Annual Report 2010-11 - West London Mental Health NHS Trust

Annual
Report
2010 2011

Our vision
Our values
Togetherness
Responsibility
Excellence
Caring
and values
Our vision is to be an excellent provider
of high quality mental health services, promoting recovery
in community and secure settings.
This year we’ve been working on a project to embed our values through the Trust, across
every role, from top to bottom. We’re now incorporating the values into the systems and
processes by which we manage our people, and most staff have participated in workshops to
identify and commit to behaviours which embody the Trust values. Senior leaders at the Trust
are charged with keeping momentum, by continuing to role-model and providing clarity in
terms of what’s expected of our staff, so that together we deliver excellent care to patients.
Our strategic aims are:
n to provide a safe and effective service
n to deliver excellent personalised care, treatment and support
n to become a provider of choice
n to continuously improve the quality and productivity of our services
n to build an engaged workforce, which is focused on recovery and the needs
of service users and carers.

Contents
Message from the Chairman 6
Message from the Chief Executive 7
Highlights of the year
We value togetherness 8 - 13
Taking responsibility is everyone’s business 14 - 21
Excellence in everything we do, is our goal 22 - 29
We care to make the difference 30 - 35
Forward plans 36 - 40
About the Trust 41 - 43
Finance 44 - 66
Who runs the Trust 67 - 70
The Allotment Group, Lakeside, Hounslow (see page 31)

Message from the Chairman
Nigel McCorkell
Message from the Chief Executive
Peter Cubbon
I am delighted with the considerable
progress we’ve made this year and I’d
like to thank all who work here for their
contribution. However, we’re all aware that
there’s still much to do.
As we strive for excellence, enhancing our
leadership skills has been a priority this year.
We’ve strengthened our Board through a
programme of development, to build our
organisational competence in managing the
challenges of today’s healthcare economy.
We’re also spending more time out talking
to patients, carers and staff, to learn more
about the realities of providing care at ‘the
front line.’
For managers at Broadmoor Hospital
we’ve invested in a bespoke leadership
and management training programme
called QUASIC (based around modules of
quality, understanding, assessment, inter/
intrapersonal skills and communications.)
We chose it because it educates clinical
teams about how good management and
leadership practices inform high quality
mental health care.
Following a thorough evaluation, QUASIC
will be extended to managers across
the Trust, where we hope to realise
the benefits we’re beginning to see at
Broadmoor Hospital.
We also have greater clarity about our
strategic direction, having agreed a timetable
for our Foundation Trust (FT) application with
our key commissioners, the Department of
Health (DH) and NHS London. Aiming for
FT gives us both a focus and a framework
for further transforming the Trust. The
demanding application process involves a
comprehensive assessment which will require
a huge commitment from everyone in the
organisation to keep improving.
We will continue to further develop the
organisation as a specialist provider of
mental health services that promotes
recovery in community and secure settings.
We already have a proven track record of
strong financial performance, and the added
freedoms we’ll gain through FT will enable
us to invest in building upon these strengths.
We’re now developing an active membership
base which will also help us be a more
responsive and dynamic organisation. We’re
aiming for a membership base of 10,000
public members and thanks to the efforts of
staff, carers and service users we’re well on
the way to achieving that.
Everyone who works in today’s health service
is aware of the challenging financial times
we face during this time of re-organisation.
We have to prioritise rigorously and be more
productive than ever if we’re to steer the
organisation to deliver the consistently high
quality care that our patients deserve.
Nigel McCorkell
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This has been a year of change, as we
continue our drive to become a leading
trust by pushing for improvements to the
patient experience.
We must never forget what we learnt from
the Care Quality Commission’s investigation
of our services, published two years ago,
and from the investigation by NHS London
into a patient homicide at Broadmoor
Hospital. We still face real challenges and
know that it will take time and sustained
effort to see lasting improvement in all the
areas of concern. We’ve included more
information on this in the ‘forward plans’
section (page 36) of the report.
Transforming the culture of the Trust
has been an area of concentrated effort.
We’ve embarked on a project to embed
common values through the Trust, across
every role, from top to bottom. We’re now
incorporating the values into the systems
and processes by which we manage our
people, and most staff have participated
in workshops to identify and commit to
behaviours which embody the values.
We’re hearing from external stakeholders
that the results of change at Broadmoor
Hospital have been noted. For mental health
trusts to provide high secure services, they
must hold a licence issued to them by the
Secretary of State for Health. Following a
process of rigorous assessment, our licence
was re-issued giving us authorisation to
provide high secure services for another
five years.
Staff at Broadmoor Hospital should also be
proud of their outstanding achievements
2010 2011
in meeting this year’s CQUIN
(Commissioning for Quality and Innovation)
targets. The assessors told us that they were
impressed by the quality of our evidence
and by the staff they spoke to, who were
engaged and knowledgeable about their
patients - an indicator of high quality care.
To support continued improvements in our
efficiency, we’ve also consulted widely on
changes to our management structures.
These will help us make better use of
resources at the same time as delivering
improved care. In addition to this we’ve
begun to re-design care pathways to make
them more patient focussed, thus improving
our patients’ experiences of care with us.
We intend to keep striving to improve
and innovate - not because we’re being
scrutinised, but because it’s what our
patients, their families and the communities
we serve have a right to expect. So, a good
year of progress, but some real challenges
ahead for us.
Peter Cubbon

We value
togetherness
This value reflects the fact that to provide excellent services our multi-disciplinary teams
need to be high performing teams, and we need to include service users, carers and
other partners in the way we work. We know we have much to do, but here are some
examples of how we’re moving in the right direction.
Jane McGrath, Steve Trenchard, Director of Nursing and Patient Experience,
Anne Aiyegbusi, Deputy Director of Nursing and Martin Morgan, Consultant OT
Patients’ art enhances the environment
Women in our Orchard Unit in Ealing worked with staff and graffiti artists from the Signal
Project to add life and warmth, through colour, to the unit’s atrium and garden area.
users who won prizes in this year’s popular service user art competition. We held our meeting
at the Waterman’s Arts Centre in Brentford, to coincide with a month long public exhibition of
the winning works of art.”
Lynne Palmer, administration manager for the Orchard, says: “This project got off to a good
start thanks to a donation from the Trust’s Charitable Fund. We employed the Signal Project,
a team of professional street artists, who worked in partnership with our patients to transform
the Orchard.”
One of the patient participants said: “It was great to be included in the project and to be part
of something that I can personally own. The end result is brilliant – I am so proud to see my
own ideas on view, for all to see.”
Service user leads our public meeting
Team effort leads to selection as recovery pilot site
Members of staff joined forces in a highly competitive application process, which resulted in our
selection as a national ImROC recovery pilot site. ImROC stands for Implementing Recovery –
Organisational Change.
Director of Nursing and Patient Experience, Steve Trenchard says: “This is excellent news for the
Trust and for people who use our services. This means that we’ll receive a package of expert
consultation, training and development for staff which will help us to improve services by
embedding recovery principles into every aspect of our care, and practice.”
Robert Westhead who uses our services in Ealing co-chaired our annual public meeting in
September, and what a great job he did! Robert says: “I enjoyed working with the staff team to
run a well-attended and interactive meeting. I know the Trust is doing lots of work to include
service users and carers in all aspects of the business of running mental health services, so I was
happy to accept the invitation to help run their public meeting. I’d like to think I helped other
patients and put members of the executive team on the spot, in a good humoured way during
the question and answer session at the end.”
Tara Ferguson Jones from the Trust’s Communications Team adds: “The meeting also gave us
the perfect opportunity to publicly recognise the artistic abilities of a number of our service
The ImROC recovery project is delivered by a partnership of mental health organisations (NHS
Confederation, the Centre for Mental Health and the National Mental Health Development
Unit) and will run at the Trust for the next two years.
“Thirty six trusts applied and we were one of six in the country selected for the project. The aim
is to improve the quality of services by understanding more fully the range of support people
require for their recovery and how the culture within organisations can support this,” says
Steve. “I’m delighted that our hard work has paid off and that we’ll benefit from this scheme.
It will help us to transform practice, place recovery at the centre the Trust’s vision for providing
excellent care and deliver significant benefits for our staff and the people we serve.”
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Website re-launched
www.wlmht.nhs.uk
This year we re-launched our website because we’d heard from patients, carers and others that
they found the existing site difficult to navigate and generally user-unfriendly.
Director of Communications, Lucy McGee says: “We decided to start from a blank sheet. So,
we ran workshops with patients, carers and staff and spoke to GPs and other partners to find
out what was important to them and how we could make the website work for our diverse,
target audience. We developed a clear picture of how the new site should look and work,
complete with a wealth of ideas for new content and features.
“After follow-up testing with these same groups, we launched the new site with an improved
service finder, a crisis support button directly from the homepage and areas wherepatients and
carers can share their own personal recovery stories to inspire others. To make the site more
than a simple shop window for the Trust, we’ve also added lots of information about different
conditions and treatments, and tips on everything from financial support for service users and
carers, to how to handle discrimination at work.
“The site will grow and evolve as we add new material regularly, including videos and more
interactive content. It’s our aim that the site becomes a valuable resource for all who visit it.
“Better technology gave us the opportunity to demonstrate that we had listened to users
of our Gender Identity Clinic in Hammersmith. They had been telling us for some time that
they wanted a unique presence within our website to reflect their information needs as a
community, but our previous system made this virtually impossible. Although part of the Trust,
they provide specialist services to a niche client group across the whole of the UK, whose
treatment is funded by their local PCT. We worked with the Clinic to find out what they wanted
from the site, and agreed a different approach to the structure and accessibility of their pages
- which our new website made possible. We’ve recently launched a unique area within our site
for the Clinic and its user community, and it’s been well received.”
Together with the other high secure hospitals
At this year’s NHS Confederation Conference we shared a stand with Nottinghamshire
Healthcare and Mersey Care to showcase the work of high secure services to the wider NHS
community. We were delighted that Andrew Lansley, the Secretary of State for Health, made a
point of visiting our stand after his keynote conference speech, and he was impressed by our
partnership working.
Relationship-building with the media
The Science Media Centre (SMC) makes staying close to the press their life’s work. Their mission
is to make science accessible and interesting to the general public. Many months’ dialogue with
them bore fruit this year when we jointly ran two press briefings, the first of which was aimed
at educating the press about secure mental health services.
Four of our medical experts made up the panel and took questions from ten national journalists
representing New Scientist, the BMJ, the Times and the Today Programme, among others. The
feedback was that it was one of the best attended, most engaging briefings that the SMC had
run, and that our team impressed.
In February this year, we were invited back to the Science Media Centre to field two more
spokespeople for a press briefing on personality disorder (PD). They took questions from a
group of health and science journalists, who grappled with understanding the differences
between PD and mental illness, and learned about the social consequences of it going
untreated, or worse, undiagnosed. Subsequent coverage on the BBC’s website included
extensive comments from our clinicians, helping put our expertise in this area on the map.
Lucy McGee, Director of Communications with Remo Marcangelo, carer
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2010 2011

