Care Quality Commission
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Regulator says patients put at risk by "seriously flawed" systems.

The Care Quality Commission today (Tuesday) said that inpatients at West London Mental Health NHS Trust had been put at risk due to a failure to properly investigate suicides and learn from serious incidents.

Following an investigation into the trust, the CQC also highlighted serious concerns relating to sub-standard buildings, not enough beds, poor physical healthcare, not enough staff and lack of staff training.

The Commission said problems had persisted over a number of years, yet the trust's leadership had repeatedly failed to address issues. It said the board lacked "vitality and vigour" and that the trust was "good at writing policies, but not good at putting them into action".

The investigation looked at high-secure, inpatient services at Broadmoor Hospital as well as community and other inpatient services in Hounslow, Ealing, Hammersmith and Fulham.

The most serious concerns relate to secure and general inpatient settings. In these services, patients have been assessed to be so unwell that hospitalisation is required, either voluntarily or through detention under the Mental Health Act 1983.

Since the investigation began, the trust has taken action to address some concerns, particularly by implementing a new system to report and investigate serious incidents and strengthening their arrangements to monitor safety and drive improvements in care.

However, CQC said much work was still to be done to ensure people using mental health services at the trust were receiving the highest possible standard of care.

Barbara Young, CQC's chairman, said: "Mental health services are inherently risky environments and this trust cares for some of the most seriously unwell patients in the country.

"Given the nature of its services, the organisation should be leading the way in managing risks, yet in some instances they tolerated poor and mediocre practices.

"The same problems about managing risk, overcrowding, sub-standard buildings and staff shortages were raised on a number of occasions, yet the trust's response was slow and piecemeal. The trust was good at writing policies, but not good at putting them into action.

"Lack of staff and beds meant that some patients had limited access to leave, therapeutic activities and physical healthcare, which are vital for a patient's recovery. Patients were considered to be at greater risk of harming themselves or others, because the trust's systems to manage risk were seriously flawed.

"This would not be acceptable in an acute hospital and people who need mental healthcare should not have to accept it either."

Mental healthcare will be a key focus of the new regulator. It will undertake a programme of work aimed at improving safety, accessibility and value for money, with a focus on improving outcomes, experience and quality of life for people using services.

Barbara Young emphasised that all mental health trusts should take note of the recommendations, particularly ahead of registration next year.

"From next year, all NHS trusts will need to register with CQC. Mental health trusts that don't have good systems in place to report, investigate and learn from serious incidents could find themselves facing sanctions.

"Looking across the sector, there is good practice out there but services are still highly variable. Acceptance of low standards is highly troubling. That mindset needs to change."

The investigation into West London Mental Health NHS Trust was triggered by concerns that service users may be at risk because the trust did not respond appropriately to serious incidents, including suicides.

Investigators conducted five announced and three unannounced visits; interviewed more than 290 people including current and former staff, service users and their relatives and voluntary organisations; and analysed more than 1000 documents.

The trust provided 95 reports into serious incidents that occurred between 2005 and 2007. Thirty-one reports related to the suicide of a patient and five to attempted suicide.

The trust's own internal review compared Broadmoor Hospital to the other two high-secure units in England. It found that between 2001 and 2008, eight suicides had occurred in Broadmoor, five by hanging, while one suicide had occurred at the high-secure service at Rampton and none occurred at Ashworth.

The investigation found that:

The trust failed to properly investigate or report serious incidents

  • There was confusion over how incidents should be investigated and the trust did not always follow its own policies for internal investigations.
  • Investigations took, on average, nine months to complete and in one case took almost two years from the time of the incident. The trust was aware of the delays, but did not take action to improve the process.
  • Some investigations did not properly examine important factors in the incident. For example, one did not make recommendations about a ligature point although suicide had occurred by hanging. In another report, the possibility of self-harm or attempted suicide was not considered despite the existence of a suicide note.
  • Some staff at Broadmoor Hospital were unsure about how incidents should be classified. For example, some staff reported incidents of self-harm as "near misses" rather than serious untoward incidents.

The trust did not learn from previous incidents or implement all previous recommendations

  • Internal investigation reports repeatedly made the same recommendations relating to management of risk, training of staff and the need to reduce the number of ligature points or minimise their risk. This suggests that the recommendations had not been implemented.
  • There was confusion among staff about who was responsible for implementing action plans arising from serious incidents and there were no clear systems in place to implement them.

