.
Speak up Friday is an initiative to during 2014 to
allow staff to raise issues confidentially by speaking
to a senior member of our staff.
Each Friday, a different senior manager will be on
a rota and is available all day to take phone calls,
respond to emails, or meet with anyone who wants
to raise a work-related concern.
Their role is to work with the individual to give
support and seek a resolution to the issue.
Staff can call or email at any time during office
hours, Monday to Friday, to make an appointment
to meet with or talk to the Speak up Friday
manager on call that week.
48
Annual Report I 2014/2015
• Be involved in action groups/projects aimed at
improving staff engagement and satisfaction.
Information Governance Toolkit
Out of the 45 IG toolkit requirements WLMHT has met
• Level 1 for 2 requirements
• Level 2 for 28 requirements and
• Level 3 across 15.
The overall rating was unsatisfactory due to the
fact that we did not reach level two or above on
two of the requirements 514 and 516. These deal
with Clinical Coding and training in Clinical Coding
and there are plans in place on how to raise those
up to level two in the coming months.
Part 3: Other information - review of quality performance
Message from the medical director, Dr Nick Broughton
As I write, the trust is preparing to be inspected
by the Care Quality Commission later this
year. We learnt of this planned inspection
shortly before Christmas last year. Whilst the
announcement has served as a catalyst for
change, it has also reinforced the importance of
work that was already in train across the trust to
improve the quality of services we provide to our
service users and patients.
Maintaining and indeed improving the quality
of care we provide remains a considerable
challenge in these times of austerity. In response
to such financial pressures we have over the
last year, like all NHS organisations, introduced
a range of cost improvement initiatives. I am
pleased to report however, that these have been
closely scrutinised and monitored to ensure that
they not only do not compromise the quality of
care we provide but wherever possible help to
improve quality.
High quality mental health care should by
definition also be efficient care. The trust is
therefore committed to developing innovative
and evidence based models of care which use
the resources available as effectively as possible.
With this in mind I am pleased to report that both
the development of Broadmoor Hospital and
the building of a new Medium Secure Unit on
the St Bernard’s site have continued to progress
well. These new facilities will allow our staff to
implement new clinical models and allow them to
spend as much time as possible engaged in direct
clinical care with our service users and patients.
The trust has continued to invest in its workforce
through the delivery of high quality training and
leadership development projects. The evidence
highlighting the importance of staff engagement
in relation to the quality of care provided by
healthcare organisations is compelling, and so
improving staff engagement will remain a high
priority for us at the trust.
49
Annual Report I 2014/2015
Last year also saw the development and expansion
of a number of our clinical services. The trust’s
highly regarded liaison psychiatry service was
expanded with the recruitment of a number of
highly able clinicians and a perinatal psychiatry
service was introduced with the support of
our commissioners. The year also saw the
development of a primary mental health service
across our 3 boroughs with community nurses now
working in close collaboration with GPs and other
colleagues in primary care to support service users
who previously would have required treatment
and support from traditional community mental
health teams. The service has been well received
by service users and going forward the model will
be expanded as we seek to transform the way we
provide mental health services in keeping with
both the desires of those who use our services and
identified best practice.
The development of the service is also a reflection
of the trust’s commitment to work in collaboration
with partner organisations and to develop
innovative models of care. This commitment is
highlighted by our contribution to Imperial College
Health Partners’ Mental Health Programme. The
partnership last year launched a comprehensive
psychosis pathway for North West London which
was developed by a team led by one of the trust’s
consultants and supported by a number of other
colleagues from the trust. The pathway will now
be implemented across North West London and
will help ensure that the treatment we provide to
individuals suffering from psychotic conditions is
consistent with best practice and delivers the best
outcomes possible.
The trust also embarked on a number of patient
safety initiatives with Imperial College Health
Partners particularly aimed at improving the
measurement and monitoring of patient safety.
Pilot projects have recently commenced and these
will be developed during the year ahead.
50
Annual Report I 2014/2015
Such projects reflect the trust’s commitment
to continuously improve the quality of care we
provide. This commitment is manifest in our
quality priorities for 2015/16. The priorities reflect
key themes and trends which emerged from
last year’s inpatient and community surveys and
were developed following a lengthy period of
consultation. I am particularly pleased that we
have committed to reducing the use to restrictive
practices across our inpatient sites, something I
know will be welcomed by those who use such
services. In addition the commitment to become a
smoke free organisation by the end of the financial
year is welcomed and a reflection of our desire to
improve the physical health or our service users
and our patients.
We clearly continue on a journey to improve the
quality of care we provide. Last year saw the
development of a new vision for the trust, to be
an outstanding healthcare provider, committed to
improving quality and caring with compassion. The
visit by the Care Quality Commission later this year
will be a step on the road to achieving this goal.
Signed
Dr Nick Broughton, medical director
Date
25th June 2015
What service users, carers and the public say - key messages and actions taken during 2014/15
The trust wants to hear and receive feedback from
our service users and carers to help us improve
our services. We have a variety of methods
available to service users and carers. We are
currently reviewing the provisions we offer in a
newly formed task and finish group, this group will
look at all of the different feedback mechanisms
and review where the gaps are.
During the reporting period 1st April 2014 to 31st
March 2015 we received and registered a total
of 366 complaints. This is substantially lower in
comparison to last year with a decrease of 18%
when compared to the 444 complaints registered in
2013/14, and an increase of 19% when compared
with 307 in 2012/13. Further analysis will be
carried out to identify the services and key factors
contributing to the fluctuation in complaints.
The trust continues to provide a dedicated PALS
Officer to work with the individual service user,
carers, families and the wider public to seek answers
or provide advice on initial concerns in consultation
with clinical services, advocates and or other agencies
as appropriate. This way of working has proved to
be very effective and the service is being fully utilised
across the trust. However we are aware that the
PALS service needs to increase its visibility, this is
something we will be working on in 2015/16.
51
Annual Report I 2014/2015
The graph below shows the comparison between complaints and PALS throughout the year.
140
120
100
PALS
80
Complaints
60
40
20
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
0
Apr
Number of Complaints & PALS
Trustwide complaints & PALS 2014/15
This year there have been changes within the CSU such as the Gender Identity Clinic, The Cassel, Mott
House and Glyn Ward were transferred in September 2014 from West London Forensic Services CSU
(previously known as Specialist & Forensic Services CSU) to Local Services CSU.
Our Local Services CSU received 157 complaints, West London Forensic Services CSU received 52
complaints, High Secure Services CSU received 151 complaints and Estates & Corporate Services CSU
received 2 complaints. This is relatively lower in comparison to the previous years, although as the service
structures are different, an exact comparison is difficult.
We consider it essential to respond to and seek to resolve complaints in a timely and effective way. We
are pleased that 87% of complaints during the year were resolved within the timeframe agreed with
the complainants which compares favourably with our performance in 2013/14 (87%). The trust set a
performance target of 90% which was agreed via the service user & carer experience sub-committee & the
Quality Assurance Committee during Quarter 3 (November 2014). This target has not been achieved at the
end of this financial year however all efforts will be made to achieve and review the target during 2015/16.
Our aim is to investigate all complaints thoroughly and provide responses within the agreed timeframe
by providing complaint investigator training and closely monitoring the deadlines through reporting and
benchmarking our performance against other trusts and national data. We can then look at how the
recommendations result in practice changes.
52
Annual Report I 2014/2015
The table below illustrates the Department of Health themes to which complaints are allocated and a trend
analysis between each quarter throughout the year.
Complaint Themes
Q1 14/15
Trend
Q2 14/15
Trend
Q3 14/15
Trend
Q4 14/15
Trend
TOTAL
All aspects of care and
treatment
37
n
30
n
27
n
39
m
133
Staff attitude
27
m
20
n
17
n
26
n
90
Communication written
and oral
9
m
10
m
3
n
10
m
32
Failure to follow agreed
procedures
4
n
5
m
5
@
6
m
20
Other category
4
n
8
m
2
n
3
m
17
Appointments
5
n
7
m
0
n
0
@
12
Property and expenses
7
n
0
n
4
m
12
m
23
Admission discharge and
transfer arrangements
3
m
2
n
2
@
4
m
11
Aids & Appliances
2
n
3
m
0
n
2
m
7
Privacy and dignity
1
n
3
m
1
n
1
@
6
Hotel Services
1
n
2
m
1
n
2
m
6
Length of waiting time
for response/to be seen
2
m
0
n
0
@
0
@
2
Personal Records
0
@
1
n
0
n
3
m
4
Complaints Handling
0
@
0
@
0
@
3
m
3
102
n
91
n
62
n
111
m
366
Total number
of complaints
Most of the complaints made about our services fall into 3 categories
• All aspects of care & treatment
- Which include feeling unhappy with admission, lack of care on the ward and in the community,
medication concerns, physical health, diagnosis, incidents on the ward, various issues around detention
and feeling unhappy with the assessment.
• Staff attitude
- Which includes not feeling listened to and perceptions of attitude, staff mannerisms, staff not being open
and honest about relatives care and staff facilitation of telephone calls on the ward.
• Communication
- Which includes being provided with incorrect information, lack of information provided regarding care &
treatment and medical records including incorrect information.
53
Annual Report I 2014/2015
In terms of learning from complaints and sharing good practice, below are some of the outcomes achieved:
Complaint
Actions we have taken
All aspects of care & treatment
Complaint about service user
feeling unhappy with the
treatment received in the
community from doctor and not
getting support/help for their flat
We apologised for the delay caused by the service not assessing the needs
regarding support with the flat and for any misunderstandings regarding the
missed appointment to see the doctor.
A support worker has now been allocated to help the service user with the flat. All
appointments offered to be followed up with a telephone call.
Complaint made on behalf of
relative about medication not
being ordered in time to be
prescribed, side effects from
medication and referral
We apologised to the relative and service user.
Staff to liaise with pharmacy in a timely manner when medication is out of stock,
recording documentation to be improved and due to the complex needs of the
service user a professionals meeting would have helped at the time to ensure the
best possible care plan is agreed.
Complaint about the trust’s decision
not to admit service user to the
hospital, inaccurate information
provided to the private psychiatrist
Apologies offered for the poor communication and inaccurate information.
The decision regarding admission was kept under review and was not felt to be
appropriate however there was a clear plan for the community team to work with
the service user.
Complaint about how section (3)
was conducted and subsequent
treatment
Apologies offered to the service user and assurance provided that the
results of the investigation of this complaint is widely considered by staff so
that they gain a better understanding of the impact of their communication
with patients and endeavour always to do better, particularly in stressful
situations such as seclusion.
The process of the Mental Health Act assessment was carried out correctly.
Staff Attitude
Complaint about feeling
pressurised and bullied by support
worker and community psychiatric
nurse (CPN) to do college courses
and voluntary work
We apologised for any upset and distress that may have been caused.
Professionals must be mindful of the pace at which the service user wishes to
progress and engage with new activities and take care not to allow the service
user to feel pressurised.
Patients property & expenses
Complaint about the handling of
a package by the postal monitors
which resulted in items going
missing
Full apology offered for any distress and inconvenience caused. Postal
monitors have been reminded to seek permission from patients before
disposing any prohibited items received in the post.
Communication / information to patients
Complaints about being discharged
from the mental health services
We apologised profusely to the patient as the discharge had occurred
in error. There is a need for effective communication and therefore the
team manager met with the service user to discuss the issues and another
appointment has now been scheduled.
Complaint about items being
removed from service user’s
room with no explanation being
provided
A full explanation provided explaining the reasons for removal of contraband items
and room searches to be carried out in response to health & safety & duty of care.
A full property list re-written and care coordinator to facilitate storage
arrangements for excel property.
54
Annual Report I 2014/2015
We have worked on reporting the PALS themes since last year and have broken down the themes into the
top five in the table below:
PALS THEMES
HSS
LS
WLFS
Estates &
corporate
Total
Any other issue
• CCG query
• contacting staff
• information about trust
45
274
21
77
417
Waiting times – appointments
• appointment delay
• admin error
• not happy about the waiting times
• cancellation
• staff unavailable
0
290
0
14
304
Any aspect of care & treatment
• assessment
• lack of treatment/neglect
• detention
• medication
• referral
• leave
• support
• physical healthcare
• consent to treatment
• visitors
• other patient action
10
186
19
6
221
Access to services
• access when in crisis
• disability obstacles
• referral difficulties
0
110
0
26
136
Lost property
4
4
4
2
16
The vast amount of the PALS concerns this year in
line with last year were regarding the appointment
delay, waiting times, contacting staff and referrals
at the Gender Identity Clinic. PALS have been
working with the clinic and the service users to
ensure that communication regarding delays,
appointments and referrals are communicated
effectively and efficiently. The telephone system at
the clinic is being reviewed to address the feedback
that service users are not able to make contact
with the clinic by telephone.