In partnership with local authorities
Our psychological therapies team, based within the fostering service in Hammersmith &
Fulham, supports the placement of children into foster care in the borough.
Psychotherapist, Mark Chidgey says: “We advise parents and carers to help them understand
and manage children’s emotional, behavioural and relationship difficulties. We also provide
consultation and training to social workers, foster carers and adoptive parents in areas relating
to the child’s mental health.
“Traditionally, ‘looked after’ children have significantly poorer outcomes, so an ‘off-the-shelf’
Child and Adult Mental Health Services (CAMHS) model is not always appropriate. In fact, we
don’t offer a ‘one size’ service to everyone. Working with our local authority colleagues, we
provide tailored support for each individual placement.”
Epsom Ward Team
“We’ve established introductory meetings at which we ask questions to find out if we’re the
right care provider for the family, what time of day suits them to see us, how regularly they
need to see us and where they want to see us. The new approach means that we’re getting
a clearer understanding of the needs of the family from day one and we’re working in true
partnership by giving them choices about their pathway of care with us.”
Mark Chidgey, Psychotherapist
An exceptional team
Our Quality Awards give us an annual opportunity to publicly recognise exceptional staff and
service users for their contribution to the organisation and its services, as well as for living the
Trust’s values.
Giving families choice
This year, our Togetherness Award went to the Epsom Ward Team at Broadmoor Hospital.
This group of staff cares for patients with complex and challenging personality disorders.
They won the award because of changes the multi-disciplinary team made to how they work
together and engage patients in their treatment, despite the challenges they face. They set
aside a therapeutic space so that patients who have not historically engaged in activities and
ogetherness
who find it difficult to cope in a ward environment now have option of a safe area to go to
and talk about their difficulties in a one to one discussion with a member of staff.
In our Child and Adolescent Mental Health Services (CAMHS) we’ve introduced a new approach
which gives families choice on when they want to see us, and where. Dr Meenal Sohani from
our Hammersmith & Fulham CAMHS team says: “We heard about the benefits of the ‘Choice
and Partnership Approach’ (CAPA) from other mental health colleagues and decided to
introduce it here. CAPA is a clinical system which ensures patients do not wait for assessment,
or between assessment and intervention. It also ensures parity and transparency of clinician
caseloads with a match between client need and clinician skill set.
This change has resulted in a significant reduction in incidents, with several patients moving on
to other wards where they are engaging more positively in treatment.
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Taking
responsibility
is everyone’s business
This value reflects the fact that all staff need to be held accountable for their
performance and, in return, empowered. We are working to develop a high
performance culture but we have a long way to go. Here are some examples of
where empowered staff are beginning to make a difference.
Jude Moore, Occupational Therapist
Meeting our financial goals
Thanks to the hard work of budget managers and staff, supported by our team in finance,
we’ve demonstrated strong financial performance during 2010/11. We managed to achieve all
of our key financial targets and deliver a £3.97m surplus. This is particularly good news because
all of this was done against a background of a savings target of £12 million to meet the
national NHS efficiency target and local pressures. To add to the pressures of last year we faced
an increase in demand for local services, and had to deal with cost and income pressures in
London forensic and estates. Positive action was taken by our staff in a number of areas during
the year to deliver recovery plans to ensure we met our overall financial target.
Role-modelling the values
Jude Moore is an award-winning occupational therapist who works in our inpatient unit in
Hammersmith. In this year’s Quality Awards, Jude came away with our Responsibility Award.
She was nominated by colleagues because she takes responsibility for running an impressive
programme of activities for patients at different stages of recovery. In their nominations,
colleagues talked about her determination to make sure the physical health needs of patients
are not ignored. To that end, the unit she works on now has an on-site gym, as a result of
Jude’s determination and her ‘can-do’ attitude.
Effectively managing the changes
Her colleagues told us: “Jude takes responsibility for making sure we’re putting the
recovery needs of our patients first - always. She is a highly valued member of our
multi-disciplinary team.”
We’ve set up a Programme Management Office (PMO) to give us the assurance we need
that we’re running our major change programmes as effectively and efficiently as possible.
Gemma Stanion, Programme and PMO Director for the Trust says: “In the past we’d have
a large number of ‘change’ programmes and projects going on at the Trust in isolation of
one another. We’ve introduced the PMO to remedy this through increased consistency and
efficiency, by providing enhanced central support for all our major pieces of work.
Mandatory training
We’ve also seen a marked increase in mandatory training attendance, and thus compliance,
as our staff step up and take better responsibility for their learning and development.
“As a result of having the PMO in place, we know that our programmes and projects are
collectively delivering the best outcomes for patients and for the Trust as a whole. Our work
is about making sure we do things in the right order, and in as streamlined a way as possible,
completing every step of the process so that the planned benefits are fully realised
as intended.”
The introduction of the mandatory training scorecard last summer, has supported this by giving
managers a clear picture of the training skills gaps of their staff across the range of mandatory
courses. The scorecard is distributed on a monthly basis to managers and published on our staff
intranet along with reports for each mandatory course.
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is given and received openly, frequently and constructively. If people see excellence in others,
they’re encouraged to praise and reinforce it. If they don’t see it, they can refer the person back
to the Charter, in the hope of inspiring a change for the better.
Learning the lessons from incidents
We’ve made far-reaching changes to our procedures for dealing with serious incidents. In the
past our processes were complicated, inconsistent and inadequately supported, which meant
that reviews were not being done in a timely way. We weren’t properly feeding back to staff,
patients and relatives, nor were we making good use of the learning from reviews.
We’ve re-written our incident reporting and management policy. We’ve communicated it widely
to our staff and provided training on it.
Susan Kimani, Nurse with Kay Allen, Acting Service Manager for Ealing
The introduction of more flexible learning opportunities has also made training more accessible
to staff. In the last year, we’ve seen over 9,000 courses completed by e-learning with over
8,300 of these courses being mandatory. Alison Webster, Head of Staff Development, says:
“We’ve had nothing but thanks from staff about the increase in on-line learning opportunities.
They told us that they were finding it hard to get away from their workplaces for training
courses, so we took action and have brought the training to them.”
A staff member said: “I thoroughly enjoy e-learning. I don’t have to travel to attend lectures,
nor does my ward have to provide cover for me. In all honesty, I find that I learn more from
e-learning in some subjects than I do in the classroom. I recommend it to all my colleagues.”
We’re giving more help now than before to staff involved in reviews, through our recently
appointed incident review facilitators, who provide support for colleagues so that reviews
are completed on time and in line with best practice standards. The team also report to our
Board on a monthly basis on both the progress made on reviews and the implementation of
recommendations aimed at improving services.
We’ve introduced an easy to use checklist which guides the incident review team through
all stages of the process to keep it on track to make sure the review is completed on time.
Critically, the new process includes activities to make sure we’re ‘closing the loop’ by giving
feedback to staff involved in reviews, and people who were involved in the incident itself
and/or their families. We also produce a monthly news bulletin for our staff to communicate
key ‘risk’ issues, so that learning is being shared widely across the organisation.
As we go to print with this annual report, we’re delighted to be able to say that this
development has earned us a place as a finalist in the Healthcare People Management
Association (HPMA) awards.
Giving our staff clarity about
what’s expected of them
Uptake of Performance Development Review (PDR) and appraisal has significantly improved in
all areas this year. This means that staff are clear about how their work contributes to the goals
of the Trust and have agreed plans for their future personal development.
We’ve also re-written our Staff and Management Charter to address concerns of patients and
carers about ‘staff attitude’ being poor in some areas. The Charter, which is aligned to our
values, spells out the everyday behaviours we should expect to see from each other and from
our leaders. Our over-arching aim is to support the development of a culture where feedback
Peter Cubbon, Chief Executive, with Incident Review Facilitators,
Caroline Sweeney and Angela Middleton
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We also run regular ‘learning lessons’ conferences and workshops, which give our people
the opportunity to discuss incidents openly, so we can learn from them and embed practice
changes across the Trust. We’ve also invited high-profile speakers to our conferences, including
Dr Peter Carter, OBE, who is Chief Executive and General Secretary of the Royal College of
Nursing. He spoke to us about the important role played by good team working in embedding
safety into the organisation’s culture. We were also delighted to welcome Malcolm Rae, OBE,
who shared with us his experiences of embedding lessons learned into clinical practice.
Our key priority is to ensure the services we provide are safe, therapeutic and
recovery-focussed.
Managing safety alerts
A straightforward new system, built into our staff intranet, is helping us to manage NHS safety
alerts more effectively.
We receive alerts about potential risk issues from numerous bodies such as the DH, NHS
Estates and MHRA Medical Device Alerts, to name but a few. In the past it was difficult to
co-ordinate alerts coming in from so many sources, so we introduced our central alerting
system to give us the ability to track the status of safety alerts, and more importantly the
actions necessary to reduce the risk, which will ultimately help us in our drive to keep patients
and staff safe at work.
Placing patient safety at the centre of our work
Being prepared for emergencies
Child visiting facilities
Our emergency and business continuity plans were subject to an assurance preparedness audit
completed last year by NHS London. We’ve also been involved in testing and exercising aspects
of our plans in liaison with key agencies.
We’ve written and shared with our staff a new suicide prevention strategy, which outlines high
priority actions for implementation over the next two years.
We aim to encourage positive risk taking within supportive and hopeful relationships, helping
service users to manage their own risks, whilst safeguarding them from harm wherever
required. The strategy reinforces the importance of effective therapeutic relationships and
promotes the principles of engagement and openness between service users, carers and staff.
The strategy covers three key areas, the first of which is relational security, which is all about
the therapeutic use of self within clear boundaries. It also looks at procedural security, which
includes the policies and procedures in place to maintain safety and security, and finally physical
security, which is about precautions such as fences, locks, personal alarms and so on, that help
to keep people safe.
Our suicide prevention steering group, made up of senior clinical staff, is responsible for
monitoring implementation of the strategy at the Trust.
We’ve developed an integrated emergency management programme, in compliance with
the statutory duties in the Civil Contingencies Act and Department of Health Guidance. This
was recognised by the International Association of Emergency Managers with a ‘Partners in
Preparedness Award’.”
Safeguarding children
“The work staff have put in and progress we’ve made embedding safeguarding children
principles into care at the Trust has been a tremendous team effort,” says Dr Clare Lucey,
Named Doctor for Child Protection.
“Lead professionals across the Trust have taken responsibility for ensuring that we ‘think
family’ in all interactions with patients. The leads have encouraged participation in mandatory
safeguarding children training, evidence of which is good attendance figures. They’ve
supported our audit activities so we have evidence that safeguarding children is part of the
culture here and they’ve helped us to ensure that child visiting facilities are maintained.
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“Information from serious case reviews is shared across the organisation through discussion at
our safeguarding children governance group and we share lessons at regular ‘learning lessons’
conferences (discussed on page 18 of this report) to which all our staff are invited.
“We’ve also introduced a safeguarding children element into supervision sessions, which means
it’s upfront in the discussions staff are having with their managers.”
A more professional approach
We’ve rationalised a number of disparate telephone processes into our central Contact Centre,
which provides a communications service, 24 hours a day, seven days a week.
In addition to managing calls to the Trust’s main telephone numbers, our small team of trained
telephone operators manages all calls into our former estates & facilities and IT helpdesks.
The Team has also been trained to respond to all calls into our Ealing Home Treatment Team
and we have plans, going forward, to share this expertise to take the pressure off other
clinical areas.
The Team has reduced our fire service call-out costs, by taking over the central management
of emergency alarms bells. This means that when an alarm is detected, the team has a target
to call the ward or department immediately, to check if a call to the emergency services is
required. In doing so the team has almost halved the number of visits to the Trust by the
emergency services in the space of twelve months, saving us money on call out costs.
Joining up a number of telephone services will result in cost efficiencies and is freeing up the
valuable time of clinicians and other staff to focus on delivering services. It’s also improving the
quality of our interfaces with those who use our services, thanks to the professional approach
and skill of those within the Contact Centre Team.
Fire safety
This year we appointed a Fire Safety Manager, Ian James, who is responsible for managing
the day to day fire related activities within the Trust. Ian says: “One of the most common
fire-related issues within the NHS is incorrect procedures taken in the event of a fire which
could have a devastating effect.”
esponsibility
Lovena Cenizo from our Contact Centre Team
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Ian is working to reduce the level of fire-related risk here at the Trust by increasing fire training
compliance and promoting fire safety management, reminding staff of their responsibilities in
this area.
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Excellence
Lynne adds: “Sujoy takes his medical lead responsibilities very seriously and, through his
leadership, has encouraged his fellow medics to adopt the same approach. He shows excellence
in everything he does, is passionate about his service and cares not only for his patients but for
his colleagues too. Sujoy demands excellence of himself and of others working with him. His
motivation is an inspiration to all those he works with.”
in everything we do
is our goal
Regular audits mean clean environments
We’re proud of the work of our domestic staff in keeping our wards and other environments
tidy, clean and free of infection. This year’s PEAT (Patient Environment Action Team) results
show steady improvements in cleanliness levels in all areas.
Our domestics carry out weekly and monthly audits in partnership with clinical staff to
ensure that our high standards are maintained, for the benefit of both staff and people being
cared for by us.
Dr Sujoy Muckherjee, Consultant Psychiatrist
High performance in this area is the result of work we did earlier in the year to re-align
cleaning hours across all areas to ensure standards are maintained in line with the NHS
Hygiene Code. At the same time we also looked at frequency of cleaning tasks based on the
classification of risk within all areas, which means that areas which need special attention get
the extra cleaning they need.
Excellence, for us, means trying to do everything that we do that little bit better.
We still have much to improve, but here are some examples which are evidence of this.
Excellence in change management
The management team in Hammersmith & Fulham’s adult services won the Excellence in
Change Management Award in our 2010 Quality Awards.
Clinicians lead the changes
In our Ealing dementia services, Dr Sujoy Muckherjee led a programme of change which has
resulted in improved relationships with GPs and higher quality of referrals into our Community
Mental Health Teams (CMHTs.) Sujoy was commended for the work he did on this, in our
annual Quality Awards.
The team came together to work on a significant change process within adult services,
which involved the reconfiguration of wards and community mental health teams. The changes
being proposed were significant and had to be completed in a short space of time. Undaunted
by the challenge ahead, the team embraced the responsibility by using the principles of
support, good communications and systematic thinking, carefully identifying risks with plans to
manage those risks.
Lynne Read who works with Sujoy in Ealing describes him as: “An advocate for new ways of
working. One of his strengths is that he works continually with the team to look for pragmatic
solutions to problems.”
As a result of the change project, length of stay in hospital has been reduced and so too
have delayed discharges. Patients in the community are now offered a first appointment for
assessment within three weeks, which is also an improvement.
He led an extensive programme of work which meant going out and talking to GPs to find out
what we could do to make our community mental health services better for their patients and
for them as the referrers. As a result of this work, we’ve changed the referral processes so that
GPs can now refer electronically into our services, if they wish to. He has provided education
on what we do, which means that the referrals we’re getting are of a better quality and more
relevant than before.
The good work done by the management team in Hammersmith & Fulham is informing
changes we’re now working on in other areas of the Trust.
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A number of our services
were awarded
accreditations for excellence
Psychiatric liaison team
during the year
This team, which provides in-reach mental health services to patients at Charing Cross and
Hammersmith Hospitals, has been accredited by the Psychiatric Liaison Accreditation Network.
This award followed a comprehensive process of review, involving the team, stakeholders and
service users, which identified the team’s good practice and high quality care. Dr Amrit Sachar,
the team’s Consultant Psychiatrist, says: “This is excellent news and evidence of the leading and
professional service we provide. We’re an innovative, can-do, energetic and caring team and it’s
great to have external recognition for what we do.”
The team has been further recognised for excellence this year as they’ve been awarded a
contract to deliver perinatal psychiatry services in Queen Charlotte’s & Chelsea Hospital.
Amrit explains: “Funding has been agreed for 15 months initially from the PCT Maternity
Matters funds and the Imperial College Healthcare Charity. Although this is non-recurrent
funding, we are hopeful that the staff appointed will be able to help secure future funding
during their time in post.”
West London Cognitive Disorders
Treatment and Research Unit
We were also delighted this year to hear that our West London Cognitive Disorders Treatment
and Research Unit at Brentford Lodge has been officially accredited as a ‘Centre of Excellence’
by the Royal College of Psychiatrists.
Psychiatric Liaison Team
The team works with older people, dealing with dementia patients on a daily basis. As one
of only five services in the country to have received this top level of accreditation our team at
Brentford Lodge is quite rightly proud of their efforts. Senior Nurse Manager, Anne Daly said
of the accreditation process: “The purpose of the Memory Services National Accreditation
programme is to help services evaluate themselves against agreed standards. The process is
carried out by peer reviews and uses a variety of audit tools including questionnaires for staff,
patients and carers, as well as audits of case notes and our environment.
“The peer assessments provide a holistic, multi-disciplinary approach involving not just the staff,
but patients and carers too. It is worth so much more to be recognised and assessed by your
patients, rather than an individual assessor.”
ECT clinic
Following a rigorous approval exercise, our Electroconvulsive Therapy (ECT) clinic in Ealing has
been rated as excellent, by the ECT Accreditation Service. During the first phase of self review,
several audits were carried out, and questionnaires were sent to patients and staff.
West London Cognitive Disorders Treatment and Research Team
This self review period was followed by the external peer review visit by a team comprising a
consultant psychiatrist, consultant anaesthetist and ECT lead nurse, all from other NHS Trusts.
Dr Ian Nnatu, ECT lead consultant said: “We hope that this rating will assure all of our patients
and referrers that the clinic not only meets excellent standards, but continues to strive for
further improvement.”
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Broadmoor Hospital
A high reliability organisation
Two years ago, the management team at Broadmoor Hospital decided to take a fresh look at
how to embed safety into the culture and management ethos of the hospital. The work used
research originally developed within the nuclear power industry following an accident in one of
the plants. This revealed that unless organisations find ways of making safety the positive focus
of their culture, the explicit purpose of their leadership, and an issue understood from multiple
perspectives by everyone, then it’s impossible to control ‘never events.’
At Broadmoor Hospital we ran workshops which have helped us take this to a new level by
linking safety to daily operational practices and behaviours which also tie in with our Trust
values. On the back of this work, we’ve agreed eight principles and action plans to help us
realise them. Everyone in the Hospital’s senior management team has accountability for driving
specific actions and reporting back progress monthly. We’re also distributing a booklet to all
of the Hospital’s staff about this and have supported it by a poster led awareness campaign,
called ‘Don’t Walk By,’ which reminds us to take responsibility when we see things that are out
of place or that pose a risk. This includes things like reporting damaged equipment, ensuring
confidential records are maintained, clearing untidy work areas and being polite and helpful to
visitors, patients and colleagues.
A safe and secure environment
Broadmoor Hospital received plaudits from the auditors from National Offenders
Management Service (NOMS) who are responsible for maintaining the highest standards of
security and safety in prisons in England. Although it’s a hospital, not a prison, Broadmoor
Hospital is a high secure facility and as such is subject to similar rules and regulations in relation
to security as prisons.
This year’s result of 95% is not only an improvement on last year’s result but represents the
Hospital’s best ever score. It’s an official confirmation that the Hospital is a ‘safe and competent’
hospital against the very rigorous standards set by the auditors.
Mike Humphrey, Director of Security, says: “This is a great result for the staff team here at the
Hospital as well as for patients, who depend on our providing a safe and secure environment
for their treatment and recovery. Much of the auditing was on the wards, where our staff
really impressed. It’s also proof that, while we still have room for improvement, all staff at the
Hospital, whatever their role, understand the importance of security and embed the principles
of safety into their clinical practice.”
Mike added: “This isn’t just about the security team. The good news is that it was ‘Team
Broadmoor’ that gave a good show, demonstrating the Trust values of togetherness,
responsibility, excellence and caring, which shine through in the results.”
Nurse-led research
Jill Robinson, Professor of Mental Health Nursing, Wellbeing and Recovery
In collaboration with Bucks New University, we’ve recently appointed a Professor of Mental
Health Nursing, Wellbeing and Recovery. Jill Robinson will work to strengthen the mental health
nursing perspective within multi-disciplinary practice and research teams. Jill will take the lead
for nursing research initiatives across the Trust and work with multi-disciplinary colleagues in
the development of research ideas, proposals and protocols.
In November we held our first research master class for nurses. Sandra Bailey, Head of Nursing
in Hammersmith & Fulham said: “The day was a turning point for the many nurses who
attended. The workshop brought to the fore the need for nurses to undertake nursing research
which will benefit the care we offer to service users. It was a very productive day and we left
the workshop with lots of ideas for future research activity.“
We’ll be running more of these to keep up momentum and encourage more of our nurses to
get involved, so that research becomes a part of all clinical practice.
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2010 2011

