The Care Quality Commission (CQC) has published a report on the mental health crisis services and health-based places of safety provided by West London NHS Trust.
CQC carried out a focused inspection in May to follow up on concerns raised about the safety and quality of the service being provided. The inspection focused on specific areas of concern raised in a Regulation 28 Prevention of Future Deaths report produced by the local coroner. The report was written following the death of a patient being cared for by the Hammersmith and Fulham crisis, assessment and treatment team (CATT).
The CATT provides initial assessments for patients in crisis who have been referred to secondary mental health services. They also provide brief interventions for periods of up to three months. The service refers to these different functions as (tier 1) crisis support and (tier 2) brief intervention therapy. The CATTs also support patients who are being discharged from hospital and gate-keep all inpatient admissions. The CATT works closely with the trust’s Single Point of Access team to ensure that patients have access to the service in a timely manner.
The core service was not rated during this inspection, therefore the previous rating of good overall still stands.
Jane Ray, CQC’s head of hospital inspection, London, said:
“I am pleased to report that West London NHS Trust has made a number of improvements to the service following the publication of the Prevention of Future Deaths report. During our inspection, we found that staff had a good understanding of patient risk and they were able to identify and respond appropriately to changing risks to patients, including a sudden deterioration in a patient’s health.
“The changes have had a positive impact on staff morale, with most staff reporting that, despite the pressures of the COVID-19 pandemic, they felt positive about the organisation, their team and the work they were doing. They said that they could raise concerns without fear of retribution, which is important in any service to ensure that issues are dealt with and learnings shared with the team.
“However, although staff were assessing and managing patient risk well, risk assessments were not always recorded and updated regularly. We pointed this out during our previous inspection, but it has not been addressed. This presents a real risk that key information may be lost, or that staff working different shift patterns may not be able to easily find the most up-to-date risk assessment information for patients. The trust is aware of the issue however and is putting systems in place to address this.
“We have told the trust that it should ensure that all the recommendations made following the serious incident investigation are fully embedded within the service and that all staff working in the Single Point of Access team undertake clinical risk training.”
Inspectors found the following:
- Leaders had the skills, knowledge and experience to perform their roles, they had a good understanding of the services they managed, and they were visible in the service and approachable for patients and staff
- Governance processes to ensure the effective running of the service were in place. The trust had established systems to identify risks and manage and reduce these. Leaders had recognised the issues with the service and had developed an action plan which was reviewed regularly
- The service assessed and managed individual patient risk appropriately. Staff responded promptly to a sudden deterioration in a patient’s health. When necessary, staff worked with patients, family and carers to develop crisis plans
- Staff developed care and treatment plans informed by a detailed assessment and, usually, in collaboration with families and carers. They provided a range of treatments that were informed by best practice guidance and suitable to the needs of the patients. Staff engaged in a clinical audit to evaluate the quality of care provided
- The service used systems and processes to safely prescribe, administer, record and store medicines. Staff working for the mental health CATT regularly reviewed the effects of medicines on each patient’s physical health
- Staff supported, informed and involved patients, families or carers appropriately. Work was being undertaken by the team to further embed standards to improve patient and carer involvement.
However:
- Changes in risk, and key information relating to the changes, was sometimes documented in an individual’s progress notes, rather than in the risk assessment documentation. The operations team was aware of the issue and was in the process of introducing a clinical portal summary to the electronic patient record system to ensure that all the key information about a patient would be held in one place.
Full details of the inspection are given in the report published on our website.
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