“
“
I just wanted to say thank you
for the recent consultation
and your advice and words of
wisdom and to thank you for
your support.
Compliments
The trust received a total of 180 compliments
during 2014/15 which is a significant increase
from previous years of 113 in 2013/14 and 34
in 2012/13. We are pleased with the increase of
compliments logged this year which has been
the highest received to date. We know we receive
many more but they are not recorded. We
encourage staff to share compliments.
Data on complaints, compliments and PALS is
collated and reported throughout the trust and
reported monthly to the board, bi-monthly to the
service user & carer experience sub-committee and
quarterly to the Quality Assurance Committee. An
annual complaints report is also published as part of
our statutory requirements.
WLMHT complaints process is accessible to all,
both within each CSU and the wider organisation.
55
Annual Report I 2014/2015
Examples of key messages and action taken
in response to incidents and serious incidents
Organisations that report more incidents usually have a better and more effective safety culture. Knowing
where the problems and challenges are supports us to take steps to learn and improve our services.
The trust aims to provide patient care that is safe, effective and high quality for a diverse range of service
users. Our priority is to reduce avoidable harm in line with the trust’s incident management policy.
Trustwide incidents
Q1
Q2
Q3
Q4
Q1 – 4 2014/15 incident total 10019
2154
2436
2574
2855
Q1 – 4 2013/14 incident total 8505
2125
2160
2234
1986
A total of 10019 incidents of all types and severity were reported across the 2 CSUs and corporate services.
This represents an increase of 15% (1’514) on the number of incidents recorded for 2013/14.
1200
1000
2014/2015
800
2013/2014
600
400
200
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
0
Apr
Number of Incidents
Trustwide incidents
Of the 10019 incidents reported for 2014/15 26% (2562) were reportable to the National Patient Safety
Agency, as these incidents are classified as causing potential or actual harm to the patient.
West London Mental Health NHS Trust has continued taking steps to improve the rate and quality of its
services by following up on the actions and recommendations from the review of the severe harm and
death incidents, holding regular learning lesson events and improving system processes for the quality
checking and timeliness of reported data. This has resulted in a sustained improvement in our reporting
rate and number of days taken to report incidents to the NRLS.
56
Annual Report I 2014/2015
Also, following a review of the incident categories reported on to the NPSA earlier this year for the reporting
period 2013/14 it is evident that more patient safety incidents have been reported to the NPSA, suggesting
that the trust’s attempts to improve and promote a reporting culture is in steady progress for the second
year running.
The most frequently reported incidents trustwide by type per quarter have been:
Highest reported incidents trustwide
Q1
2013/14
Q1
2014/15
Q2
2013/14
Q2
2014/15
Q3
2013/14
Q3
2014/15
Q4
2013/14
Q4
2014/15
Verbal abuse to staff
401
296
389
365
392
464
376
471
Security incidents
326
384
325
503
345
401
281
455
Self-injury to patient
173
161
178
140
135
173
125
137
Medication incidents
106
102
95
159
106
253
89
417
Physical assaults to staff
164
200
182
202
236
215
197
211
Verbal abuse towards staff has been highly
reported in High Secure Services and staff across
all areas of the organisation, it is continually
encouraged to report all types of abuse to allow
the identification of any themes and trends.
A trustwide thematic review was conducted on all
security incidents. As a result the following actions
have been taken:-
Physical assaults to staff have remained consistent
throughout the year, however, by introducing the
early warning signs of verbal abuse a number
of actions have been put in place to manage the
threats of harm to staff and others to managed
more efficiently.
• Lists of contraband items have been reviewed
and displayed.
This has been integral to identifying behaviours and
early warning signs to allow immediate action and
more timely assessments for care planning and risk.
The ‘Don’t be a victim’ campaign has been
implemented in High Secure services which has
introduced additional awareness training for staff
on the potential areas for assault. It is hoped
that by introducing initiatives and evaluating the
success of these that the trust will see a reduction
in abuse and assaults in the forthcoming year.
• Local guidance and escalation procedures have
been implemented for staff guidance.
• Search protocols have been reviewed providing
guidance for staff on how to manage incidents effectively.
The trust will continue to monitor these incidents to
ensure the actions taken have had a positive impact.
Self-injury to patients’ has reduced in the last
12 months. The trust has implemented regular
ligature audits and taken immediate actions as
a result of these audits. Suicide and self-harm
steering groups and strategy have been introduced
and monthly audits completed on enhanced
engagement and observations.
Medication incidents have appeared in the highest
reported for the first time in the last 3 quarters
to over 400 in Q4, mainly for refusal of treatment
incidents recorded for High Secure.
57
Annual Report I 2014/2015
Trustwide serious incident reviews
Q1
Q2
Q3
Q4
2014/15 Serious incident review total 76
12
22
23
19
2013/14 Serious incident review total 61
14
21
9
17
The above table shows that there has been an increase of 20% in the amount of serious incidents
commissioned in 2014/15 from the last financial year.
Grade 2 reviews commissioned
trustwide Q1 - 4 2014/15
4
2014/2015
3
2013/2014
2
1
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
0
Grade 1 reviews commissioned
trustwide Q1 - 4 2014/15
12
10
8
6
2014/2015
4
2013/2014
2
58
Annual Report I 2014/2015
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
Apr
0
The trust uses these reports to identify and take
action to prevent emerging patterns of incidents
and it supports clinicians to learn about why
patient safety incidents happen within their own
service and what they can do to keep their patients
safe from avoidable harm.
As a result the trust has undertaken a number of
serious incident reviews which has led to a number
of improvement actions being taken:
Grade 2 serious incident review
Patient suicide
A patient was found on the floor by ward staff with
a ligature around their neck.
The ligature was removed and resuscitation
attempts were made, but proved unsuccessful and
the patient died.
Findings and actions:
1) There was a delay in ligature removal due to:
• Staff initially reported feeling panicked and did not
follow what was taught during AED training.
• Emergency bag was not brought to the scene, items
were removed from the bag in the clinic room.
• Ligature removal was not covered as part of the
trust’s mandatory annual AED training.
• The guidance for removing ligatures states that the
fish hook cutters should be used, which were not
effective in this case.
• Rescue scissors would have been more appropriate
for removing the ligature in this instance.
Action taken:
Ward based life support scenario training is delivered
to enable staff to keep their skills refreshed in as
realistic a setting and circumstance as possible.
Ligature removal and medical emergencies is now
taught as part of the trustwide AED training and,
includes methods of ligature removal when the fish
hook ligature cutter cannot be used.
2) A key anniversary was not held by the MDT
The panel discovered the significance of the date
through reading the progress notes, but it was not
highlighted as part of the risk assessment or the
care plan. Not all in the MDT knew of its significance
nor did the nursing staff on duty that day.
Action taken:
Each ward now keeps a record of all significant
anniversaries (where possible) so that extra
support can be offered at any time when distress
may be increased.
3) Psychology session was not handed over to
nursing staff
The panel accept that normal practice was that
sessions were handed over and what happened on
this day was unusual. The psychologist typically makes
their entries the following day so this is not a safeguard
in the absence of a handover. Even if a more timely
entry had been made there is no guarantee that this
would have been read by the staff.
Action taken:
MDT members have been reminded to handover
their session to staff before leaving the ward. This will then be followed up via documentation.
4) The ‘personal distress signature’ was not being used
Despite a lot of effort initially to implement the
personal distress signature, the momentum was
lost and it was not in use in the service at that time,
nor had the tool been linked with care planning.
Action taken:
The tool has been reviewed and agreed by the MDT
and cascaded during staff meetings. It is now being
incorporated into the distress signature during
primary nurse sessions, clinical team meetings and
within care plans. Feedback from staff and patients
has been positive with recognition of it being more
simplified and easy to access.
Good/notable practice:
• There was a multifaceted treatment approach
with regular multidisciplinary involvement and
regular direct contact with the patient. The MDT
were able to manage her care without excessive
use of continuous observations which would have
significantly improved her quality of life.
• The documentation was of good quality.
59
Annual Report I 2014/2015
Further action:
The trust has received an accreditation from
the London Ambulance Service for rolling out
defibrillators across all of our services.
We are the first mental health trust to receive an
accreditation by the London Ambulance Service as
part of their ‘Shockingly Easy’ campaign to get 1,000
extra defibrillators in public places across the capital.
All staff, patients and visitors to the trust have
the best possible chance of survival if they suffer
a cardiac arrest. More defibrillators have been
installed meaning that the trust now has over 80
defibrillators across our sites and staff have been
trained to use them.
We were initially responding to an incident that
happened in a community centre. We followed
the advice on best practice from the London
Ambulance Service which was that defibrillators
should be no further than two minutes away from
the site of any potential incident.
The trust is now able to offer emergency treatment
for cardiac arrests for all patients, staff and visitors.
We are integrating mental and physical health care
and this accreditation is a step in the right direction
to providing holistic care.
Grade 1 serious incident review
Patient death
The police were requested to make a welfare check
on a patient who had failed to return to the ward
from leave.
The police found the patient collapsed at their
home address and they were transferred to
hospital where they later died of natural causes.
Findings and actions:
1) Considering the patients presentation there
was no dual diagnosis care plan on RiO which
is recommended by NICE guidelines.
60
Annual Report I 2014/2015
Action taken:
The trust has developed a trust-wide dual diagnosis
strategy which brings clinical practice in line with
NICE Guidelines. The strategy also includes a
specific section on ‘Audit to improve practice’ to help
monitor its implementation.
An executive director has been appointed as
executive trust-wide lead for dual diagnosis.
A dual diagnosis steering group has been
developed and now meets on a quarterly basis and
is chaired by the executive director lead.
2) There were significant delays in WLMHT staff
communicating with patient’s family at three
different stages:
• When the patient did not return from leave
• When the patient was brought to Ealing Hospital for
emergency medical treatment
• After the patient’s death
Guidance about communicating with family
members outlined in both the Missing Persons and
Patients Absent Without Leave Policy (P1), and the
Death of a Patient Policy (D6) was not adhered to.
Action taken:
The ‘Missing persons and patients absent without
leave’ policy (P1) has been reviewed in collaborative
working with the Metropolitan Police to introduce
the AWOL grab pack and has been implemented by
all local services teams.
The ‘Death of a patient’ policy has been reviewed
and circulated across the trust via the Exchange
policy process.
Good/notable practice:
• The panel found evidence of good standard
practice from WLMHT staff.
Ward staff appear to have worked hard to respect
the patient’s wishes and autonomy even though at
times this was at odds with what they believed to
be in the patient’s best interests.
Coroners Rule 28
This rule gives coroners the power to make reports
to the organisation where the coroner believes
action needs to be taken to prevent future deaths
and where the organisation may have the power
to act. The coroner announces his intention at the
end of the inquest hearing.
The trust received 2 Rule 28’s in 2014/15 which wer
issued in July 2014 and March 2015.
Local Services Rule 28 issued in July 2014:- relating
to an inquest because the coroner was concerned
that there was no system in place to ensure
that both GPs and psychiatrists are aware of all
medication a patient is taking, regardless of who is
responsible for prescribing it and why.
This response also included full details of the
current understanding of engagement and
observation, information on how we are in the
process of reviewing our current policy which is
due to be ratified. It included information on the
responsibility of the nurse in charge to allocate
staff and the details of the policy in place for
‘Management of Radio Communication and the
Radio Network Broadmoor Hospital.
Health and safety executive (HSE)
The HSE has issued no improvement or prohibition
notices to the trust during the last year.
Response: - A formal response was given describing
the actions taken following the rule 28, the action
taken by the trust’s medical director and chief
pharmacist which was issuing an alert on 22nd July
2014 to all prescribers to prevent further incidents
of unsafe prescribing of multiple medicines.
Broadmoor Hospital Rule 28 issued in March 2015:
- relating to an inquest because the coroner was
concerned that only controlled drugs were being
audited and their whereabouts monitored. That
nursing staff did not fully understand the four –
hourly observations of patients and nursing staff
understanding of the duties of the radio nurse on
an admission ward.
Response: - A formal response was given to the
coroner describing the process for non-controlled
medication and how they are managed between
the pharmacy and the ward. This included
information on recording medication that is not
given to the patient, or is dropped etc reporting
these as an incident and disposing medication in
waste containers.
61
Annual Report I 2014/2015
West London Mental Health NHS Trust considers
safeguarding an essential component of the
trust’s culture and safeguarding performance is a
barometer for the organisation’s ability to deliver its
values. As a result, the trust has put considerable
resource into developing safeguarding over the last
year and this is reflected in the improved quality
indicators for safeguarding functions.
Safeguarding governance and quality assurance
During the last year the trust has continued to
improve its awareness of safeguarding quality
which has been underpinned by a number of
initiatives, some in collaboration with partner
agencies, to ensure we offer quality services to the
people who use our services.