Patients help us to help them
Our patient information group (PIG) is a valuable resource in making sure the information
we produce for patients is understandable and relevant for each particular audience or patient
group. The group, run by our Communications Team, is made up of clinical staff, services users
and carers, who advise on everything from the content of publications to the style and
length of them.
Jules Tennick is one of the service users on the group, and she says: “I think it’s great that
service users are now involved in this work as we’re able to give a real reflection of what is
important to us and what we need to know when we’re under the care of the Trust. The
discussions we have within the group are also helping us to make sure the format of the
information is as clear and as good as it can be.”
Moving towards research and development excellence
We’ve launched a five year Research and Development (R&D) Strategy which sets out our aim
to increase R&D participation across the Trust, to enable us to grow as a centre of excellence
for research.
Dr Craig Ritchie, Director of R&D, says: “Our strategy gives an overview of the work
we’re doing with clinicians to help them overcome the barriers they face in undertaking
and supporting research, promoting studies to people who engage with our services and
strengthening our relationships with our affiliated academic institutions and industry partners.
“All research projects going forward will be mapped to the new clinical pathways we’re
developing. From an R&D perspective the link will be through several new Clinical Research
Domains. The main areas of focus for our research work will initially be in the areas of
cognitive impairment and dementia, and forensic mental health. Research projects will also be
supported and promoted in the areas of affective (mood) and personality disorders, psychosis,
gender, and children, young people and families.”
Patient access to the internet
Thanks to the work of our IT team, patients in our main inpatient units in local services now
have access to the internet. We’ve invested in computers for these areas to give people
improved opportunities to participate in life ‘outside of the ward’ which helps towards their
recovery. Patients have told us that they’re grateful for the opportunity to do things like online
banking and shopping and even online training courses whilst on the ward. It’s also making it
easier for some of our patients to keep in touch with their family and friends.
excellence
Members of the Patient Information Group including, Megan Singleton, Communications Manager,
Jules Tennick, service user and Diana Wiggins, Service Manager in Hammersmith & Fulham
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2010 2011