Some buildings are not a safe environment for care

  • Broadmoor Hospital was described in 2003 by a former regulator (the Commission for Health Improvement) as "totally unfit for purpose" and lacking in "basic standards of dignity and privacy". That remains the case today.
  • It is not possible to eliminate all ligature points at Broadmoor because the building is listed.
    Layout of the wards at Broadmoor makes it difficult for staff to observe patients. Because of the layout and shortages of staff, wards were sometimes "locked-off" to allow patients to be more easily monitored. This, however, presented a risk as staff were stationed outside the locked door.
  • Redevelopment plans for Broadmoor Hospital began in 2003, with a provisional completion date now set for 2016. In July this year the trust submitted to NHS London a business case for the complete redevelopment of the hospital.
  • St Bernard's Hospital, a secure service in Ealing, has buildings dating back to 1830 and needs to be upgraded urgently.
  • No concerns were raised about the modern inpatient facilities at Hounslow and Hammersmith and Fulham.

Wards at some sites were overcrowded

  • The Royal College of Psychiatrists recommends that bed occupancy rates should not be higher than 85% if a safe environment is to be provided. Yet bed occupancy at some sites was often higher than 110%.
  • Between January 2008 and September 2008, there were 76 occassions at Hammersmith and Fulham when patients did not sleep in beds because none were available. Staff reported that this caused some patients to become upset and angry. Staff did not recognise the potential risks of this and a non-executive director said it was "better than nothing".
  • Psychiatric Intensive Care Units (PICUs) are for patients in an acutely disturbed phase of a serious mental disorder and are intended for short periods of care until the acute episode is over. Patients often remained in the Hammersmith and Fulham PICU for longer than necessary because no beds were available on other wards. In one case, a patient remained in the PICU for four months longer than necessary. Spare beds in the PICU were also used to accommodate patients overnight when beds could not be found for them on other wards. Accommodating people in such settings could adversely affect their recovery.
  • Despite problems with bed occupancy, there is no evidence that until recently, the trust robustly reviewed its services to determine whether it had the right number of beds in the right type of services.

People in secure services have limited access to primary care services.

  • Patients at secure services in Ealing have no access to primary healthcare.
  • GP services at Broadmoor have been reduced from four to one day a week. Patients at Broadmoor described physical healthcare as "poor".
  • Patients were sometimes unable to attend doctor appointments because no staff member was available to escort them or because necessary paper work and security checks had not been completed.

There was a shortage of staff at many services and absence due to sickness was high. Attendance at mandatory training was extremely low.

  • Staff shortages were a persistent problem at Broadmoor Hospital, with vacancy levels reaching as high as 22% on some wards. Staff reported working 15 hours a day on some occasions.
  • Between 2005 and 2008, the average vacancy levels at one ward in Hounslow was almost 36%.
  • There is evidence that the trust tried to address staff shortages and retention, however it reported that recruitment was hampered by lengthy security checks.
  • Between 2005 and 2008, the average sickness rate in most wards at Broadmoor was greater than 10%. In 2006, the national average for trusts providing mental health services was 4.5%.
  • From 2006 to 2008, proportion of staff who had attended mandatory training did not exceed 32%. On some wards, attendance was as low as 9%.

For further information please contact Megan Tudehope in the CQC press office on 0207 448 9018 or on 07917 232 143 after hours.

Notes to editors

About the CQC

  • The Care Quality Commission (CQC) is the (new) independent regulator of all health and adult social care in England. We inspect all health and adult social care services in England, whether they're provided by the NHS, local authorities, private companies or voluntary organisations. And, we protect the interests of people detained under the Mental Health Act. We make sure that essential common standards of quality are met everywhere care is provided, from hospitals to private care homes, and we work towards their improvement. We promote the rights and interests of people who use services and we have a wide range of enforcement powers to take action on their behalf if services are unacceptably poor.
  • Our work brings together independent regulation of health, mental health and adult social care (for the first time). Before April 1st 2009, this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection.
  • Our aim is to make sure better care is provided for everyone, whether that's in hospital, in care homes, in people's own homes, or anywhere else that care is provided.

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