The mechanisms for organisational awareness of
safeguarding functions have been embedded in
practice across the trust and this is reflected in the
improved accuracy of our safeguarding reports as
well as a notable improvement in functioning. This
has helped strengthen the link between the trust
board and frontline services.
The governance structures that underpin
safeguarding performance have been maintained
as the trust has migrated it services into service
lines by developing feedback to specific services
and teams about their safeguarding functions.
The specific datasets that were developed during
2013-14 are now continuously used within the
team, and all services that are low reporters of
safeguarding concerns are now identified monthly
and they feedback on how their performance can
be improved.
The safeguarding team noted an increase in
enquiries from staff about managing allegations
made about historical abuse that are reported by
service users. As a result we have developed and
trialled a flowchart for managing these allegations
and this has been incorporated into a new revised
safeguarding child policy.
The safeguarding team have continued to develop
relationships with stakeholder partners through
active engagement with the safeguarding boards in
62
Annual Report I 2014/2015
“
“
Safeguarding children and adults at risk
I would like to thank all the staff
that have been looking after my
son for the past year or so. It is
very difficult when your child is
sick and you cannot look after
them/comfort them, yourself.
The next best thing is to know
someone is doing that job and
doing it well. I am very grateful to
all the staff on the ward who have
made my sons life sweeter, a bit
more comfortable, and who have
helped him through the difficult
periods showing compassion and
understanding.
all the boroughs where we provide services. The engagement with Safeguarding Adult boards
has developed significantly as these assumed
their new statutory responsibility with the
implementation of the Care Act 2014. In particular,
we have engaged in supporting safeguarding
adult partnership boards preparing for their
responsibilities under the Act by participating
in the local reviews of their governance and by
supporting policy development.
The trust’s commissioners continue to receive
quarterly updates on safeguarding performance as
part of our responsibility to maintain transparency
about our functioning. The challenge provided
through these forums supports our on-going
development of quality in safeguarding.
The Safeguarding Children Team developed a
Safeguarding Quality Guide during the last year
which has been cascaded to all staff and which
supports staff awareness of all their professional
responsibilities in respect of safeguarding children
and adults at risk. We are presently measuring
the impact of the guide through a trustwide audit
and learning generated by the results will inform
development plans for next year.
Safeguarding quality and performance indicators April 2014 – March 2015
Actual performance
April 14 – March 15
Target / measure
West London
Forensic
High Secure
Services
18
Total
2014-15: 90
Total
2014-15: 7
Total
2014-15: 7
(Total
2013-14: 26)
(Total
2013-14: 31)
(Total
2013-14: 0)
(Total
2013-14: 0)
23
(2013-14: 0)
10
(2013-14: 0)
18
(2013-14: 3)
1
(2013-14: 0)
0
(2013-14: 0)
98
(2013-14: 63)
42
(2013-14: 60)
57
(2013-14: 60)
125
(2013-14: 75)
52
(2013-14: 96)
1 x 3 night
1 x day
Total: 2
(2013-14: 4)
1 x 1 night
1 x 12hrs
1 x 2 nights
Total: 3
(2013-14: 4)
1 x 12 nights
2 x 1 night
Total: 3
(2013-14: 4)
N/A
N/A
0
1
0
0
2
(2013-14: 2)
(2013-14: 0)
(2013-14: 0)
(2013-14: 0)
(2013-14: 0)
% Number of service
users who are known TO BE parents or carers
of children at the point
of assessment
6 Inpatient
5.6%
29 Community
26.9%
10 Inpatient
9.3%
43 Community
40.2%
9 Inpatient
4.0%
32 community
14.2%
0 Inpatient
0%
0 Community
0%
% Number of service
users who are known
NOT to be parents or
carers of children at the
point of assessment
0 Inpatient
0%
5 Community
4.6%
5 Inpatient
4.7%
18 Community
16.8%
6 Inpatient
2.7%
9 Community
4%
1 Inpatient
25%
0 Community
0%
% Number of users of the
service where their status
as parents or carers of
children is unknown
4 Inpatient
3.7%
64 Community
59.3%
3 Inpatient
2.8%
28 Community
26.2%
6 Inpatient
2.7%
164 Community
72.6%
1 Inpatient
25%
2 Community
50%
Ealing
H&F
Hounslow
Inpatient
Inpatient
Inpatient
20
13
37
Community
Community
Community
89
52
35
CAMHS
CAMHS
CAMHS
9
Total
2014-15: 118
17
Total
2014-15: 82
(Total
2013-14: 37)
Number of meetings
attended: strategy mtg,
case conference, CP
mtgs, core group mtg,
court hearings
Number of child visits made
Service priorities – quarterly
Safeguarding children activity
Number of referrals to
children’s social care
Number of children
admitted to adult wards
Number of allegations
referred to LADO.
(safeguarding children)
RiO Records
being
implemented
– report not
available
63
Annual Report I 2014/2015
Safeguarding quality and performance indicators April 2014 – March 2015
Actual performance
April 14 – March 15
Target / measure
Ealing
H&F
Hounslow
Inpatient
Inpatient
Inpatient
98
13
37
Community
Community
Community
137
52
35
0
1
0
West London
Forensic
High Secure
Services
45
62
1
0
Service priorities – quarterly
Safeguarding adult activity
Number of safeguarding
adult referrals
Referrals
Safeguarding children
The trust continues to complete self-assessments of
compliance with the requirements of Section 11 of
the Children’s Act for the Local Safeguarding boards
(LSCB’s) of all the boroughs where we offer services.
The results are scrutinised and challenged by our
LSCB partners and development opportunities
identified are progressed as part of an action plan
over the following year.
Following publication of an update to the
Intercollegiate Guidance - Safeguarding children
and young people: roles and competences for
health care staff, in March 2014, we have updated
our training strategy for safeguarding children to
reflect the revision in skills and competencies that
are required of our staff. We have also revised our
training content and continue to deliver high-quality
training that gets excellent feedback from our staff.
In May 2014 we hosted a Safeguarding Conference
for our staff on domestic violence. We invited leading
experts on the subject to lead discussions on the
day. The result has been an increased awareness of
the topic amongst the staff providing safeguarding
leadership as well as strengthening relationships with
key stakeholder partners, e.g. Standing Together,
the organisation providing MARAC services in the
London Boroughs. This partnership has resulted in
developing additional jointly delivered resource for
specific domestic violence training for our staff during
2015-2016.
64
Annual Report I 2014/2015
Although there were no serious case reviews in
the previous year, we did contribute to a number
of multi-agency learning events where cases were
identified that could provide information that could
lead to improved safeguarding. However, a serious
case review will be completed in the next year and
any relevant learning that is generated from it will
be embedded in the trust.
Last year we reported on the development of
Guidance for the Management of Children and Young
People at Risk of Suicide which had emanated from
an previous serious case review. We have been able
to roll out the co-produced training programmes with
our Local Authority colleagues in Ealing, as planned
and the training has had much positive feedback.
In addition, the guidance and training gained a
national profile when it was presented at the annual
conference of the London Safeguarding Children
board in late 2014.
The safeguarding team identified a need for more
targeted information for service users about why the
trust needs to know about their families. As a result,
we have co-produced a new information leaflet for
service users, titled: “Looking After Your Family – Why
we ask about your children”. The use of the leaflet
is aimed at improving our relationships with service
users and how we work together to identify and
improve the support they receive for their families.
This is linked to the data we are now reporting
regularly about numbers of service-users with children
or caring responsibilities which we developed last year.
We have also developed a new interagency protocol,
jointly with our local authority partners, describing
new standards for working arrangements between
Children’s Social Care and Adult Mental Health
Services. The protocol is presently being audited
and it is expected that the audit will be repeated
annually to allow reflection on the functioning of
the working relationship between the trust and local
authority partners.
Safeguarding adults
During the last year, we completed the Safeguarding
Adults Assessment Tool (SAAT) – a new selfassessment measure for NHS Trusts to reflect
on their safeguarding adult functioning. Our selfassessment was validated at challenge events
hosted by all the Safeguarding Adult Partnerships
boards we are members of. The learning from the
challenge events were incorporated into an action
plan we are using to guide our development over
the coming year.
We have continued to review and update our
internal safeguarding adults training package.
Presently we are refining a set of vignettes that
will support training by illustrating practically the
competencies we expect our staff to achieve by
completing training. All staff also receive PREVENT
awareness training as part of safeguarding adults
induction and update training. Both safeguarding
adult and safeguarding child team staff will
complete the revised training for trainers in
respect of PREVENT in the coming year. This
decision is based on emerging internal evidence
that children and young people are also at risk of
radicalisation and likely to require referring under
the channel procedures.
In September 2015 the trust management
team approved a business case to expand the
safeguarding adults professional resource by
developing two new posts: a Band 8b Named
professional for Safeguarding Adults as well as a
Band 7 Trainer /Advisor for Safeguarding Adults.
We have completed a run of recruitment but
were unable to appoint to the posts substantively.
At present a secondment opportunity has been
agreed for an internal staff member and it is
anticipated they will transition into the named
professional role shortly. The trainer post will
be re-advertised with a view to substantive
recruitment with immediate effect.
There has been a notable increase in the numbers
of safeguarding alerts raised in the last year. This
follows the efforts made by the trust to raise the
profile of Safeguarding Adults and is linked to the
reports now generated that highlight any trust service
that is identified as a low reporter of safeguarding
adult concerns in the monthly quality report.
65
Annual Report I 2014/2015
Allegations involving Jimmy Savile
Safeguarding key development plans – 2015
After the trust was named in the historical
allegations relating to the late Jimmy Savile,
an external review was commissioned by the
Department of Health into the period when it
managed Broadmoor Hospital. The document
“Jimmy Savile Investigation: Broadmoor Hospital
– Report to the West London Mental Health NHS
Trust and the Department of Health” is the report
authored by Bill Kirkupp, CBE and Paul Marshall.
During 2014-2015 we implemented the first phase
of development in line with our safeguarding quality
strategy. The four key areas for development that
were identified in the safeguarding strategy are:
This was published in June 2014. The trust
has implemented recommendations made
subsequently and, of note, the report made positive
comment on the trust present safeguarding
arrangements. A subsequent independent review
of trust governance was commissioned by the chief
executive of the West London Mental Health NHS
Trust to provide additional assurance on progress
and development of governance arrangements.
The trust has developed an action plan to meet
the recommendations of this review. This was
published in January 2015 and this review
commented positively on the safeguarding
functions in the trust. The recommendations that
were made are being implemented.
1. Organisational intelligence: The need for the
organisation to have good knowledge of how
well it is delivering its safeguarding functions
across all services. We have continued to
develop our quality metrics and this is reflected
in the summary of performance metrics
included in the report. We will continue to learn
from, and improve the quality and performance
report in the next year.
2. Partnership working: Our joint initiatives in
respect of training and partnership working
arrangements reflect our commitment to
partnership arrangements. As we develop our
safeguarding adult professional resource internally,
we will develop capacity to support partnership
working further by involvement in board subgroups and joint initiatives. For the next year the
trust’s director of Safeguarding will chair a triBorough LSCB subgroup on Parental Mental Health
and Safeguarding. This group will co-ordinate a
yearlong programme of work across agencies
in the boroughs of Westminster, Kensington &
Chelsea and Hammersmith & Fulham to inform
and improve arrangements supporting parents
with serious mental illness in these boroughs.
3. User and carer involvement: Our leaflet has
been presented at the national conference for
professionals to promote the work we have
done in collaboration with our service users
and carers. The plan is to translate the leaflet
into other languages to improve access to the
information for our service users. We plan to
replicate the work with safeguarding adult
information subsequently.
4. Safeguarding resource: We will continue to
develop our resource over the coming year.
This includes completing the recruitment for
safeguarding adult resource and strengthening
the team-based safeguarding leadership in the
coming year by building on the governance
arrangements embedded in the service line
structure of the trust.
66
Annual Report I 2014/2015
Other quality and improvement initiatives
Governance restructure for R&D
In 2014/15 the then R&D director was appointed to
a chair at the University of Edinburgh.
Dr Kevin Murray, previously clinical director
at Broadmoor Hospital, was appointed as his
successor with the remit of reviewing and updating
the existing R&D strategy and increasing clinician
input. To date there has been significant progress
with recruitment into studies at the Clinical Trials
Unit, to the extent that the service is looking for
additional space to provide for the numbers of
patients being recruited to trials.
There has been a strategic decision for the trust to
seek a new home for the Corsellis Collection, an
internationally important collection of some 8,000
neuropathology specimens, at a service which
has neuropathology as its core business. Finally,
the trust management team have endorsed the
proposal to realign former diagnostically based
Clinical Research Domains with the new service
lines, which form the business units in the trust’s
Local Services.
Implementing the physical health strategy
The physical health strategy has continued to
be implemented throughout 2014 leading to a
number of improvements made to the physical
health care provided.