We care
caring
High quality care is what will earn us Foundation Trust status. We’re continuing to
strive for consistency, which we know remains a challenge. Here are some examples
which illustrate what we’re capable of.
Care plans to be proud of
to make the difference
On World Mental Day we ran a campaign to reinforce the message to our staff, service users
and carers, about the fundamental importance of care planning. We ran a series of events
across our sites at which staff were reminded how important it is that patients are meaningfully
involved in all stages of care planning. Patients too were reminded of their right to be involved
and to ask for a copy of their care plan if they don’t already have one.
Our campaign was followed with the introduction of ‘My Personal Recovery’ plans for all
patients. The booklets are being used by our patients to help them document the progress
they’re making via a series of questions which help them to reflect on their mental health and
wellbeing, and take an active part in preserving or restoring it. It also helps ensure their wishes
sit at the centre of the care planning process.
Joe, discusses his recovery plans with Staff Nurse, Pravin Ramnath
Anne Aiyegbusi, Head of Nursing for our West London Forensic Services says: “The plans
are maintained by service users who may choose to invite other people to provide support in
completing them. Supporters may be care-coordinators, carers, occupational therapists or
any other person who the service user feels is important in terms of helping to maintain
their wellness.”
Meeting the spiritual needs of patients
This year we launched a new strategy of our vision in spiritual and pastoral care. Steve
Trenchard, Director of Nursing and Patient Experience says: “The strategy supports a more
individual approach to understanding mental distress. It fits well with a recovery approach
and supports our aim to make spiritual care and recovery more central to the services
we’re providing.”
Clinical staff have been asked to sign up as spiritual care advocates so they can support our
Spiritual and Pastoral Care Team to implement the new strategy by providing a resource for
service users and their colleagues across the Trust.
Helping users integrate into local communities
In our Hounslow services, our very successful allotment group, called the ‘Sowing Seeds
Project,’ is helping service users develop skills by working as part of a community. The project
is an innovative collaboration between our occupational therapists, a local charity called
Groundwork and the Hounslow Refugee Council. The project was originally set up for asylum
seekers in the Hounslow area thanks to a grant from the Big Lottery Fund, secured by the
Refugee Council, to provide gardening classes. We then joined the project so our service users
could learn how to grow their own fruit and vegetables.
Natalie Waterfield, Head of Occupational Therapy, says: “The work of the group has enabled
service users to integrate and become part of a community as well as improving physical and
mental health. This project focussed around growing food has cut across social and cultural
differences, bringing together a unique set of people working on one project for the benefit of
everyone involved. Some of our service users who’ve been involved have gained the confidence
to go on to do further training or work.”
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2010 2011