A resuscitation committee has been established
and has been meeting over the last 12 months
to ensure an overview of resuscitation services.
The trust has worked closely with the London
Ambulance Service to provide external clinical
advice, and we have become the first mental health
trust in London to be accredited as providing high
quality resuscitation services as part of the LAS
“Shockingly Easy” campaign.
In May 2014, the Broadmoor Hospital, together
with the other 2 high secure hospitals, Rampton
and Ashworth, ran a successful conference on
physical health in secure environments. We were
fortunate to have both the national clinical director
and the minister of health Norman Lamb speaking
at the conference. A two day conference is planned
for 2015, working in partnership with the Royal
college of General Practitioners and the Royal
College of Psychiatry.
An independent external review of the service has
been undertaken where we engaged the expertise
of an experienced external GP who can spend a day
looking at the care we provide, and review the skills
and knowledge of the staff. Our aim was to make
recommendations for improvement, and implement
where required. The plan is to role this out across
our other services.
During 2014, a physical healthcare service was
provided to the older peoples units The Limes
and Jubilee. The Limes in particular cares for the
most complex of patients, with severe mental and
physical health problems. Although some progress
has been made to address their health care needs,
further work is needed during 2015, to ensure
that the same of level of care is provided for their
physical health as for their mental health.
From April 2014, a national CQUIN was commissioned
to assess the cardiovascular risk of all in-patients.
This national CQUIN built heavily on work already
undertaken in the primary care service at WLMHT for
patients at Broadmoor Hospital and Ealing forensic
services. The official result of the first year’s set of data
from the RCPsych is not yet available.
West London Forensic service has pioneered an
innovative service where a visiting consultant meets
with the primary care team to discuss complex
patients. They hold regular meetings as ward rounds
to discuss patients with diabetes and endocrine
disorders, and separately with a respiratory specialist
to discuss patients with asthma and chronic
obstructive pulmonary disease. These meetings not
only ensure that we are providing the most up to
date and appropriate treatment for complex patients
but they have also become an important learning
opportunity for the team.
During 2015 the physical healthcare department will
be changing its I.T. system to EMIS Web. This will bring
it in line with most other practices in England, and
ensure that we continue to be able to demonstrate
through hard data, the quality of care that we provide.
67
Annual Report I 2014/2015
Patient safety measurement project
Health outcomes continue to improve through
new and more effective treatment, and improved
capacity to deliver treatment effectively. However
at the same time harm to patients remains a major
issue in all healthcare systems.
Studies have shown that between 8–12% of patients
in all systems suffer as the result of errors and
harm. In mental health trusts the most common
forms of harm are patient suicide, violence and not
feeling safe on inpatient units. Other forms of harm
given prominence are DVT, pressure sores and
falling. It should be noted that the focus on specific
incidents can lead to a failure to address forms of
harm such as renal compromise arising from poor
fluid management.
Research has revealed (C. Vincent) that what is
currently measured is not how safe healthcare
systems are now, but how harmful they have been
in the past; Patient safety cannot be improved until
there is a clear understanding of how to know if
care is safe in the first place. Maintaining the safety
of individual patients in a hazardous environment
through constant monitoring, reflection and action
are needed to keep an organisation running safety.
The Patient Safety Measurement Project addresses
critical issues facing the West London Mental Health
NHS Trust. Delivery of safe mental healthcare is
characterised by numerous safety critical processes
with patient safety and clinical risk management
being a high priority.
The project seeks to achieve a reduction in
avoidable harm by identifying and refining safety
critical processes. An outcome is to develop a
more proactive culture across the organisation
which utilises effective analysis of information and
knowledge to underpin decisions related to the
prevention of harm, early detection of problems,
and early intervention and dissemination of learning
with measureable improvements. This will be done
in partnership with service users and carers.
68
Annual Report I 2014/2015
The aim of the West London Mental Health NHS
Trust Patient Safety Measurement and Monitoring
Project is to make an enquiry to answer the
question, “How safe are our low secure wards?” by
evaluating the measures and informal methods
currently used to review.
1. An evaluation of past harm – has patient care
been safe in the past? Looking at measures
which may include mortality; incident reporting;
reporting of ‘never events’; inquests; complaints;
health and safety incidents.
2. An evaluation of reliability – are the trusts
clinical systems and processes reliable? Looking
at routine audits and other perhaps less
formalised approaches to measuring this.
3. An evaluation of the sensitivity to operations –
is care safety today within the unit? Looking at
measures which may include whistleblowing
policies and procedures; complaints; patient
and staff surveys.
4. An evaluation of how the unit can anticipate
future safety events – will care be safe in the
future? Looking at what does the trust has in
place for supporting this? How do we measure
its effectiveness? Staff indicators.
5. An evaluation of the capacity of integration and
learning – is the trust responding and improving?
Looking at the systems that the trust has in place;
the protocols and their effectiveness. Asking the
question how does the trust ensure the learning
system is kept up to date?
Once the trust has an understanding of its baseline,
it can then determine feasible improvements that
can be made at local and more global levels.
The patient safety framework will be used to provide
a structure around the review to identify bottlenecks
and areas for improvement. The trust will identify
problems in real time so that patient safety intelligence
can be used by the clinical team in a timely way.
It is hoped that this will create an environment of
continuous service improvement driven from a
bottom-up view for the benefit of patients.
By undertaking a structured enquiry over a 12
month period using the patient safety framework
the aim is to arrive at a set of recommendations
which define specifically;
• What is working well and should be continued.
• What isn’t working well and should be improved.
• What are the suggested improvements.
The vision is to deliver demonstrable improvements
in health and prosperity for the people of West
London and beyond, through collaboration and
innovation.
This vision will be achieved through the following
strategic objectives;
• Enable the discovery of best practice and
innovation.
• Support the systematic adoption and diffusion
of best practice at pace and scale.
• Contribute to the prosperity of West London.
The aim of the project is to test the evidence-based
patient safety framework designed by Professor
Charles Vincent published in early 2013. The
framework will be used to provide a structure around
the review to identify bottlenecks and areas for
improvement. The trust aims to identify problems
in real time so that patient safety intelligence can be
used by the clinical team in a timely way. It is hoped
that this will create an environment of continuous
service improvement driven from a bottom-up view
for the benefit of patients.
Psychosis project - Imperial College Health Partners
Aspects of the care for patients with psychosis may
fall short of best practice and require improvement to
achieve greater value for patients and commissioners.
This project is testing whether this can be delivered by
the development and implementation of an evidencebased best practice care pathway.
In 2013 the board of directors of Imperial College
Health Partners (The ICHP Board) established
a Mental Health Project Steering Group. In
partnership, NHS England, together with CNWL
and WLMHT, agreed in December 2013 to set
up a programme of work to develop North West
London as a pilot site. The aim was to deliver
improved outcomes for patients and to improve
public value. A Psychosis Steering Group was set up
with responsibility for overseeing the development
and piloting of a best practice pathway of care for
patients with psychosis in North West London.
The pathway would address adult mental health
services for patients with psychosis, including early
intervention services. The starting point for this
pathway was the latest published NICE guidance.
A series of multidisciplinary co-production
workshops, including service users and carers,
primary care clinicians and social care experts as
well as mental health professionals were held in
2014 to develop and test a best practice pathway,
review the evidence base supporting this and
identify and refine appropriate metrics. In addition,
extensive data analysis was undertaken, reviewing
linked mental health and physical health data, to
get baseline information on variables such as the
number of people with psychosis using accident
and emergency, number of bed-days, healthcare
professional contacts used, etc. An agreed best
practice pathway was a launched on February
10th 2015. The decision was taken to prioritise
early intervention services for measurement
and implementation against the new pathway.
Those responsible for delivery planning in early
intervention services in WLMHT and the other
relevant organisations have now developed a
programme of work to implement best practice
care, ongoing measurement and monitoring of care
and a social media campaign to reduce the duration
of untreated psychosis. This programme will be
funded by NHSE with funds jointly applied for by
local CCGs and Imperial College Health Partners.
69
Annual Report I 2014/2015
Medical revalidation
Medicines management
The trust continues to comply with medical
revalidation statutory requirements introduced
by the General Medical Council (GMC) in 2012.
The board maintains oversight of the revalidation
process with the responsible officer providing an
annual responsible officer report.
Improving patient experience
In 2014/15 98% of trust doctors had a completed
appraisal document. The trust has undertaken an
external quality assurance process of appraisal
documentation to inform development of the
appraisal and revalidation system for 2015/16.
The audit indicated that appraisal and medical
revalidation are fully established and working
well at the trust. The recommendations of the
audit are being taken forward by the responsible
officer. In addition, the responsible officer made
recommendations to the GMC in relation to licence
renewal for 55 doctors.
Pharmacy worked in collaboration with West London
Collaborative, Jane McGrath, Sally Gomme, Michele
Sie and Flippa Watkeys to organise a ground breaking
conference on ‘Shared decision making in medication’.
The event was attended by 130, staff, service users,
carers and partner organisations who came together
at the Double Tree Hilton in Ealing for a conference
with a difference where world renowned speakers: Dr
Pat Bracken, Dr Joanna Moncrieff, Professor Michael
Maier, Professor David Taylor, Dr Eleanor Longden,
Dr Suman Fenando, Dr Florian Birkmayer and Peter
Bullimore challenged, justified and debated the use of
medication, prescribing and alternatives to dominant
mental health paradigms.
The conference objective was to promote a
broad, honest and radical debate. This hopefully
promoted parallel discussions across the mental
health arena for meaningful change to take place.
Lord Nigel Crisp chaired a ’question time’ style
enthusiastic debate to conclude the day with
questions such as “Whose responsibility is it to
inform us about side effects of medication so we
can make informed decisions?” Lord Crisp also
announced at the conference that he was chairing
a Royal College of Psychiatrists review on inpatient
beds in mental health.
The day was skilfully overseen and summarised by
Professor Mike Slade allowing us all to reflect on a
very full and active day.
It was great to be provided with the opportunity
for this challenging sharing of views in order to
promote a productive dialogue.
Comments from the conference:
“That was quite possibly the most impressive
conference I’ve been to in 22 years as a medic. It was ground breaking”
Dr Sian McIver
We thank McPin Foundation for sponsoring the event.
The pharmacy team are also working with service
users on a co-production project on ‘shared
decision making on medicines’.
70
Annual Report I 2014/2015
Dr Sian McIver
“
“
“That was quite possibly the
most impressive conference I’ve
been to in 22 years as a medic.
It was ground breaking”
Pharmacists continue to work to improve access
for patients and carers to pharmacy advice and
carry this out in many ways including: offering 1:1
sessions for inpatients, facilitating carer group and
patient education sessions in inpatient units and
in the community and contributing to patient led
recovery college workshops.
Clinical effectiveness
The pharmacy team have developed a junior
doctor’s induction handbook which provides a
quick reference summary of important medicines
management issues for ward doctors.
The team have launched medicines management
and optimisation exchange page. This page is
a wealth of resources on information about
medicines for all staff.
The pharmacy continues to provide in-house and
external teaching on a number of medication
related topics and has developed and implemented
a medicines safety study day.
The pharmacy department continues to support all
aspects of medication for clinical trials medication.
Pharmacists are regularly involved in virtual
diabetic and respiratory ward rounds and GP
medicines reviews for forensic patients.
Pharmacists are members of the clinical pharmacy
respiratory network and the secure pharmacist
network and this ensures that good practice is
shared and embedded across organisations.
Pharmacy have invested in staff and have had a
programme of training staff in clinical pharmacy,
coaching skills and leadership. This ensures staff
have the skills to work as effectively and efficiently
as possible.
Patient safety
Pharmacy has launched a monthly Medicines
Matters Bulletin that is disseminated to all staff.
This bulletin provides an update including new
guidance on medicines in mental health, audits
carried out on medicines in the trust, news and
reviews on medicines and learning lessons from
medication incidents.
In response to an NHS England Patient Safety
Alert that highlighted the importance of improving
medication error incident reporting and learning,
the trust appointed a pharmacist as the Medicines
Safety Officer (MSO). This initiative has supported
increased reporting of medication incidents and
has enabled the trust to action patient safety
alerts from NHS England in a timely fashion. The
MSO has also been promoting the importance of
medication incident reporting by presenting at
Learning lessons conferences and facilitating local
workshops at a team level.
The MSO reviews all medication incidents that
occur in the trust and identifies common themes.
Common themes are written up as learning
lessons and are disseminated in the trusts monthly
medicines matters bulletin.
The MSO is also a member of the national
medication safety network, this allows for lessons
to be shared between organisations and for the
trust to learn from incidents occurring in the wider
health arena.
Pharmacies have also been able to increase their input
into incident reviews to provide a detailed review of
pharmacological treatment and trust systems around
medicines to improve medicines safety.