Attached to the new restaurant is a vending facility and internet café which is available to the
Hospital’s 950 staff, 24 hours a day.
Lisa Thompson who project managed the catering side of the redevelopment work says:
“We’ve named the restaurant ‘Citrus,’ a name chosen from more than 200 suggestions
submitted by our customers. Feedback from staff about the new service has been excellent and
we’re seeing a far greater take-up of services for staff than before.”
Caring for the world we live in
This year we appointed a Sustainable Development Manager to help us embed sustainable
development principles into all of our policies, plans, operations and behaviours both clinical
and non-clinical.
On-line health information
Lucy Smith, Sustainable Development Manager
We’ve signed up to a new employee wellbeing website, and have invited everyone who works
here and their family members to join – for free. We’ve done this because we know how
important it is for all of us working in the health service to look after our own health, so that
we’re fit, healthy and able to come to work to look after others.
The website is called Revitalised and it offers health and fitness advice in addition to preferential
rates from a number of health-related suppliers including Champneys, Marriott, LA Fitness and
Holland & Barrett.
Lucy Smith, who joined us from the Environment Agency, says: “This is such an important area
for a large organisation like ours because our internal and external stakeholders care about the
world we live in and expect us to care about it too, and to show it by doing everything within
our power to reduce our impacts. Then there’s the increasingly large amounts of legislation
requiring us to do this, otherwise we’ll face fines and risks to our reputation. There are also
significant financial benefits associated with reducing our impacts (less waste disposal costs,
lower energy bills, reduced travel costs…) leaving us more money for patient care.
“We’ve had a Board approved sustainable development strategy in place since March 2010,
highlighting our commitment to the sustainable development agenda. This year we’ve
registered for the NHS Good Corporate Citizenship Assessment Model and we’ll be reassessing
our scores on a regular basis as we move forward with our strategic delivery plan.
“We’ve calculated the carbon footprint from our building energy use and our business travel
for the last three years and estimated our annual commuter impacts. We’re now starting to
look at our supply chain (procurement) impacts and associated carbon footprints and working
to find ways to reduce it. Recycling has been introduced at those of our sites where it is not
already happening, including toner cartridges and battery recycling.
Sara Spence, Intranet Design Analyst, says: “I signed up as a member of Revitalised a few
months ago and was delighted to save about £180 on a spa weekend at a hotel in Bath. I even
treated my mum and her friend to a spa weekend at another resort where we got a twenty
percent discount.”
Improved facilities
We’ve invested in our staff at Broadmoor Hospital, so they have their own restaurant facilities
within the secure perimeter walls of the Hospital. In the past they had to leave the building,
going out and then coming back in through our security systems to take time out to eat.
“We’re working to deliver the statutory and voluntary travel planning obligations on the Trust
ensuring travel choices exist for our staff and we realise the social, environmental and financial
benefits of sustainable travel. Cyclescheme, the salary sacrifice discount employee bicycle
scheme, has also been introduced and we’ll be adding car-sharing software across the Trust this
coming summer. Our staff have also been invited to participate in various events programmed
for Walk to Work Week and Bike to Work Week 2011 to highlight the health, financial and
environmental benefits of sustainable forms of travel.
caring
“We’ll be promoting awareness and looking for action from all our staff over the next year
on the carbon and climate change agenda, while looking at the potential impacts of climate
change on our models of care and infrastructure.”
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Care for the Carers
It’s not just our staff who’ve been involved in the roll-out of our values this year. Carers in
our Ealing services gave us an insight into how they want us to treat them, to enable them
to perform their caring role to the highest standard. They used our values as headings for
suggestions on how they’d like to be treated when they come into contact with our services.
For example, under the value of responsibility, they said: “Because we’re often under pressure
it’s important that you don’t keep us waiting too long. Take responsibility for making best use
of time.” Under the value of caring they told us: “Always introduce yourself and also ask for
our names, so that we, and those we care for, feel valued.”
We’ve shared the thoughts of our carers with staff by putting them onto posters and into our
staff magazine for all to see.
Professor Allan Young, Clinical Lead
She encourages us to look after our physical health through healthy eating, cooking sessions
and exercise. She shows us through her actions how much she cares and always listens to
what we have to say.”
New service offers hope to patients with the most
complex mental health problems
We’ve recently established a new specialist service offering hope for people with treatment
resistant mental illness.
Working in a research partnership with Imperial College, we’re developing and delivering
proven, evidence-based, emerging treatments for some of the most complex and enduring
mental health problems.
Our specialist Affective Disorder Service is a ‘tertiary service’ providing assessment and
treatment to those complex and treatment resistant patients who need something more than
what’s offered through established secondary care pathways. Patients benefiting from the
service would normally have failed to have responded adequately to a number of evidencebased
interventions provided in mainstream specialist mental health services.
A caring role-model
Kay Maloney, carer with Margaret Rioja, Service User and Involvement Co-ordinator
Dione Simpson is an Activity Co-ordinator in our West London Forensic Services. She picked
up the award for ‘Caring’ in our annual Quality Awards after being nominated by the patients
she works with. They said of her: “Dione brings the sunshine and lights up the ward as if
she is Florence Nightingale. She touches our hearts with warmth and kindness. Dione spends
time listening to service users and explains changes happening here in a way we understand.
Professor Allan Young, is the clinical lead for the service. He holds the Chair of Psychiatry at
Imperial College London where he is also Director of the Centre for Mental Health within the
Division of Experimental Medicine.
Allan says: “I’m a passionate advocate of the view that no individual or condition is beyond
help.” He has worked with patients all over the world on treatment innovations that help them
realise improved quality of life through better sustained health and well-being.
“In offering this pioneering new service to our patients we hope to make recovery a real
prospect, for them,” says Allan.
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Forward plans
which embody our values. We will continue this work in the years ahead, and will measure
progress by conducting a follow-up survey of staff and service users as a comparison against
the baseline measurement taken at the start of this process.
As mentioned already throughout the report, we’re very aware of the challenges
we still face both inside and outside the organisation. In this section of the report
we describe these challenges, and the plans we have to address them. In terms of
the changes we’ve made this past year, some of which have been described in the
report, our focus remains firmly on maintaining momentum as we strive for
further improvement.
Last year we made changes to our mandatory training programmes and introduced a new
reporting system which has resulted in significantly improved levels of staff attendance and,
thereby, compliance. Making the training as accessible as possible for our staff will continue to
be an area of focus and further expansion of online training is likely for those topics that can be
effectively covered electronically.
This year we’ve been consulting our staff on making changes to our management structures
to help us realise the efficiencies we need to make, by reducing duplication, and to help us
improve accountability in the organisation. We want to shift more of the responsibility in the
organisation to where it should be, close to service users and carers – that is on the wards and
in the community teams.
Our leadership
We know through benchmarking work recently carried out that we still have much work to
do to improve the skills and capabilities of those who lead in the organisation. Developing our
leaders will help us to increase the quality and productivity of our services. To that end we’ll be
rolling out the QUASIC training (described on page 6 of the report) to all our senior nursing
staff, therapists and doctors. Investing in our leaders will help us move towards our goal of
being in the top quartile of high performing mental health trusts in England, as measured by
those who use our services.
This year, we started a programme of Board development which we will continue, so that our
senior leadership team is equipped with the skills and knowledge required to lead this diverse
organisation and deal with changes in the health economy. Board members will continue to
prioritise spending time out in our communities talking to service users, staff and carers to
make sure they’re fully aware of the real front-line challenges at the Trust. These insights will
inform the decisions they make about the future direction of the Trust.
We’re currently putting our new management structures in place. In our local services this
means re-configuring three borough-based service delivery units into one clinical service
unit, reporting into our Interim Director of Local Services, Jean George. She is responsible for
working with our partners, and making sure that we’re sharing best practice across all three
units to provide greater consistency, as well as improve quality and productivity. We’ll also be
seeding some of our corporate services into our clinical service units, bringing them closer to
the teams of staff they provide services to.
Becoming a Foundation Trust
A major focus in the year ahead will be the work required to gain accreditation as a Foundation
Trust (FT). We’re aiming to achieve this by the winter of 2012 and will need the support of
everyone who works here and our stakeholders to achieve our ambitious goal. Current data
from staff and patient surveys tells us that we have much work to do in engaging everyone in
this mission and delivering services of which we can all be proud.
Our staff
Two years ago the Care Quality Commission highlighted the need for widespread and lasting
cultural change in the organisation. This year much of our focus has been on transforming the
culture of the Trust by embedding our shared values of Togetherness, Responsibility, Excellence
and Caring through the organisation, across every role and every team, from top to bottom.
We know there is still a great deal of work to be done in this area until our values become an
everyday part of the working lives of all our staff.
We’ve begun to incorporate the values into the systems and processes by which we manage
our people and most staff have participated in workshops to identify and commit to behaviours
We now have clarity about our strategic direction, having agreed a timetable for our
Foundation Trust (FT) application with our key commissioners, the Department of Health (DH)
and NHS London. We’re preparing for the three stages of due diligence review, the first of
which will be carried out by NHS London. Subject to the speed at which we progress through
this initial review phase, we’re hoping to have completed the second review by the Department
of Health by the summer of 2012. We’ll then face Monitor, the independent regulator of
Foundation Trusts, for the final stage of due diligence review, before we can progress as an FT.
In the summer of 2011 we’ll run a consultation, during which we’ll be discussing the proposal
and benefits of becoming an FT with our staff, service users, carers, partner organisations
and local residents. The statutory consultation will give our stakeholders the opportunity to
comment on our future plans and proposed constitution.
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We’ve already made good progress in terms of establishing a strong membership base
with the aim of recruiting 10,000 public members. Having an active membership base is a
crucial component of becoming an FT as it will give people from our local communities a voice
in the strategic development and decision-making processes in the organisation. We’re also
preparing to run elections, which will take place later in the year to establish an active
Council of Governors.
We’ve been working on a number of enabling strategies covering areas such as estates,
membership, involvement and clinical governance, all of which will be key in helping us achieve
our aims to become an FT. We’ll be putting these supporting strategies into action in the
year ahead.
More purposeful involvement
Our involvement agenda is expanding because we know we need to be more inclusive and
work more closely with service users and carers than we have in the past in improving and
developing services.
We’re currently working with service users, carers and our Trust-wide involvement leads to
review all of our involvement activities. Our aim is to re-focus these so they become more
central to the business of the Trust. This means making sure that the contribution of service
users and carers consistently influences the way we develop, evaluate, plan and improve
services. It’s also our aim that all involvement activities are recovery-focussed, so benefiting the
service users who opt to work with us.
Changing our governance arrangements
A review of our governance structures showed us that there was substantial room for
improvement. We have plans in place to change our governance structures this year to give us
the assurance we need that we’re delivering safe, cost effective and quality services in all areas
of our business.
The new committees are:
1. Trust Management Team (replaces the current Operations Board) and will be the main
executive decision-making meeting of the Trust.
2. Finance and Investment Committee will provide overview and assurance on financial
performance, strategic financial and capital planning.
3. Quality Committee is the senior clinical governance committee for the Trust that will
oversee a programme of work in relation to clinical effectiveness, patient safety and
patient and carer experience. The Research and Development Group also reports into
this committee and a new forum called Quality Watch will provide an opportunity for
commissioners and partners of the Trust to meet and review quality initiatives.
Service users at Ealing
4. Audit Committee retains its position as the senior committee of the Board providing
assurance on all aspects of the Trust’s business.
Clinical dashboards
Following a thorough assessment of the presentation and use of policies and procedures at
the Trust we’ve successfully maintained NHSLA level 1. (The National Health Service Litigation
Authority (NHSLA) handles negligence claims and works to improve risk management practices
in the NHS.)
The next step is to work towards level 2, which we hope to be in a strong enough position to
achieve next year. Before that, and based on feedback from our level 1 assessment, we have a
great deal of work still to do which we’ve put into an action plan to make sure the necessary
actions are owned and carried out.
Service users and carers continue to tell us that quality of care is not consistently excellent
across the Trust. To address this we’ll be introducing clinical dashboards which will be used by
our staff across the organisation.
The dashboards, visible when people log onto their computers, will give real-time information
on measures which reflect the safety and clinical effectiveness of services, as well as information
regarding service users’ experiences of our services. This will give us a clear picture of the quality
of our services and will help us steer our efforts towards further improvement.
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Cost improvement plans
About the Trust
In common with other mental health trusts across the country we’re well aware of the
challenges of today’s economic climate. We’re working to find ways to create efficiencies in our
services, due to a reduction in funds being made available to us from commissioners.
We have set financial targets for the year ahead which will enable us to remain financially
viable. We’ll continually monitor the effects of our cost improvement plans to make sure they
do not impact negatively on our frontline services.
Redeveloping Broadmoor Hospital and our St Bernard’s site
We’re expecting to gain approval for the outline business case (OBC) for the redevelopment
of Broadmoor Hospital this year. We’ve been working on the plans for the hospital with our
internal and external stakeholders, to ensure their views on a redeveloped hospital have been
heard, and given due consideration. The plans for 234 beds to accommodate at least 210
patients will be submitted for planning approval in June 2011.
Whilst awaiting approval for the OBC, we’ve continued to invest in the hospital in readiness
for the future.
West London Mental Health NHS Trust was formed in 2001 from a merger of Ealing,
Hammersmith and Fulham and Broadmoor Hospital Authority and was further
expanded by the absorption of Hounslow mental health services in 2002. We employ
around 4,400 staff across 32 sites and have an annual budget of £253.7million.
We provide local mental health services for adults, older people and children in the boroughs
of Ealing, Hammersmith & Fulham and Hounslow. These services are jointly commissioned
by primary care trusts and local authorities. We also provide forensic mental health services,
including high secure services at Broadmoor Hospital in Berkshire. Our forensic services in
London and at Broadmoor Hospital have a catchment area of London and the south of
England. We also provide two specialist services which are available nationally: services for
families, and an Emerging and Severe Personality Disorder (ESPD) service at the Cassel in Ham,
Richmond and our Gender Identity Clinic in Hammersmith.
This year NHS London has approved our strategic outline case (SOC) for the redevelopment
of our St Bernard’s site. We need to develop the site so that forensic patients in medium and
low secure care who are currently treated in older Victorian buildings will in the future receive
treatment in a modern therapeutic environment. We plan to use receipts from the sale of
surplus buildings and land on the site to support the funding of the project.
Structure
Following a consultation with our staff and service users we’ve recently re-structured our Trust
into three clinical service units (CSUs). The three CSUs are:
This year there has been much discussion with staff from all disciplines, service users and
their carers about this redevelopment project as we prepare to submit an OBC with a view to
delivering the new facilities by 2015. To achieve this aim, we’ve been developing an integrated
plan with our local services currently on the St Bernard’s site, which will support their strategic
aim of moving to more community provision.
1.
2.
3.
Local Services
Broadmoor Hospital
Specialist and Forensic Services
Each of our CSUs is led by a Director and a Clinical Director.
Redesigning our care pathways service models
Diversity
We’ve begun work on redesigning service models in our local services. We’re working towards
having an assessment and rehabilitation recovery model, as we move towards more community
based provision and closer working with colleagues in the primary care sector.
We’re expecting to see a reduction in inpatient beds as we transfer more care for children,
adults and older people into community settings. All of our major project work is being
supported by our Project Management Office (PMO), which was established earlier this year
(discussed earlier in this report on page 14).
We serve a diverse population and it’s important that we attract and develop staff who reflect
the communities we serve and deliver services that are culturally sensitive and appropriate. We
have a dedicated diversity advisory service which focuses on making diversity from both an
employment and service provision perspective, part of our day to day business.
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Over the last year we have developed a Single Equality Scheme with objectives which look
at our services and how we behave as an employer, covering all nine of the diversity strands.
We’re now implementing this across the Trust. We’re currently consulting on guidance we’ve
produced on caring for the needs of gender variant users and staff.
Our Count Me In Census data findings, which look at the last five years, have been
analysed and through that work we’ve identified a number of actions to take, including:
increasing the number of staff accessing diversity training, commissioning specialist training
on issues, such as honour based violence and a leadership program looking at the impact of
culture and power relationships.
A dyslexia support group for staff and students also meets regularly at the Trust. Our Black
and Minority Ethnic (BME) staff network, which is a partnership with local NHS trusts in
Ealing, provides support and celebrates the diversity of staff within the Trusts; a multi-faith
spiritual and pastoral care service; and various bullying and harassment and measures to reduce
discrimination and bullying among patients and staff.
Our Single Equality Scheme is available on our website, www.wlmht.nhs.uk
Employee relations
We work very closely with the trade unions who represent their colleagues. We believe strongly
in partnership working and this is why we have a Trust Partnership Forum, where union officers
meet with the Trust’s directors and senior managers on a regular basis to discuss current issues
of the Trust and its staff.
We work to address overarching complaint themes and at the same time actions are taken at
an individual complaint level. This ranges from expediting a payment to a carer, to retrieving
and delivering property. As well as having mechanisms in place for learning from complaints, it’s
our priority to apologise, learn from people’s experience and do everything we can to prevent a
re-occurrence.
The Trust Board recognises the need to do as much as possible to give complainants the
sense that we have heard, acted upon and learnt from their concerns to avoid any
reoccurrence. We set targets around response times and learning from complaints is closely
monitored by the Board, providing assurance that we will improve practice and, in turn, the
patient experience.
Performance indicators
We were registered by the Care Quality Commission (CQC) on 1 April 2010 with three
conditions on our registration. These conditions were lifted in June and September.
Our priority is to continue to drive up standards so patients receive consistently high quality
care in all of our units and in the community. We’re committed to providing excellent care,
and the CQC have confirmed that we’re moving in the right direction, following their recent,
regular inspection visits.
Complaints
Our integrated Patient Advisory and Liaison Service (PALS) and complaints team provides us
with a valuable source of feedback on the experiences of people using our services. Complaints
about trust services should be sent to the Complaints Team, West London Mental Health Trust,
Uxbridge Road, Southall UB1 3EU. During 2010/11, we received 224 complaints. We’re pleased
to report that we responded to 98% of complaints in an agreed timeframe.
The key themes from complaints were around aspects of care and treatment and staff attitude.
Care and treatment cover a wide range of issues from families being unhappy with admission
of a relative to hospital, to disagreement following a ward move or discontent with policies
such as our smoking policy. Staff attitude includes such things as service users telling us that
they feel like they are not being treated with respect.
Annual Report
42
43
2010 2011