Pharmacy continue to carry out regular audits on
safe and secure handling of medicines, controlled
drugs management, and have audited omitted
doses and medicines reconciliation this year.
Pharmacy has also responded to and, where
appropriate, taken action on alerts on medication
including developing posters and stickers to
highlight patients safety alerts related to medicines.
71
Annual Report I 2014/2015
Objectives
Objectives
Vision
& BEHAV
IO
S
Objectives
S
UE
UR
VA
L
Where we want to be our goal
Objectives
Objectives
Steps along the way
to help us reach our
destination
Values
Mission
Our purpose why the trust exists
What we believe in our compass
OUR MISSION
“Promoting hope and wellbeing together”
Our mission statement is about our purpose - why we exist.
You can think of it like the trust’s job description.
OUR VISION
“To be an outstanding healthcare provider, committed to improving
quality and caring with compassion”
Our vision is the goal for the organisation - this is what we are all working towards.
OUR OBJECTIVES
Be outstanding (We collaborate and innovate)
Improve quality (We invest. We listen and learn)
Care with compassion (We work together. We are recommended)
Our objectives are the points along the way that will help us to fulfil our vision. They are the
individual steps we need to take to move along our chosen route.
OUR VALUES & BEHAVIOURS
Togetherness, responsibility, excellence and caring
Our trust values are like a compass to help us stay on the right path. They help patients and
carers understand what they can expect form our staff, and remind us of the things we won’t
compromise on as we try to reach our goal.
72
Annual Report I 2014/2015
Patient
The Friends and Family Test (FFT) is an important
feedback tool, which supports the fundamental
principle that people who use NHS services
should have the opportunity to provide feedback
on their experience.
It asks our patients if they would recommend
the services they have used to their friends
or family using a Likert scale to measure their
satisfaction, then there is space to write why
they made their choice. When combined with
supplementary follow-up questions, the FFT
provides a mechanism to highlight both good
and poor patient experiences. It comes in the
form of a postcard which are available in all of
our buildings, inpatient and community for our
patients to complete. The feedback we receive
will be used to improve the services we provide.
This kind of feedback is vital in transforming NHS
services and supporting patient choice.
FFT became available to all NHS Mental Health
Services from January 2015, which is when it was
implemented trustwide. Quality Health delivers a
service to us whereby they provide the materials,
organise the delivery, analyse the data and
produce a monthly report.
Staff
We implemented the Staff Friends and Family Test
in April 2014 when NHS England introduced it to
NHS Acute Services. The vision is for staff to have
the opportunity to feedback their views on their
organisation at least once per year. It is hoped that
Staff FFT will help to promote a big cultural shift in
the NHS, where staff have further opportunity and
confidence to speak up, and where the views of
staff are increasingly heard and are acted upon.
The methodology used was an entirely web based
approach, using a randomised sample of staff.
This means that over the remaining quarters all
staff were surveyed once over the year.
The reports are produced through UNIFY and will
be available in the coming month.
“
Just to say a BIG THANK YOU
for your kindness and patience.
You helped me to make my
life happier and easier by
encouraging me to do challenges.
Thank you again.
“
Friends and family test
73
Annual Report I 2014/2015
WLMHT Sign up to Safety leads are:Executive lead:
Dr Nick Broughton medical director
Co-ordination/safety lead:
Vanessa Ford deputy director of nursing/ director
of governance
Data requirements/SI reporting:
Carl Dorey SI/ incident manager
Sign up to safety campaign
Communications lead:
Helene Feger director of communications
WLMHT has committed to the national Sign up to
Safety Campaign to provide a structured approach
and increase the focus of patient safety improvement
initiatives that the organisation is implementing.
WLMHT is supporting the NHS England’s national
Sign Up To Safety campaign and the goal to reduce
avoidable harm by 50% and saving 6,000 lives, by
committing to the following pledges:-
The initiatives include:
1. Putting safety first: we will
Leadership for safety & safety culture - The
Francis report raised questions about leadership
and organisational culture that allowed patients
to be harmed whilst receiving care. WLMHT is
committed to developing a culture that promotes
openness and honesty and dedicated to learning
and continually strives to improve the quality of
service delivery.
Patient safety – The overall aim of patient safety
is to make improvements in the way we work
and reducing avoidable harm to inpatients and
community patients in our care. By focusing on
identified works stream we will aim to ensure an
improved patient experience.
Improving patient experience – Ensuring our
patients have a good quality experience is integral
to the work and priorities of the trust. Patient
experience is a key component of quality and
better patient outcomes and patient collaboration
will be central to all care that we deliver.
Clinical effectiveness – The trust is committed to
providing timely and effective care to all our service
users and patients, delivered by proud, motivated
highly skilled staff informed by both local and
national guidelines, evidence and best practice.
74
Annual Report I 2014/2015
• Set annual targets to reduce avoidable harm.
• Ensure that annual measurable safety quality
priorities are agreed with individual services
across the trust.
• Launch a patient safety campaign focusing on the
importance of positive reporting and learning to
improve quality.
• Ensure that the annual trustwide ‘lessons
learned’ conference/workshop shares learning
and showcase clinical improvement based on
lessons learned.
• Ensure that key meetings have emerging risks to
patient safety as a standing agenda item.
• Board visits to clinical teams will have a visible
focus on patient safety and provide timely
feedback on action.
• Join the National Patient Safety Thermometer
in October 2014 to improve information and
analysis of safety incidents in key activities.
2. Continually learning: we will
• Improve the systems, processes, analysis and
triangulation of information by reviewing our
complaints and PALs service to maximise learning
by effective engagement.
• Increase the involvement of service users in
reviewing safety issues and lessons learned via
community team meetings and service user
forums and committees.
• Provide service users with better information about
safety themes and performance by publishing
regular information on the trust website and quality
notice boards in clinical areas about safety incidents
and what we have learned and what we have done
to improve quality and reduce harm.
• Provide training, advice and guidance on the
duties for staff.
• Introduce a daily rota of senior directors and
managers to be available to staff who wish to
raise a concern.
4. Collaborating: we will
• Work collaboratively with partner organisations
and commissioners to develop a systems wide
approach to reducing harm.
• Work with Imperial College London to assess
look at ways of reviewing the current critical
processes in mental health practice based on
the findings of the Berwick Report as part of the
local safety collaborative.
• Setup a series of action learning sets as part of
the leadership programme in preparation for the
introduction of service lines on the key elements
of governance and service improvement.
5. Supporting: we will
3. Being honest: we will
• Establish action learning sets focusing on safety
and how we can improve.
• Implement the ‘Duty of Candour’ by having clear
systems and processes to support staff and
regularly report to the board on compliance
with this duty.
• Launch a ‘Speak up’ campaign to encourage
people to raise concerns about safety.
• Increase the numbers of staff trained and
knowledgeable about Root Cause Analysis by 20%
to improve understanding, capacity and capability.
• Provide timely and effective analysis of
information related to safety to local teams to
support decision making.
• Encourage staff to report incidents to aid learning
without fear of recriminations.
75
Annual Report I 2014/2015
Reporting incidents - it is good to report
Developing an open and progressive culture
where we are encouraged and confident to report
incidents and near misses, is priority.
We recently, reviewed our performance on incident
reporting via the National Reporting and Learning
System which publishes the latest data.
Some of the safest NHS hospitals in the country are
characterised by high levels of incident reporting,
where people discuss mistakes and near-misses
openly with their managers and with colleagues, so
that learning can be shared to the benefit of patients.
West London Mental Health NHS Trust still have
a significant gap to close in the area of incident
reporting having come up again as one of the
lowest reporters in data published by the NHS
National Reporting and Learning System, which
looked at reporting across 54 other Mental Health
Trusts in the NHS.
Acknowledgements are noted to the staff who do
report, and from recent reporting of the incidents
and near misses reported, this happens much
more promptly here than in the majority of other
trusts, which is excellent. In fact 88% of incidents
reported at WLMHT are recorded within two hours
of the incident happening.
When reporting happens it’s done in a timely way,
but it needs to be encouraged further across the
trust, particularly in areas that report no incidents
or very few. We have a fundamental responsibility
to do this. If we’re not reporting all incidents and
near misses, we’re not doing enough to keep
people safe.
Staff are encouraged to report incidents and nearmisses but there still seems to be a worry for staff
from recent feedback, staff worry that it will reflect
badly on them.
76
Annual Report I 2014/2015
Because of the work we do with people, it’s inevitable
that incidents do happen from time to time.
Nationally, 70 per cent of incidents are reported as
no harm incidents, but none the less it’s absolutely
crucial that they are documented. We need to know
that an incident has happened to enable us to learn
from them and make suggested improvements to
our systems and processes that may have been
causative to the incident in the first place.
We are committed to driving this essential cultural
change at the trust and this means getting every
level of management in the organisation to
view the importance of reporting incidents with
fresh eyes and see the positive learning and
improvement that can come from doing so. We
have been focusing our efforts on getting that
message across to our managers, so they’re
supportive of colleagues who report incidents.
The trust is sharing this learning through our regular
learning lessons conferences and through other
reports that we produce and distribute. We plan to
set up a working group to focus on incident reporting.
This group will do more dedicated work with
colleagues on our wards and community teams
to give reminders about what you should be
reporting, and when and remind you that it is
good to report because it’s an essential part of our
patient safety and quality improvement objectives.
We are also looking closely at the internal metrics
to identify where reporting is high and where
it doesn’t happen so we can give some more
targeted support to staff in those areas.
Initiatives and improvements - West London Forensic Services
Recovery programme
User and carer experience
During 2014/15 we have further developed our
recovery programme within WLFS.
During Q2 2014-15 we have reviewed and established
new Governance arrangements which include:
We have appointed a service user and carer
engagement coordinator and 3 part-time service
users consultants who are actively involved in the
planning, development, delivery and implementation
of a range of recovery oriented initiatives.
Launch of Recovery College in October 2014
• Monthly women service user forum (co-chaired by
service user)
• Monthly men service user forum (co-chaired by
service user)
• Monthly carers forum (co-chaired by carer)
• Quarterly service user and carer experience forum
(co-chaired by a service user and carer rep)
• Quarterly carer event
We trained 6 trainers (3 staff and 3 service users)
to plan, co-ordinate and facilitate recovery college
workshops. All training events are co-developed
and co-delivered. Since launching on October 2014
we have also recruited 3 inpatient service user and
a carer to co-deliver training.
We are in the process of reviewing our patient
education provision to ensure it meets the needs
of our service users and is supportive of recovery
and care pathway transition.
Collaborative risk assessment:
Restrictive interventions
This is a 2014-15 CQUIN target; the decision to
host and deliver this training within the recovery
college underpins the importance of collaborative
working for better outcomes.
A Restrictive Interventions Reduction Committee
was established in December 2014 in response
to contemporary national guidance and policy.
The focus of the committee is to promote and
support innovative restrictive intervention
reduction programmes (e.g. Safewards) and to
identify, review and monitor the use of restrictive
interventions to ensure appropriateness, quality
and safety.
Between October 2014 and April 2015 79% of all
MDT qualified staff and 100% of eligible patients had
attended this workshop. Training was co-produced
and co-delivered by service users, carers and staff.
We are delivering workshops to facilitate
preparation for transition to community and
welcome and engagement workshops for staff.
We are progressing plans to establish an inpatient
Hearing voices network; trainer training for
recovery team staff and service user consultants
is planned for early May 2015 with roll out in
June. One of our service user consultants edits
‘user matters’ an in-house magazine for service
users and staff, this is now hosted on the trust
exchange and the recovery team are leading START
Programmes on 8 wards.
To support the increased activity during 201415 we have established a revised recovery
programme board in December 2014 to provide
better governance and assurance particularly in
relation to reporting and outcomes measurement.
Safewards
An evidence intervention to reduce conflict and
restrictive interventions which we are piloting in 6
wards. We will evaluate the pilot in May 2015 with a
view to service wide roll out across service.
MAVAS (Management of Aggression and
Violence Attitude Scale)
Completed a survey of staff and patient attitude
to the causes and management of violence and
aggression (WLFS and HSS). Initial report provides
a baseline measure. In liaison with Prof Colin
Martin (Bucks New University) we are currently
progressing further analysis to inform our
restrictive intervention reduction programmes; we
Intend to repeat this survey as one of a number of
outcome measures to measure change.
77
Annual Report I 2014/2015
Suicide prevention
Occupational therapy
The suicide prevention steering group has
introduced a revised Ligature Audit programme.
Annual ligature audits are undertaken by each ward
manager in collaboration with MDT colleague and
estates staff. Actions to manage risks are recorded,
progressed and updated quarterly via the risk
register. High risk ligature points which require
remediation are now tracked and progressed in
collaboration with our Head of administration and
patient services and estates department.