Financial Review
for the year ended
March 2011
Expenditure
The Trust’s main expenditure is on paying staff which amounts to £196 million. This is 80%
of total Trust expenditure. The chart below shows the breakdown of costs by staff group.
Pay costs 2010/11
The Trust continued to demonstrate strong financial performance in 2010/11. The Trust
achieved its key financial targets and delivered an operating surplus, before impairments
of £3.9m. This was better than the plan agreed by the Board.
Income and Expenditure
Income
n
n
n
n
n
n
Other Expenditure
Non-pay costs 2010/11
n
n
n
n
n Primary Care Trusts 90%
n Local Authorities 2%
n
n Other 2%
n
n Education, training and research 3%
n
n Strategic Health Authorities 1%
n
n NHS Trusts and Foundation Trusts 2%
The Trust generated total income in 2010/11 of £254 million. Clinical Income accounted
for £243 million, 90% from PCTs either through local agreements or national specialist
commissioning. Education, training and research and non-healthcare services account for
the remaining income. The majority of Trust healthcare income is through block service level
agreements. This provides a measure of certainty of income but it also presents a risk to the
Trust as for most local services the financial risk of unexpected increases in patient activity
falls on the Trust.
The following chart shows the main sources of income for the Trust.
Main sources of income 2010/11
Qualified nursing staff 33%
Scientific, theraputic and technical staff 14%
Medical and dental 15%
Managers and senior managers 7%
Administration and estates 13%
Healthcare assistants and other support staff 18%
Expenditure other than pay amounts to £46 million. During the year an amount of £185,000
was paid to PricewaterhouseCoopers LLP, the Trust’s external auditors in relation to audit fees,
and £20,000 in relation to other fees. We have complied with Treasury’s guidance on setting
charges for information.
The main non pay costs relate to depreciation charges and premises costs. The chart gives an
analysis of non pay expenditure.
Depreciation 23%
Impairments 9%
Training and education 4%
Other 7%
n Premises17%
n
n
Establishment costs 8%
Consultancy costs 1%
General supplies and services 11%
Clinical supplies and services 10%
Purchase of healthcare from non-NHS bodies 9%
Services from other NHS organisations and FTs 1%
Annual Report
44
45
2010 2011

Final out-turn
The Trust exceeded its NHS financial performance duty of break-even by achieving a £3.9million
surplus. The final out-turn position as reported in the Statement of Comprehensive Income
(SOCI) was a net deficit of £205K. This includes impairment charges of £4.2million. Impairment
charges arise due to changes in the value of assets. Under International Finance Reporting
Standards, these are shown as expenditure in the out-turn position, but are not included when
assessing an NHS Trusts’s performance against statutory targets and do not incur a cash loss.
The achievement of the £3.9million surplus is demonstrated in the note on the SOCI, “Reported
NHS Financial Performance Position.”
The Trust financial plan was to achieve a 1% surplus before impairments, £2.5million and so
the Trust exceeded its target by £1.5million (0.6%). The main reason for the positive variance
was the accounting treatment of an asset whose ownership was clarified in 2010/11. This
clarification meant the asset that had been previously included on the Trust asset register
was removed. The initial prudent view was that the charge that arose should be treated as
an expenditure item to impact on the operating surplus. It was finally determined to be more
properly treated as impairment and this resulted in an improved operating position.
Cash
The Trust balance at bank at March 2011 was £10.4million, an increase in the cash balance
from April 2010 of £5.3million. The improvement in the cash position was mainly a
consequence of successful action in year to reduce the level of debtors.
The Trust achieved the required performance on the target to pay creditors in line with the
better payment practice. The Prompt Payment Code has been devised by the government to
encourage and promote best practice between organisations and their suppliers. The target
is to pay 95% of creditors in 30 days. NHS creditors achieved 96% and trade creditors 95%.
Current performance can be seen in Note 9 of the accounts.
The table below shows the position on the Trust’s statutory and administrative financial duties
for the last three years
Financial Year 2008/9 2009/10 2010/11
Breakeven/Surplus on Income and Expenditure Account 4 4 4
Public Service Payment Policy (PSPP)* 4 4 4
External Financing Limit (EFL) 4 4 4
Capital Resource Limit 4 4 4
Capital Cost Absorption Rate 8 4 4
The achievement of the planned financial duties was against a background of a savings target
of £12 million to meet the national NHS efficiency target and local pressures. In year the Trust
faced further financial pressure in increased demand for local services, and cost and income
pressures in London forensic and estates. Action was taken to put in place recovery plans to
ensure all Trust areas achieved a positive run rate by year end. Despite this the Trust was able
to make some investment in other areas to improve patient care and strengthen the Trust
governance. An example of this investment was £0.5m to improve standards of cleanliness
across all patient areas.
The financial plan for 2011/12 is to achieve a 1% surplus. This will enable the Trust to further
strengthen its position as it progresses its Foundation Trust application. Generating surpluses
will provide support for capital investment. The Trust has significant commitments built into
its capital planning to enable the reprovision of medium secure services on its Ealing site and
its required contribution to the Broadmoor redevelopment. There will be an ongoing demand
for capital investment in other areas to enable the Trust to continue to thrive and deliver high
quality safe care and generating surpluses can support this.
Annual Report
46
47
2010 2011

Reportable segments
From April 2009 the Trust has been required to adhere to International Financial Reporting
Standards (IFRS). Among other requirements of IFRS is the need to identify reportable segments.
The Trust has five reportable segments as shown. These segments are classified as Service
Delivery Units (SDU’s)
Reportable
Segments
2010/11 2009/10
£000 £000
Income Expenditure Income Expenditure
Broadmoor SDU 86,246 (54,221) 83,064 (52,512)
Ealing SDU 40,836 (31,804) 41,083 (32,090)
Hammersmith & Fulham SDU 28,147 (22,171) 27,236 (22,711)
Hounslow SDU 25,431 (21,912) 25,736 (21,904)
West London Forensic SDU 60,451 (48,271) 61,678 (47,853)
Total of reportable segments 241,111 (178,379) 238,797 (177,070)
Corporate 12,662 (48,768) 13,048 (50,965)
Interest, dividend, depreciation (22,656) 0 (22,643)
Trust total 253,773 (249,803) 251,845 (250,678)
Retained surplus for the year 3,970 1,167
Once approved, this will proceed to the Full Business Case approval (FBC), with an expected
completion date of 2017. The project is planned to be largely publicly funded and in 2010/11
DH have allocated funds to keep the project on track and the Trust anticipates a decision
on the OBC by June 2011. The other major scheme is the reprovision of medium secure
accommodation on the St Bernard’s site. This project has received Strategic Outline Case
approval by NHS London. The Trust continues to work to an affordable OBC being approved in
December 2011. The project will be self funded and this presents a number of challenges given
the downturn in land values and the nature of the site at St Bernard’s. This is a major focus of
work in 2011/12 and will be a key development modelled in the Integrated Business Plan. The
reprovision of forensic accommodation is strategic necessity to remain as a specialist mental
health provider in the longer term.
Future Financial Performance
The Trust faces a number of challenges in the next few years. These are summarised as:
n External Environment
Continued impact of the economic downturn on publicly funded services, changes in
commissioning and the potential for increased competition. Responding to the outcome of
reviews of forensic pilot projects
n Internal
The increasingly challenging requirement for cost improvements. The Trust will fundamentally
change its model of local services to a stronger community focus with less dependence on
inpatient beds
n Capital
Securing funding for two major business cases and developing the associated high quality,
affordable revenue model
Capital
Overall the Trust Fixed Assets remained broadly stable in year at £344 million (£343 million
2009/10).
Barbara Byrne
Director of Finance & Information
West London Mental Health NHS Trust
The Trust has a large capital programme at both the Broadmoor Hospital site and London sites.
In 2010/11, £14 million was invested in Trust infrastructure.
The Trust has two major capital projects planned, the first of which is the redevelopment
of Broadmoor hospital, which is with the Department of Health (DH) awaiting approval
of the Outline Business Case (OBC). The OBC was approved by NHS London in 2010/11.
Annual Report
48
49
2010 2011

Summary Financial Statements
West London Mental Health NHS Trust
Annual Accounts 2010/11
Statement of financial position
as at 31 March 2011 31 March 2011
£000
Non-current assets
Restated*
31 March 2010
£000
Restated*
1 April 2009
£000
Property, plant and equipment 343,802 342,654 356,170
Statement of comprehensive income for the
year ended 31 March 2011
31 March
2010/11
£000
Restated*
31 March
2009/10
£000
Intangible assets 10 13 0
Total non-current assets 343,812 342,667 356,170
Current assets
Revenue
Revenue from patient care activities 242,576 240,068
Other operating revenue 11,168 11,720
Operating expenses (242,395) (241,338)
Operating surplus 11,349 10,450
Inventories 315 327 294
Trade and other receivables 6,231 13,630 14,432
Cash and cash equivalents 10,424 4,957 6,847
Non-Current Assets Held for Sale 835 - -
Total current assets 17,805 18,914 21,573
Total assets 361,617 361,581 377,743
Finance costs
Investment revenue 27 57
Finance costs (47) (94)
Surplus for the financial year 11,329 10,413
Public dividend capital dividends payable (11,534) (11,933)
Retained (deficit) for the year (205) (1,520)
Other comprehensive income
Impairments and reversals (2,808) (47,919)
Gains on revaluations 5,578 26,123
Current liabilities
Trade and other payables (17,820) (25,580) (21,675)
Provisions (1,903) (768) (2,526)
Net current (liabilities) (1,918) (7,434) (2,628)
Total assets less current liabilities 341,894 335,233 353,542
Non-current liabilities
Trade and other payables (142) (154) (176)
Provisions (1,721) (1,474) (1,750)
Total assets employed 340,031 333,605 351,616
Reclassification adjustments:
Transfers from donated and government grant reserves (39) (64)
Financed by taxpayers’ equity
Total comprehensive income for the year 2,526 (23,380)
Public dividend capital 257,362 253,462 249,916
Retained earnings (16,188) (15,983) (16,286)
Reported NHS financial performance position
Retained (deficit) for the year (205) (1,520)
Impairments 4,175 2,687
Revaluation reserve 96,518 93,786 116,294
Donated asset reserve 2,343 2,344 1,696
Government grant reserve 460 460 460
Other reserves (464) (464) (464)
Reported NHS financial performance position
(adjusted retained surplus) 3,970 1,167
* The 2009/10 Statement of Comprehensive Income has been restated as a result of the prior period adjustment
outlined under the Statement of Changes in Taxpayers’ Equity.
Total Taxpayers’ Equity 340,031 333,605 351,616
* The 2009/10 Statement of Financial Position has been restated as a result of the prior period adjustment
outlined under the Statement of Changes in Taxpayers’ Equity.
Annual Report
50
51
2010 2011

Statement of
changes in
Taxpayers’ equity
Public
dividend
capital
(PDC)
Retained
earnings
Revaluation
reserve
Donated
asset
reserve
Government
grant reserve
Other
reserves
Total
taxpayers
equity
£000 £000 £000 £000 £000 £000 £000
Balance at
1 April 2010 253,462 (15,983) 93,786 2,344 460 (464) 333,605
Changes in taxpayers’
equity for 2009-10
Total Comprehensive
Income for the year - - - - - -
Retained (deficit) for the
year - (205) - - - - (205)
Impairments and
reversals - - (2,808) - - - (2,808)
Gains on revaluation
of property, plant,
equipment - - 5,540 38 - - 5,578
Reclassification
adjustments: - - - - - - -
transfer from donated
asset/government grant
reserve - - - (39) - - (39)
New PDC received 3,900 - - - - - 3,900
Balance at
31 March 2011 257,362 (16,188) 96,518 2,343 460 (464) 340,031
Prior Period adjustment
A prior period adjustment has been reflected in the 2010/11 accounts, as a result of errors identified in previous
years. The Trust has identified that a number of assets have been included as both “furniture and fittings” and
“buildings” in the 2009/10 financial statements. The issue arose during the 2009/10 District Valuer (“DV”) estate
valuation, where a number of fittings were valued by the DV as part of the fabric of the buildings. Therefore, when
the building values were adjusted to reflect the DV’s report, the value of these fixtures and fittings were included
in the “buildings” classification, whilst historically they were also included the “fixtures and fittings” classification
by the Trust. The Trust has therefore removed the double counted assets from the “fixtures and fittings” balances.
The estimated net book value of these assets is £4.5m and is considered to be material. The Trust has therefore
amended the values through a prior period adjustment, removing the assets from both the 2010/11 and
2009/10 balances.
As a result of this prior period adjustment, the comparative figures for the year ended 31 March 2010 have been
adjusted as follows:
Prior Period adjustment
Retained surplus for the
year ended 31 March 2010
Total assets employed
Revaluation
Reserve
£000 £000 £000
As previously stated 303 338,453 119,319
Revaluation and Indexation adjustment (1,823) (4,848) (3,025)
As restated (1,520) 333,605 116,294
Impairments 2,687
Reported NHS Financial position 1,167
The 2009/10 SOFP, SOCI, and SOCITE have been restated to reflect the prior period adjustment, as have operating
expenses and property, plant and equipment. The impact of these adjustments are as follows:
Operating expenses
31 March 2011
£000
Restated
31 March 2010
£000
Original
April 2009
£000
Impairments 4,175 2,687 864
Public dividend capital (PDC) relates to the Trust’s originating capital. Additional PDC is received to fund capital
projects following approval by the Department of Health. The retained earnings is the cumulative surplus/
deficit made by the Trust since its inception. It is held in perpetuity and cannot be released to the Statement of
Comprehensive Income. The revaluation reserve reflects movements in the value of property, plant and equipment
and intangible assets as set out in the accounting policy. The revaluation reserve balance relating to each asset is
released to the retained earnings reserve/genera. The donated asset reserve is the value of building assets donated
to the Trust in prior years. The government grants reserve represents items of deferred income that existed in
the accounts at 1 April 2001.The value of these items of deferred income has been adjusted to equal the net
book value of the assets they had funded. This has been achieved. Other reserves represent the cost of settling
the outstanding net liabilities allocated to the Trust in respect of the transfer of responsibility for the provision of
mental health services in Hounslow from Hounslow and Spelthorne NHS Trust.
Property, plant and equipment prior year 2009/10
Cost or valuation at 1 April 2009
Furniture and fittings
£000
As previously stated 25,194
Prior period adjustment (8,046)
Revised balance 17,148
Depreciation at 1 April 2009
As previously stated 10,621
Prior period adjustment (3,198)
Revised balance 7,423
Annual Report
52
53
2010 2011

Management Costs
Statement of cash flows for the year ended
31 March 2011
2010/11 2009/10
£000 £000
Full Year Trust Management Costs £16,685,000
Cash flows from operating activities
Full Year Trust Income £246,780,000
Operating surplus 11,349 10,450
Management Costs as Percentage of Trust Income 6.76%
Depreciation and amortisation 10,930 10,710
Impairments and reversals 4,175 2,687
Management costs are calculated in accordance with the guidance on the DH’s website.
Transfer from donated asset reserve (39) (64)
Interest paid - (1)
PDC dividends paid (12,724) (10,933)
Better Payment Practice Code
(Increase)/decrease in inventories 12 (33)
Better Payment Practice Code
measure of compliance
2010/11 2009/10
Number £000 Number £000
Decrease in trade and other receivables 7,399 802
Increase/(decrease) in trade and other payables (6,875) 4,103
Increase/(decrease) in provisions 1,335 (2,127)
Net cash inflow from operating activities 15,562 15,594
Total Non-NHS trade invoices paid in the year 40,138 59,824 48,293 71,196
Cash flows from investing activities
Total Non NHS trade invoices paid within target 37,765 57,098 45,390 68,479
Interest received 27 57
Percentage of Non-NHS trade invoices
paid within target
94% 95% 94% 96%
(Payments) for property, plant and equipment (14,022) (21,074)
(Payments) for intangible assets - (13)
Total NHS trade invoices paid in the year 667 4,460 779 5,589
(Payments) for other financial assets - -
Net cash (outflow) from investing activities (13,995) (21,030)
Total NHS trade invoices paid within target 642 4,353 749 5,479
Net cash inflow/(outflow) before financing 1,567 (5,436)
Percentage of NHS trade invoices
paid within target
96% 98% 96% 98%
Cash flows from financing activities
Public dividend capital received 3,900 3,546
The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices by the due date or within
30 days of receipt of goods or a valid invoice, whichever is later.
Net increase/decrease in cash and cash equivalents 5,467 (1,890)
The Late Payment of Commercial Debts (Interest) Act 1998
The Trust did not incur any expenditure in relation to this Act during 2010/11 or 2009/10.
Cash (and) cash equivalents (and bank overdrafts) at the
beginning of the financial year 4,957 6,847
Cash (and) cash equivalents (and bank overdrafts) at the end
of the financial year 10,424 4,957
Annual Report
54
55
2010 2011

Directors’ Remuneration
Salary and Pension Entitlements of Senior Managers
Name and Title
Salary
(bands of
£5,000)
2010/11 2009/10
Other
remuneration Benefits Salary
(bands of
£5,000)
rounded
to £100
(bands of
£5,000)
Other
remuneration
(bands of
£5,000)
Benefits
rounded
to £100
Peter Cubbon, Chief Executive 175-180 - - 135-140 - -
Steve Trenchard, Director of Nursing
and Patient Experience 110-115 - - 35-40 - -
Barbara Byrne, Director of Finance and
Information 115-120 - - 115-120 - -
Ian Kent, Deputy Chief Executive
until 01/08/2010 40-45 - - 120-125 - -
Liz Fellow-Smith, Medical Director
until 31/08/2010 80-85 - - 180-185 - -
Leeanne McGee
Director of High Secure Services 110-115 - - 15-20 - -
Ruth Lewis, Director of Organisational
Development and Workforce 110-115 - - 15-20 - -
Dr Nick Broughton, Medical Director
from 01/09/2010 120-125 - - - - -
Nigel Leonard, Director of Planning
and Corporate Affairs 90-95 - - - - -
Jean George, Interim Director of Local
Services, from 08/11/2010 40-45 - - - - -
Andy Weir, Director of Forensic Services,
from 30/11/2010 40-45 - - - - -
Nigel McCorkell, Chairman 20-25 - - 20-25 - -
Directors’ Remuneration
Pension benefits
Name and Title
Real increase
in pension
& related
lump sum at
age 60
(bands of
£2,500)
Total accrued
pension
& related
lump sum at
age 60
Cash
equivalent
transfer value
at 31 March
2011
Cash
equivalent
transfer value
at 31 March
2010
Real increase
in cash
equivalent
transfer
(bands of
£5,000) £000 £000 £000
Peter Cubbon, Chief Executive 0-2.5 305-310 1466 1448 -54
Steve Trenchard, Director of Nursing
and Patient Experience 0-2.5 0-5 21 8 13
Barbara Byrne
Director of Finance and Information 20-22.5 165-170 867 894 -71
Ian Kent, Deputy Chief Executive
until 01/08/2010 - 140-145 550 601 -81
Liz Fellow-Smith
Medical Director until 31/08/2010 5-7.5 245-250 1123 1142 -76
Leeanne McGee
Director of High Secure Services - - - - -
Ruth Lewis, Director of Organisational
Development and Workforce 5-7.5 25-30 127 100 21
Dr Nick Broughton
Medical Director from 01/09/2010 57.5-60 100-105 301 - -
Nigel Leonard, Director of Planning
and Corporate Affairs 90-92.5 90-95 347 - -
Jean George, Interim Director of Local
Services, from 08/11/2010 37.5-40 70-75 318 - -
Andy Weir, Director of Forensic Services,
from 30/11/2010 25-27.5 75-80 218 - -
Ann Chapman, Non-executive director 5-10 - - 5-10 - -
Barbara Kerin, Non-executive director 5-10 - - 0-5 - -
Lisa Harrington, Non-executive director
until 31/08/2010 0-5 - - 0-5 - -
Christine Higgins, Non-executive
director 5-10 - - 0-5 - -
Dame Sally Powell
Non-executive director 5-10 - - 0-5 - -
Signed _______________________________________________________________________
Peter Cubbon Chief Executive
Prof Lefkos Middleton, Non-executive
director, from 01/07/2010 0-5 - - - - -
Neville Manuel, Non-executive director
from 01/09/2010 0-5 - - - - -
These summary financial statements might not contain sufficient information for a full
understanding of the entity’s financial position and performance.
Geoff Rose, Non-executive director 5-10 - - 0-5 - -
Annual Report
56
57
2010 2011

Statement of the Chief Executive’s
responsibilities as the accountable officer
of the Trust
The Chief Executive of the NHS has designated that the Chief Executive should be the
Accountable Officer to the trust. The relevant responsibilities of Accountable Officers are set out
in the Accountable Officers Memorandum issued by the Department of Health. These include
ensuring that:
n there are effective management systems in place to safeguard public funds and assets and
assist in the implementation of corporate governance;
n value for money is achieved from the resources available to the trust;
n the expenditure and income of the trust has been applied to the purposes intended by
Parliament and conform to the authorities which govern them;
n effective and sound financial management systems are in place; and
n annual statutory accounts are prepared in a format directed by the Secretary of State with
the approval of the Treasury to give a true and fair view of the state of affairs as at the end
of the financial year and the income and expenditure, recognised gains and losses and cash
flows for the year.
To the best of my knowledge and belief, I have properly discharged the responsibilities set out
in my letter of appointment as an Accountable Officer.
Signed _______________________________________________________________________
Peter Cubbon Chief Executive
Independent auditors’ statement to the Directors of
the Board of West London Mental Health NHS Trust
We have examined the summary financial statement for the year ended 31 March 2011 which
comprises the Statement of Comprehensive Income, the Statement of Financial Position, the
Statement of Changes in Taxpayers’ Equity, the Statement of Cash Flows, the related notes and
information in the Directors’ Remuneration Report that is described as having been audited.
Respective responsibilities of directors and auditors
The directors are responsible for preparing the Annual Report and summary financial statement,
in accordance with directions issued by the Secretary of State.
Our responsibility is to report to you our opinion on the consistency of the summary financial
statement within the Annual Report with the statutory financial statement and the Directors’
Remuneration Report and its compliance with the relevant requirements of the directions issued
by the Secretary of State.
We also read the other information contained in the Annual Report and consider the
implications for our statement if we become aware of any apparent misstatements or material
inconsistencies with the summary financial statement.
This statement, including the opinion, has been prepared for, and only for, the Board of West
London Mental Health NHS Trust in accordance with Part II of the Audit Commission Act 1998,
as set out in paragraph 45 of the Statement of Responsibilities of Auditors and of Audited
Bodies (Local NHS Bodies) published by the Audit Commission in March 2010 and for no other
purpose. We do not, in giving this opinion, accept or assume responsibility for any other
purpose or to any other person to whom this statement is shown or into whose hands it may
come save where expressly agreed by our prior consent in writing.
We conducted our work in accordance with Bulletin 2008/3 issued by the Auditing Practices
Board. Our report on the statutory financial statements describes the basis of our audit opinion
on those financial statements, the Directors’ Report and the Directors’ Remuneration Report.
Opinion
In our opinion the summary financial statement is consistent with the statutory financial
statements and the Directors’ Remuneration Report of the Trust for the year ended 31 March
2011 and complies with the relevant requirements of the directions issued by the Secretary of
State.
Date
_______________________________________________________________________
8th June 2011
Sarah Isted, Engagement Lead
30 June 2011
For and on behalf of
PricewaterhouseCoopers LLP
Appointed Auditors
7 More London Riverside
London SE1 2RT
Annual Report
58
59
2010 2011