Significant improvement in recruitment and
retention following a review of the management
and supervisory arrangements for occupational
therapists. A number of initiatives (work
experience via a new café in THW; review of
patient education) to increase the range of
vocational and educational opportunities for
service users is being actively progressed.
WLFS and HSS staff in collaboration with colleagues
from NHS England (NPSA) have developed
and published a secure services version of the
‘Preventing suicide audit tool (Carthy, J., Gordon,
V., Schofield, T. Knowles, P (2014) Preventing
suicide audit tool: Secure services version. NHS
England). This audit tool has been implemented
from January 2015 to assist ward managers ensure
suicide prevention arrangements in each ward
meet national standards.
MSU redevelopment
Over the past year we have been able to ensure
appropriate clinical staff and service user
engagement in the redevelopment programme
that has led to the completion of a clinical model
based on a iecovery approach and psychosocial
interventions. A number of active work-streams
continue involving clinical teams, carers and service
users to prepare for transition to the new unit due
to open January 2016.
Clinical supervision for nurses
Clinical supervision uptake has increased from 32%
in May 2014 to 96% in February 2015. The WLFS
deputy director of nursing is leading a trustwide
programme designed to develop and assure the
quality of supervision through a pilot training
programme and implementation of an annual
evaluation (MCSS).
78
Annual Report I 2014/2015
PMVA
PMVA department (Ealing) provide training and
for WLFS and local services, in addition POMVA
trainers have historically provided advice to
clinical teams relating to complex and challenging
risks of violence and aggression. During 201415 the ability to deliver core training and advice
was compromised by a reduction in fulltime and
part-time PMVA trainers. During 2014-15 we
commissioned a PMVA review and in collaboration
with senior managers in WLFS and local services
are progressing all recommendations to improve
and sustain the service provided. We have
appointed an interim PMVA lead, a full time PMVA
tutor and 5 part-time instructors; we are able to
confirm that all mandatory training requirements
will be met for 2015-16, in addition we are again
able to respond to requests for advice and support
from clinical teams.
Initiatives and improvements in High Secure Services
Recovery College
We were really pleased to formally open the
Recovery College in 2014. This now provides a
space where coproduction events such as training,
workshops etc. take place. The opening of the
Recovery College has been well received by patients,
staff and visitors. The college now provides a clear
focus for the hospital to support the recovery work
being undertaken across all the wards and other
services. The College has been running various
workshops including understanding conflict and
understanding and managing medication.
ITV documentary
The hospital worked with the trust communications
team and external producers, ITV to make a
two part documentary around the daily life of
the hospital and its patients and staff. This was
screened in November 2014. The programme
aimed to challenge preconceptions around the
hospital and also to provide an opportunity to
share what we do. The documentary received high
viewing figures and feedback was overwhelmingly
positive. Our clinical director appeared on
various media outlets to promote and explain the
programme. The press and social media positively
commented on the programme which we feel went
some way in challenging stigma in mental health.
They prompted widespread discussion in the media
and particularly the social media about the causes
of mental illness, the nature and quality of the care
provided in the NHS for mentally ill patients and
aspects of treatment that require further thought.
Broadmoor Hospital is iconic to the media and
the public; it is perceived as the end of the line, a
life sentence for society’s most irreparably broken
minds. The documentary team sought to challenge
these myths and misconceptions by giving voice to
the men who are being treated at the hospital. The
patients spoke compellingly, for the first time, about
their past lives, illnesses, day to day care and hopes
for recovery and a life beyond Broadmoor Hospital.
The audience for the two documentaries was an
impressive nine million viewers and they generated
14,500 mostly favourable tweets with a reach of 30
million. The first programme was trending No1 on
twitter in the UK and third worldwide; the second
episode was No 3 on twitter in the UK and fifth
worldwide. In all, 9,000 people visited the trust’s
website in the two days following the broadcasts.
The documentary addressed key issues in mental
health care through the viewpoints of patients
and staff, so the public could have a better
understanding of the causes of mental ill health
and the range of therapeutic approaches available
to clinicians dealing with complex mental illness
and personality disorder. The documentary
explored the use of restraint and the administration
of medication against someone’s will. The patients’
and staff perspectives of these very challenging
aspects of care were explored openly and honestly.
79
Annual Report I 2014/2015
Research & development
Over the past year several research projects have
been completed including a NIHR funded multisite project investigating prevalence of ADHD
across mental health settings, a MRI study to
examine biological correlates with childhood abuse,
a validation of an objective measure of victim
empathy, and drug trials reporting outcomes for
use of clozapine and olanzapine. These have led
to four accepted publications and two publications
currently under consideration in British Journal
of Psychiatry, Psychiatry Research, Australian
& New Zealand Journal of Psychiatry, Journal
of Psychiatric Research, CNS Spectrums and
Therapeutic Advances in Psychopharmacology.
Working in collaboration with academic partners
at Imperial College London, Kings College London
and University of Canterbury, current research
at Broadmoor Hospital aims to determine if next
generation sequencing can lead to clinically relevant
genetic diagnosis in extreme personality disorder
and mental illness; investigate clinical predictors of
treatment outcomes using objective measures and
evaluate a fire setting group intervention.
80
Annual Report I 2014/2015
The Forensic Clinical Research Domain is
committed to both national and international
dissemination to the wider forensic community
through the publication of our high quality
research conducted at Broadmoor Hospital in
peer-reviewed scientific journals. In addition we
have presented findings at national conferences
including the British Psychological Society,
the Royal College of Forensic Psychiatry and
Andrew Sims annual conferences, as well as at
international conferences in Denmark, Turkey,
Iceland and Switzerland. In addition we hosted
a conference ‘Broadcasts from Broadmoor
Hospital: Current Issues in Forensic Mental Health’
which was attended by over 100 delegates and
received excellent feedback. Presentations from
this conference were recorded and are widely
available to staff, patients and the public through
website and social media links to postings on
YouTube. Extending this theme, five staff will be
presenting a workshop seminar at the XXXIVth
International Congress on Law and Mental Health
to be held in Vienna in July 2015 titled ‘Broadcasts
from Broadmoor Hospital: Advances in Working
with High Risk Mentally Disordered Offenders’.
Local methods of dissemination include ward
noticeboards, a visitor reception noticeboard,
reports in the WLMHT publication Mental Health
Matters and the R&D website.
Patient Safety Initiative
We have been working with a private company,
Oxehealth, to test a remote monitoring system
(physical healthcare signs). This project aims to
improve the health and safety of our population. It
is an exciting opportunity and innovation which we
are pleased to be involved in. In using the Oxecam,
the project trialled camera-based health monitoring
software to enable the unobtrusive, non-contact
monitoring of patients vital signs in a secure room
setting, increasing patient health and safety.
Violence Reduction Centre
Our new Violence Reduction Centre was opened
by the Minister for Health, Norman Lamb in
September 2014. The Centre is a new state of the
art building which provides a full range of training
rooms that allow a range of scenarios to be
practiced. This includes a dedicated lecture theatre.
PMVA (Prevention and Management of Violence and Aggression) Development
events organised by the Diversity Group and
Sports & Leisure department. These events prove
very popular. Recovery was also measured using
the DREEM (Developing Recovery Enhancing
Environments Measure) scale.
We have recruited an ‘Expert by Experience’ to
work with us on developing and providing training
opportunities for our patients and in making us
continually question our practice. This has included
input into the hospital’s redevelopment.
We have also piloted a patient experience survey
which we will be undertaking again in 2015.
Patients have been working with staff to develop
a self-report tool. This has been piloted on some
wards and demonstrates self-motivation. This
hospital has also worked with RETHINK mental
health charity to look at improving patient
involvement in their own risk assessment.
Carers’ events
The PMVA Department have been involved in
the National consultations around introducing
positive and safe guidelines from the Department
of Health. The Department is also leading the
development of a National PMVA training manual
for High Secure Mental Health Services in the
UK. This work has been commissioned nationally
through the Clinical Secure Practice Forum.
Carers’ events continue to be held quarterly. Following
feedback from carers these events are now held
within the hospital perimeter. These have included
presentations and discussions on psychological
therapies, redevelopment etc. The hospital has
undertaken the ‘Triangle of Care’, assessment and is
continuing to look at how carers can be meaningfully
involved further with the hospital.
The PMVA Department has also introduced
coproduction workshops within the Recovery
College and has worked with ‘Experts by
Experience’ to review and deliver training within
the Centre. This is a really exciting development
which embraces coproduction and valuing the
work of ‘Experts by Experience.’
Carers have also had the opportunity to view the
bedroom prototype for the new hospital. This
feedback has proved a useful addition to the
design of the room.
User involvement and recovery
The hospital has continued with its work in
implementing a recovery approach for all patients.
Several wards and departments have been
involved in the START (Systems Transfer and
Recovery Teams) programme. This work includes
joint MDT and patient workshops to describe and
develop plans for local recovery programmes on
wards. There has been several recovery events
held for patients within the hospital including
Restorative justice
The hospital is exploring introducing a restorative
justice programme. Some staff have been trained
in restorative justice and we will look at developing
this further within the hospital.
Safewards programme
The Safewards programme, developed at the
Institute of Psychiatry which promotes reducing
points of conflict and containment, has been
introduced to the hospital. This follows a presentation
to the hospital by the Institute of Psychiatry.
81
Annual Report I 2014/2015
“
Meridian is the system implemented for recording
and reporting real time patient experience.
In total we received 9197 completed feedback
questionnaires from across the trust from 1st April
2014 to 31st March 2015. The mean satisfaction
score of all questionnaires relating to service user
and carer feedback is 81% which is an increase of 1%
compared with the same time period as last year.
Here is a sample of some of the comments
received from the final question added to all
questionnaires/surveys “Is there anything you
would like to tell us about?”
I’m very grateful to you for the
time you gave, the support; it
was very helpful and it’s been a
pleasure meeting you.
• Thanks to all the staff who have helped me on my
way through this.
• Can you establish an email address for routine enquiries.
West London Forensic Services
• I am happy on the ward.
• More nurses to help patients.
Broadmoor Hospital High Secure Services
• Freedom of speech.
• I am very happy the way the teams are dealing
with recent problems on the ward, many thanks to
you all.
• More activity like PS3/Console.
• Toilets need regular cleaning.
• Healthy environment and information is always
kept confidential.
• There is not enough staff on the ward to facilitate
all patient needs. Staff are often left to struggle
without a break.
• Communication is the key.
• The music is too loud and staff don’t always say
turn it down.
“
Comments for Meridian
• Would like to have a befriender.
• Sometimes I feel the staff are not quick enough to
act on my requests.
Carers questionnaire
• The staff are very nice and helpful and care for my
husband so well.
• It was a good assessment as someone listened for
a change thank you.
• Waited too long.
• I think there should be classical music in the
background as it’s so quiet sometimes.
Local Services Inpatients
• Caring can be very difficult at times.
• Everything here is good.
• Very informative session today which isn’t always
the case on previous appointment.
• Good ward. Staff are very good and helpful.
• I would like a duvet rather than all the sheets and
blankets.
• I find being on the ward most interesting.
• The toilets are not kept clean, the service users do
not tidy up after use.
• Things to do it’s so boring.
Local Services Community
• The whole NHS deserves money and love.
• I am happy with my care.
• I am satisfied with the support I get from the services.
• No good, everything was rushed, crisis handled badly.
82
Annual Report I 2014/2015
As well as the patient experience reports being
completed for the trust and service lines, each ward/
area has a quality noticeboard to which responses to
comments are shared and other statistics relevant to
patient feedback are added for information and for
local actions to be implemented.
In 2015/16 we will transfer to a new methodology
of capturing patient experience which will replace
Meridian, the new modal will be used collaborating all
existing information on patient experience data such
as friends and family test results, complaints, PALS
and serious incidents.
Annex 1: NHS Ealing CCG Statement
for WLMHT Quality Account 2014-15
NHS Ealing Clinical Commissioning Group (CCG) has reviewed the West London Mental Health NHS Trust’s
Quality Account (QA) for the year 2014-15 with support from the Hounslow CCG and Hammersmith &
Fulham CCG. We have reviewed the content of the Quality Account and confirm that this complies with
the prescribed information, form and content as set out by the Department of Health. In the version we
reviewed there were some gaps in data which we have not been able to validate. We were not as involved
with the development and content as we would have liked to have been we believe that the account
represents a balanced overview of the quality of care at the trust.
It demonstrates the progress made on achievement of last year’s priorities and the plans for future
development. It provides a clear rationale for the coming priorities alongside expected delivery dates. The
priorities for quality improvements in 2015-16 are supported by Ealing CCG. We would like to take this
opportunity to highlight the marked improvements we have seen in the reporting and investigation of Serious
Incidents. The process and the quality of the investigations are notably better than 12 months ago and we are
pleased with the progress we continue to see with dissemination of the learning across the organisation. The
CCG also acknowledges the pledge to continue this improvement in the sign up to safety campaign.
The CCG acknowledges the work that has gone into improving patient experience although we did not see
the outcomes of this yet when we looked at the national survey. We do hope that the various work streams
do impact on this year’s survey results. We do welcome the addition of an executive lead for this area and
look forward to working with the trust to improve this important area over the forthcoming year.
The CCG’s do think it would be helpful to include a borough breakdown of the local measures such as
Delayed Transfers of Care (DTOC) for the quality account. This is an area where there is variation due to
local service provision and the local pathways of care and we believe it would be clearer for patients to
have the local level data available. We will continue to monitor and aim for improvements to be made
through the local quality group this year.
The CCG is working with the trust specifically around the ward to board assurance process of monitoring
key Quality issues. The CCG will continue to work collaboratively with you to help shape how we move the
quality agenda forward both from a commissioner and provider perspective in 2015/16.
Ealing CCG hopes that West London Mental Health NHS Trust has found these comments helpful and we
look forward to continuous improvements and productive collaborative working in the coming year.
Dr Mohini Parmar,
chair, Ealing CCG
Dr Serena Foo,
clinical lead GP
Tessa Sandall,
managing director, Ealing CCG
83
Annual Report I 2014/2015
Healthwatch Central West London response to the West London Mental Health NHS
Trust Quality Account 2014-15
Healthwatch CWL appreciates our working relationship with West London Mental Health Trust (WLMHT).
We acknowledge the work of the trust in aiming to improve the quality of services for patients. We
commend overall improvements from last year in various quality areas and have the following comments
on progress on last year’s priorities:
Local Services
Patient safety
Reducing physical assaults on service users and staff
We welcome the commitment from the trust to work with patients through co-production events to provide
safer ward environments, however there seems to be a large difference between what was to be achieved and
what has been. The accounts state that the aim was to not only hold co-production events but to focus on care
planning and de-escalation. However the only outcome reported is increased reporting to the police and an
agreed joint capacity assessment. Whilst the value of reporting to the police is clear we are unsure what work
if any has taken place to increase safety on wards for both staff and patients. Our recent assessments of the
Hammersmith and Fulham Mental Health Unit found safety continues to be of significant concern to patients.
To improve the service user experience of engagement and communication with staff
This section was still to be completed in the version shared with Healthwatch, we would welcome the
opportunity to comment on this once completed. Our recent assessments of the Hammersmith and Fulham
Mental Health Unit found significant scope for improving frontline staff communication with patients, and in
general the trusts communication and engagement across all its services could be improved.
Improve the detection and management of long term physical health conditions
Whilst we note the trust exceeded their first target regarding the recording of physical healthcare diagnosis
it is disappointing and worrying that the trust has not sought to audit their performance against their
second target concerning the recording of physical healthcare diagnoses on RiO care plans.
We are disappointed that for all the above priorities, information on the trusts performance is vague and
without detail, with often just one sentence detailing how they have performed, we would urge the trust to
give far more detail in future.
Patient experience
Improved clinical supervision improves lessons learnt from incidents, complaints, improves team
working, patient experience and safety
We share the trusts disappointment in not meeting this target and are pleased to see they will continue to
work on increasing the level throughout 2015/2016.
To improve the service user experience of engagement and communication with staff
Whilst we commend the trust for seeking to improve service user engagement and the use of service
user views we are concerned about the reliance on the Meridian system. On our visits to the WLMHT
inpatient unit based at Charing Cross Hospital in Hammersmith & Fulham he static Meridian system was
not working and staff informed us it had never worked, in addition we were told that there was a mobile
unit but that this was used with staff supervision. We don’t believe either situation will lead to accurate or
comprehensive reporting of patient experiences and would urge the trust to look at expanding its patient
experience collecting activities to complement the Meridian system.
84
Annual Report I 2014/2015
Healthwatch CWL has the following comments on WLMHTs priorities for 2015/2016:
Access and Urgent Care – Service Line
Patient Experience
Healthwatch is pleased to note a new welcome pack is now being developed for patients and would hope
these will be co-produced with and accessible to patients. Under ensuring clinical environments are safe
we note that the trust intends to use feedback through the Meridian system to review the success of
this measure. We note that on all our visits to the WLMHT unit based at Charing Cross Hospital the static
Meridian system has not been operational and most patients are not aware of any alternative access. We
urge the trust to take action to ensure the Meridian system is accessible to all to ensure accurate measures.
Overall accessibility and layout
We applaud the trust on the overall accessibility of the quality account; the language used is not too
technical or filled with jargon. We would encourage the trust to make the final quality account document
more colourful and vibrant to make it more appealing to the public and would encourage the inclusion of
an executive summary complete with info graphics and patient stories.
Other comments
Healthwatch CWL Dignity Champion project visited the WLMHT unit based at Charing Cross Hospital on the
4th February 2015 as a follow up to our previous visit in March 2014. We were particularly interested to see if
improvements had been made to the service that we had recommended following our previous visit. Dignity
Champions were pleased to see that improvements had been made to the environment since our last visit
in March 2014. However there are still a number of significant concerns, particularly around the quantity and
quality of staff interaction and communication with patients, as such we made the following recommendations:
1. Ensure that regular audits are completed to identify cleaning and repairs that are needed and ensure
they are completed in a timely manner.
2. Ensure staff are allocated the time and encouraged to communicate positively with patients.
3. Work collaboratively with patients to create a warmer, more homely environment at the unit.
4. Ensure, monitor and report on the involvement of all patients in writing their care plans and are aware
of their contents and how to access them.
5. Ensure that discharge planning begins with patients as soon as they are admitted and ensure all patients are
aware of what support will be available post discharge. Please see the emerging recommendations from the
Healthwatch CWL work on the national Special Inquiry on Unsafe Discharge: Mental Health briefing.
6. Ensure everyone is asked for their opinion about the services they receive on a regular basis – both
through individual and group meetings – and use this feedback on an ongoing basis to improve the
service. As we flagged twelve months ago, the Meridian i-pad system should be repaired or another
alternative for gathering patient feedback considered.
7. Consider an alternative serving arrangement at meal times to avoid long queuing times.
8. As Healthwatch has been flagging concerns about staff patient/interaction and about care planning
for over two years (August 2012), and as the trust in relatively unique locally in not inviting external
representatives to participate on their quality committee, we would strongly encourage the trust
management to meet with Healthwatch CWL on a regular basis to ensure these recommendations are
implemented now in an effective and timely manner.
The full report can be found on our website. http://healthwatchcwl.co.uk/wp-content/
uploads/2014/03/WLMHT-spot-check-feb15-FINAL.pdf
85
Annual Report I 2014/2015
We note with concern that the older people’s inpatient service based at Charing Cross Hospital (Meridian
Ward) is planned to close and be replaced with an ageless recovery ward, resulting in the trust providing
specialist older people’s inpatient services solely in Ealing. It is a concern that resident from H&F may
now have to travel to Ealing to receive the services they need and contributes to wider worries about the
amount of out of borough placements for H&F residents as a result of bed reductions.
We also note that the trusts plans to provide a ‘step down’ recovery house in H&F are currently on hold and
we would urge the trust to communicate these plans to patients and to assure them that this service will be
provided in H&F.
Keith Mallinson,
chair
Samuel Wallace,
borough manager
Healthwatch CWL
Unit 25/26 Shaftesbury Centre
85 Barlby Road
W10 6BN
Healthwatch Ealing response to West London Mental Health NHS Trust Quality
Account 2014-15.
Overall it is good to see the work the trust in undertaking to improve services for people in West London,
we would want to give the following comments:Integrating physical healthcare
We welcome the work being undertaken to improve physical health care for patients, as this is an area
Ealing LINk had raised for improvement some years ago.
Improvement initiatives
We are pleased to see there a range of initiatives to support the improvement in quality and patient
experience. From a Healthwatch point of view we would want to see the evidence of patient and carer
involvement from the start and embedded in any improvement initiatives.
Communication
Through feedback to us there are still concerns about communication between the trust and patients
and carers in terms of letters, inaccurate records, lack of information about services available and how to
access them.
Interpersonal interactions, many patients and carers do not feel listened to and understood by a range of
professionals in the trust.
We have had reports of poor communication channels between the trust and primary care, which at times
leaves the patient feeling vulnerable.
In our view, the points above will impact on quality of patient and carer engagement within the coproduction principles. We wish to see ongoing improvements which evidence patient and carers
involvement in driving change in communication in the coming year.
86
Annual Report I 2014/2015
Gaps we feel should be addressed
We could not see enough detail on services in relation to substance misuse. We would want to see more on
the services in the community which support the majority of service users.
Equality data – this would help to identify any trends or issues that need to be addressed within such a
diverse area of London.
As Healthwatch Ealing we would welcome the opportunity to follow up with the trust, on the points we
raised in the coming year.
Suzanne Lyn-Cook,
director
Healthwatch Bracknell Forest response to West London Mental Health NHS Trust
Quality Account 2014-15
Thank you for the opportunity to comment on your 2014-15 quality account. Broadmoor Hospital, West
London’s high secure service, is based within the Borough of Bracknell Forest and we shall comment on the
particular parts of the quality account relating to this service only.
Healthwatch Bracknell Forest, as the local voice of patients and carers, is interested in patient experience
and the care environment.
We are pleased improving service user experience of engagement and communication with staff was a
priority for 2014/2015 and that the trust report an increase in the uptake of patients providing a written
report for their CPA. We welcome the extension of the Friends and Family Test to patients within the service
and Healthwatch Bracknell Forest would welcome access to this data.
Patient feedback from Meridian: Information received by Healthwatch Bracknell Forest during the year
and from observations on visits and the conducting of PLACE in April 2014 supports some of the sample
comments concerning cleanliness and staffing levels. We were disappointed with some aspects of the care
environment and are pleased to see that this is included in the priorities for the coming year.
We are aware that the current hospital site is an old building, not fit for purpose, and that there is a new
development but small improvements and maintaining standards of cleanliness and staffing levels that
allow people access to facilities such as the gym makes a significant impact on patient experience. During
the PLACE visit in April 2015 we were pleased to see the improvements of the external terrace area and the
new cycle pathway.
Healthwatch Bracknell Forest have been working with senior managers of the high secure service about the
introduction of the Healthwatch service within the hospital. We hope that this will be possible early in the
coming year to allow us to fully carry out our duties and provide a more comprehensive service to patients,
support the work of the advocacy service and the trust in general.
We look forward to continuing to work with West London Mental Health NHS Trust with the aim to improve
patient engagement and experience.
87
Annual Report I 2014/2015
London Borough of Ealing Health and Adult Social Services Standing Scrutiny Panel
response to West London Mental Health NHS Trust Quality Account 2014/15.
General
The panel welcomes the principles that West London Mental Health Trust has based its quality
improvement work on: putting service users at the heart of what it does; focussing on measurable clinical
outcomes; and having informed, engaged and empowered staff to innovate and drive forward service
improvements. The panel strongly agrees that staff are key to the success of any organisation and will be
interested to see the impact of the initiatives being undertaken by the trust to improve staff engagement.
The panel congratulates the trust on meeting all essential standards of quality and safety as assessed by
the Care Quality Commission (CQC) in inspections.
Progress against priorities for quality improvement in 2014-15
The panel welcomes the trust’s efforts in improving patient safety, clinical effectiveness, and the patient
experience. However the panel were disappointed to note that for most of the quality priorities for 2014-15
the Quality Account did not set out targets or provide data which would indicate to what extent the trust
had met them.
Quality priorities for 2015-16
The panel is pleased to note that the trust has introduced a model of clinical leadership based around its seven
service lines and that the progress of the quality priorities will be evidenced by each of these service areas.
The panel is also pleased to note that the trust has identified one of its priorities as ensuring a positive and
open culture of reporting incidents and embedding the lessons that are learnt. It is hoped that the trust
will be able to close the gap in the area of incident reporting having come up again as one of the lowest
reporters in data published by the NHS National Reporting and Learning System. It is also important that
the trust is able to assure staff that reporting incidents and near misses will not reflect badly on them, as
some appeared to believe from recent feedback obtained by the trust.
The panel commends the trust for the clear way in which it has set out examples of key messages and
actions taken in response to incidents and serious incidents.
Complaints
The panel commends the trust for its work on identifying learning from complaints and PALSs and
sharing good practice. We would like to see the trust meeting and exceeding its target of 90% for resolving
complaints within the timeframe agreed with the complainant.
The panel would also have been interested in knowing what actions the trust were putting in place to
address the Coroner’s Rule 43 Prevent Further Death (PFD) issued in July 2014. The draft report supplied
to the panel did not explain what the trust was doing to address the coroner’s concern that there was no
system in place to ensure that both GPs and psychiatrists are aware of all medication a patient is taking,
regardless for who is responsible for prescribing it and why.
Safeguarding children and adults at risk
The panel notes the work that has been undertaken by the trust to developing safeguarding over the last year
and the expansion of the safeguarding adults professional resource by developing two new posts. The panel
was pleased to note the positive comments that the trust received on its present safeguarding arrangements
in the external review of the historical allegations relating to Jimmy Saville and Broadmoor Hospital.
The panel looks forward to continuing to work with West London Mental Health NHS Trust.
88
Annual Report I 2014/2015
Annex 2: Statement of directors’ responsibilities
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health issued guidance on the form and content of annual Quality Accounts
(which incorporate the legal requirements in the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment
Regulations 2011 and the National Health Service (Quality Accounts) Amendment Regulations 2012).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
• The Quality Account presents a balanced picture of the trust’s performance over the period covered.
• The performance information reported in the Quality Account is reliable and accurate:
• There are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are working
effectively in practice.
• The data underpinning the measures of performance reported in the Quality Account is robust and reliable,
conforms to specified data quality standards and prescribed definitions, and is subject to appropriate
scrutiny and review.
• The Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the board
Signed
Signed
Tom Hayhoe, chairman
Date
25th June 2015
Dr Nick Broughton, medical director
on behalf of Steve Shrubb, chief executive
Date
25th June 2015
89
Annual Report I 2014/2015
Annex 3: How our services are structured
Local and Specialist Services CSU
Forensic Services CSU
Liaison and long-term conditions
West London Forensic Services
Gender Identity Clinic
Men’s services:
Health / neuro psychology
- Low secure, medium secure and rehabilitation
IAPT
Women’s services:
Integrated care pilot
- Enhanced medium secure and low secure
Liaison psychiatry
Adolescent services:
Stop smoking services
- Community forensic services
Access and urgent care
High Secure Services (Broadmoor Hospital)
Assessment service
Mental illness services
Crisis resolution teams (CRT)
Personality disorder services
Electro-convulsive therapy (ECT)
Centralised group work services
Inpatient assessment service
Rehabilitation therapy services
Inpatient recovery service
MH Act assessment service
Psychiatric intensive care unit (PICU)
Recovery houses
Service user telephone support line (SUTS)
Primary and planned mental health care
Cassel Hospital services
Clozapine clinics
Community recovery teams
Early intervention service
Eating disorder service
Placement & repatriation work
Primary care mental health service
Psychotherapy and personality disorder service
Rehabilitation service (Glyn & Mott)
Cognitive impairment and dementia (CID)
CID community services
CID inpatient services
CAMHS and developmental services
Adult neurodevelopmental services (in development)
CAMHS
CAMHS learning disabilities
90
Annual Report I 2014/2015
Annex 4: Internal Governance Structure
High Secure Services
TRUST
Clinical Effectiveness
& Compliance
Service User &
Carer Experience
Patient Safety
& Safeguarding
Incident Review
Broadmoor
Chair’s Report
Broadmoor SMT
HOSPITAL
Clinical
Effectiveness
Patient
Experience
Safety &
Safeguarding
Incident Review
Ward
Chair’s Report
Clinical Director Bulletin &
input from the ward MOT
WARD
Ward CIGs
Local Services
New Clinical Governance Structure
TRUST
Clinical Effectiveness
& Compliance
Patient Safety
& Safeguarding
Service User &
Carer Experience
Incident Review
Local Services SMT
LOCAL
SERVICES
SERVICE
LINES
Clinical Effectiveness
& Compliance
Liason & LTC
SMT
Patient Safety
& Safeguarding
Cognitive
Impairment &
Dementia SMT
Service User &
Carer Experience
Primary &
Planned Care
SMT
Incident Review
Access &
Urgent Care
SMT
CAMHS &
Developmental
SMT
Team/Ward Clinical Improvement Groups
91
Annual Report I 2014/2015
West London Forensic Services
Clinical Governance Structure
WLFS SMT
MONTHLY
Patient safety
& safeguarding
governance
IRG
MONTHLY
MONTHLY
Restrictive
intervention
reduction
committee
WLFS User &
Carer Experience
Group
QUARTERLY
WLFS Carer’s events
4 MEETINGS PER YEAR
WLFS Carer’s forum
8 MEETINGS PER YEAR
WLFS Service User Forums
MONTHLY
WLFS Equality &
Diversity Steering Group
MONTHLY
WLFS Recovery board
MONTHLY
92
Annual Report I 2014/2015
Annex 5: Independent auditors’ limited assurance report to the directors
of West London Mental Health NHS Trust on the Annual Quality Account
We have been engaged by the board of directors of West London Mental Health NHS Trust to perform an
independent assurance engagement in respect of West London Mental Health NHS Trust’s Quality Account for
the year ended 31 March 2015 (“the Quality Account”) and specified performance indicators contained therein.
In accordance with section 8 of the Health Act 2009 (“the Health Act”) and the National Health Service
(Quality Accounts) Regulations 2010 and subsequent amendments thereto (the “Regulations”), the trust is
required to prepare a Quality Account annually.
NHS Quality Accounts Auditor Guidance 2014/15 (the “Auditor Guidance”), published in March 2015 by NHS
England, sets out the requirements for our limited assurance work, including the choice of indicators to be tested.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance (the “specified indicators”)
and marked with the symbol A in the Quality Account, consist of the following indicators as mandated
by NHS England:
Specified indicators
Specified indicators criteria
Percentage of patients on Care Programme Approach
(CPA) followed up within seven days of discharge
Page 97 of the Quality Account
Percentage of patient safety incidents resulting in
severe harm or death
Page 97 of the Quality Account
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:
• the Quality Account presents a balanced picture of the trust’s performance over the period covered;
• the performance information reported in the Quality Account is reliable and accurate;
• there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are working
effectively in practice;
• the data underpinning the measures of performance reported in the Quality Account is robust and reliable,
conforms to specified data quality standards and prescribed definitions, and is subject to appropriate
scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health guidance.
The directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
93
Annual Report I 2014/2015
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything
has come to our attention that causes us to believe that:
• the Quality Account has not been prepared in line with the requirements set out in the Regulations;
• the Quality Account is not consistent in all material respects with the sources specified in Auditor
Guidance, issued by NHS England in March 2015 and specified below; and
• the specified indicators in the Quality Account identified as having been the subject of limited assurance
in the Quality Account have not been prepared in all material respects in accordance with the Regulations
and the six dimensions of data quality set out in the Auditor Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the
Regulations and to consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
• board minutes for the period April 2014 to May 2015 (inclusive);
• Integrated Performance Reports presented at board meetings during the period April 2014 to June 2015
(inclusive);
• feedback from the Ealing Council Adult Social Services Standing Scrutiny Panel dated 01/06/2015;
• feedback from Healthwatch Central West London dated 01/06/2015
• feedback from Healthwatch Ealing dated 01/06/2015;
• feedback from Healthwatch Bracknell Forrest dated 01/06/2015;
• the trust’s complaints report published under regulation 18 of the Local Authority, Social Services and
NHS Complaints (England) Regulations 2009, dated 03/06/2015;
• feedback from NHS Ealing Clinical Commissioning Group dated 01/06/2015;
• West London Mental Health NHS Trust’s outcomes in the 2014 national NHS patient survey;
• West London Mental Health NHS Trust’s outcomes in the 2014 national NHS staff survey;
• West London Mental Health NHS Trust’s outcomes the 2014 CQC community mental health survey;
• the Head of Internal Audit’s annual opinion over the trust’s control environment dated 27/05/2015;
• the annual governance statement dated 27/05/2015; and
• Care Quality Commission Intelligent Monitoring Report dated November 2014.
We consider the implications for our report if we become aware of any apparent misstatements or material
inconsistencies with these documents (collectively the “documents”). Our responsibilities do not extend to
any other information.
This report, including the conclusion, is made solely to the board of directors of West London Mental
Health NHS Trust. We permit the disclosure of this report to enable the board of directors to demonstrate
that they have discharged their governance responsibilities by commissioning an independent assurance
report in connection with the indicators. To the fullest extent permissible by law, we do not accept or
assume responsibility to anyone other than the board of directors as a body and West London Mental
Health NHS Trust for our work or this report save where terms are expressly agreed and with our prior
consent in writing.
We are in compliance with the applicable independence and competency requirements of the Institute
of Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics. Our team comprised assurance
practitioners and relevant subject matter experts.
94
Annual Report I 2014/2015
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on Assurance
Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of Historical Financial
Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’) and the
Auditor Guidance. Our limited assurance procedures included:
• reviewing the content of the Quality Account against the requirements of the Regulations;
• reviewing the Quality Account for consistency against the documents specified above;
• obtaining an understanding of the design and operation of the controls in place in relation to the collation
and reporting of the specified indicators, including controls over third party information (if applicable)
and performing walkthroughs to confirm our understanding;
• based on our understanding, assessing the risks that the performance against the specified indicators
may be materially misstated and determining the nature, timing and extent of further procedures;
• making enquiries of relevant management, personnel and, where relevant, third parties;
• considering significant judgements made by the management in preparation of the specified indicators;
• performing limited testing, on a selective basis of evidence supporting the reported performance
indicators, and assessing the related disclosures; and
• reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature,
timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative
to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information, given
the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different measurements
and can impact comparability. The precision of different measurement techniques may also vary.
Furthermore, the nature and methods used to determine such information, as well as the measurement
criteria and the precision thereof, may change over time. It is important to read the Quality Account in the
context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health.
This may result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by West London Mental Health NHS Trust.
95
Annual Report I 2014/2015
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that,
for the year ended 31 March 2015:
• the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
• the Quality Account is not consistent in all material respects with the sources specified above; and
• the indicators in the Quality Account subject to limited assurance have not been prepared in all material respects
in accordance with the Regulations and the six dimensions of data quality set out in the Auditor Guidance.
PricewaterhouseCoopers LLP
1 Embankment Place
London
WC2N 6RH
29th June 2015
Note: The maintenance and integrity of West London Mental Health NHS Trust’s website is the
responsibility of the directors; the work carried out by the assurance providers does not involve
consideration of these matters and, accordingly, the assurance providers accept no responsibility for any
changes that may have occurred to the reported performance indicators or criteria since they were initially
presented on the website.
96
Annual Report I 2014/2015
Annex 6: Criteria applied for the measurement of the
indicators tested by PricewaterhouseCoopers LLP
Our external auditors PricewaterhouseCoopers LLP are required under the Audit Commission’s ‘NHS
Quality Accounts Auditor Guidance 2014-15’ to perform testing on two national indicators. A detailed
definition and explanation of the criteria applied for the measurement of the indicators tested by
PricewaterhouseCoopers LLP is included below.
Percentage of patient safety incidents that result in severe harm or death
The trust uses the following criteria for measuring the indicator for inclusion in the Quality Account:
• The indicator is expressed as a percentage of patient safety incidents reported to the National Reporting
and Learning Service (NRLS) that have resulted in severe harm or death;
• A patient safety incident is defined as ‘any unintended or unexpected incident(s) that could or did lead to
harm for one of more person(s) receiving NHS funded healthcare’; and
• The ‘degree of harm’ for patient safety incidents is defined as follows: ‘severe’ – the patient has been permanently
harmed as a result of the incident; and ‘death’ – the incident has resulted in the death of the patient.
The percentage of patient safety incidents that result in severe harm or death for the period 2014/15 was 0.7% A .
Percentage of patients on Care Programme Approach (CPA) followed up within seven days of discharge
The trust uses the following criteria for measuring the indicator for inclusion in the Quality Account:
• The indicator is expressed as a the proportion of those patients on Care Programme Approach (CPA)
discharged from inpatient care who are followed up within seven days;
• ‘Patients discharged’ includes patients discharged to their place of residence, care home, residential
accommodation, or to non-psychiatric care, or to prison;
• The indicator excludes patients who die within seven days of discharge;
• The indicator excludes patients removed from the country as a result of legal precedence within seven
days of discharge;
• The indicator excludes patients transferred to NHS psychiatric inpatient ward when discharged from
inpatient care;
• The indicator excludes CAMHS (children and adolescent mental health services), i.e. patients aged under 18;
• Those that are recorded as followed up receive face to face contact or a telephone conversation (not text
or phone messages); and
• The seven day period should be measured in days not hours and should start on the day after discharge.
The percentage patients on Care Programme Approach (CPA) followed up within seven days of discharge
for the period 2014/15 was 95.3% A .
97
Annual Report I 2014/2015
Promoting hope
and wellbeing
together
West London Mental Health NHS Trust,
Uxbridge Road,
Southall,
Middlesex UB1 3EU
020 8354 8354
www.wlmht.nhs.uk
For alternative formats please contact the
Trust’s Communications Department on 020 8354 8737
Design by Lucid Graphics – www.lucidgraphics.co.uk
Photography by Ralph Hodgson