Statement on internal control 2010/11
from the Chief Executive
The Medical Director is the designated executive director with overall responsibility for risk
management clinical and non-clinical, and has lead for clinical governance. The Director of
Nursing & Patient Experience has responsibility for infection control, medicines management,
and registration with the Care Quality Commission.
1. Scope of responsibility
The Board is accountable for internal control. As Accountable Officer, and Chief Executive of
this Board, I have responsibility for maintaining a sound system of internal control that supports
the achievement of the organisation’s policies, aims and objectives. I also have responsibility
for safeguarding the public funds and the organisation’s assets for which I am personally
responsible as set out in the Accountable Officer Memorandum.
Operational Directors are responsible for ensuring risk is assessed, and managed within their
area of responsibility. The Board is aware of the risks in the organisation through the population
of the risk register and is responsible for ensuring action plans are in place to manage those
risks. Risks are managed in different ways including risk transfer and developing systems to
mitigate risks. Risks that cannot be managed within the directorates are escalated to the Trust
wide risk register. There will be some residual risk that cannot reasonably be eliminated that the
Board will choose to accept where this is necessary to deliver its objectives.
I am accountable to the Chairman of West London Mental Health Trust, with whom I agree my
objectives annually. The Chairman reviews progress with the objectives in year and
performance at the end of the year. I am also accountable to NHS London for the performance
of the Trust. There are separate performance reviews with NHS London for the services provided
by the high secure hospital, Broadmoor. I work in partnership with PCTs, Local Authorities
and the Police, through local partnership boards, to deliver objectives that cut across
organisational boundaries.
2. The purpose of the system of internal control
3.2 Education & Training
The Trust has in place a programme of training and education. This programme includes risk
management training.
Mandatory training is a Key Workforce Performance Indicator and a more robust monitoring
system has been introduced in 2010. Improved measurement systems have focused line
attention on this aspect of performance, which has resulted in an improvement in year.
Mandatory training was reviewed by internal audit review in year and the outcome provided
further reassurance of improvement.
The system of internal control is designed to manage risk to a reasonable level rather than to
eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide
reasonable and not absolute assurance of effectiveness. The system of internal control is based
on an ongoing process designed to:
The Trust Board receives monthly reports on performance and will continue to monitor the
achievement of required attendance.
n identify and prioritise the risks to the achievement of the organisation’s policies, aims
and objectives,
n evaluate the likelihood of those risks being realised and the impact should they be realised,
and to manage them efficiently, effectively and economically.
The system of internal control has been in place in West London Mental Health Trust for the
year ended 31 March 2011 and up to the date of approval of the annual report and accounts.
3. Leadership of the Risk Management Process
3.1 The Responsibility of the Trust Chief Executive
The Chief Executive has overall responsibility for having an effective risk management process
in place. The Trust has a Quality & Risk Committee in place which is chaired by a non executive
Director of the Trust.
4. The risk and control framework
The risk management strategy/policy defines the lines of accountability and the
responsibilities of all staff, including accountability arrangements with key stakeholders.
It sets out the committee structure in place to support risk management and ensure that the
Board has information on the principal risks to the Trust and how it is mitigating and managing
those risks.
The overarching mechanism for managing risk to delivery of the Trust strategic objectives and
gaining assurance is the Assurance Framework. The Assurance Framework identifies risks to
the strategic objectives, the controls in place to manage those risks, any gaps in controls and
the source of assurance. The Assurance Framework was in place at the start of the year and
has been significantly reviewed and revised in year by the Board. Board sub committees and
Executive Directors review the Assurance framework regularly. The delivery against corporate
objectives is performance managed and reported to the Board through the approved business
planning process. The Trust is supported in the systematic identification and management of
risk in the Trust by a number of functions across the organisation.
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4.1 Clinical Risk Management
The Trust in accordance with NHSLA requirements for biennial review was reassessed against
the NHSLA standards in February 2011. The Trust was successful in retaining the mental health
NHSLA level 1 standards.
Complaints
The Trust’s Complaints Policy is in line with the National Health Service (Complaints)
Regulations. The system of managing complaints is reviewed by the Quality & Risk Committee
to ensure that improvements in care as a result of complaints are evident. There is now an
improved process in place for management and learning from complaints. The timescale for
completion of complaints is reported monthly to the Board. Internal Audit provided positive
assurance over these processes.
Carbon Reduction Delivery Plans have been developed to cover Trust buildings, transport and
travel, procurement and other key areas. These are undergoing consultation prior to Board
approval for delivery during 2011/12 and subsequent years.
Due to concern raised internally regarding the overall arrangements for the management of the
operational capital programme I commissioned an advisory audit from Internal Audit. This made
a number of recommendations to strengthen project planning and control. Many of these have
been implemented in year and I gained further reassurance of improvement by a formal reaudit
undertaken in March 2011, which concluded that adequate progress had been made to
implement the recommendations outlined previously.
4.3 Information Governance (IG)
Accident/Incident Reporting & Review
The Trust has an electronic accident/ incident reporting system throughout the organisation for
reporting all incidents, including “near misses”. A summary Integrated Complaints, Incidents
and Claims report is presented to the Quality & Risk Committee to ensure that issues identified
are shared more widely. The Trust has instigated a thorough review of this system and continues
to improve the process.
A new version (version 8) of the information governance self assessment was published by
Connecting for Health in July 2010 and a comprehensive information governance work plan
was put in place in September 2010 reflecting these changes.
The Trust has achieved a score of 68% for 2010-2011. Internal Audit has assessed a sample of
the scores that we self-assessed and has agreed with our scoring in all cases.
4.2 Finance, Resources & Environment
NHS organisations are also required to include in their annual reports details of serious incidents
involving data loss or breach of confidentiality.
The Trust has a robust system to maintain regular oversight of its financial position. This
includes the Finance & Performance Committee.
There were no major incidents in West London Mental Health NHS Trust in 2010-11.
As an employer with staff entitled to membership of the NHS Pension Scheme, control
measures are in place to ensure all employer obligations contained within the Scheme
regulations are complied with. This includes ensuring that deductions from salary, employer’s
contributions and payments in to the Scheme are in accordance with the Scheme rules, and
that member Pension Scheme records are accurately updated in accordance with the timescales
detailed in the Regulations.
4.4 Other personal data-related incidents in 2010/20
Category Nature of Incident Total
I
Loss of inadequately protected electronic equipment, devices or paper
documents from secured NHS premises. 0
Control measures are in place to ensure that all the organisation’s obligations under equality,
diversity and human rights legislation are complied with.
II
Loss of inadequately protected electronic equipment, devices or paper
documents from outside secured NHS premises. 0
The Trust has undertaken risk assessments in accordance with emergency preparedness and
civil contingency requirements (based on UKCIP 2009 weather projections) to ensure it meets
its obligations under the Climate Change Act and the Adaptation Reporting requirements.
Business Continuity Plans (BCPs) include heat wave and severe weather episodes. The BCP
annual review process will capture flood events at applicable sites and acknowledge and
address the risks that climate change pose to the continued function and performance of the
Trust. Capital redevelopment projects consider the impacts of climate change on drainage and
flood risk management strategies.
III
Insecure disposal of inadequately protected electronic equipment, devices or
paper documents. 0
IV Unauthorised disclosure. 2
V Other. 19
Other covers minor potential internal breaches of confidentiality where there is no actual
personal data losses When incidents are reported they are reviewed and appropriate action
taken and any wider lessons learned shared.
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4.5 Infection Control & Registration
The Trust continues to implement its Infection Control Action plan which is overseen by the
Infection Control group and report into the Physical Healthcare group. An annual report is
submitted to the Quality and Risk Committee. Monthly audits are undertaken and actions
implemented accordingly.
monitoring and reporting of spend. An action plan to address the identified weaknesses was
agreed with management and follow-up work recently undertaken in this area has indicated
that reasonable progress has been made in resolving these issues and has identified actions for
further improvement in governance and controls.”
Executive Directors within the organisation who have responsibility for the development and
maintenance of the system of internal control provide me with assurance.
4.6 Care Quality Commission Report
The Trust implemented the action plan agreed with CQC and this was performance managed
by NHS London initially on a monthly basis and quarterly from November 2010. The Trust is
now being monitored by CQC in line with registration requirements as with any other Trust.
The Assurance Framework itself provides me with evidence that effectiveness of controls that
manage risks to the organisation achieving its principal objectives have been reviewed.
The Board Assurance Framework identifies two high risks to patient safety:
Inability to manage suicide risk on wards
Ligature risk in inpatient settings
4.7 Preparation for Foundation Trust
The Trust is in the process of preparing for an application to Secretary of State for approval as
a Foundation Trust or equivalent. As part of the preparation and to ensure the Trust can thrive
against the background of public sector finance reductions I have undertaken a review of the
governance framework. The recommendations of the review, will be discussed by the Board
in April 2011. I also initiated a restructuring to move from 5 Service Delivery Units to 3 Clinical
Service Units (CSUs). The CSUs are headed by an Executive Director. During 2011/12
the process of restructuring will continue.
These risks arise due to the ‘old’ buildings in which some of the Trust inpatient services are
delivered. These risks will be eliminated with the delivery of new accommodation. I have
determined that, whilst considerable work has been done to mitigate these risks, they should
remain rated as high risks and further work is in place to mitigate the risk as far as possible until
the new buildings are commissioned.
5.2 Registration with the CQC
5. Review of Effectiveness
The CQC authorised the Trust as a regulated provider from 1st April 2010 with 3 conditions.
The conditions were:
As Accountable Officer, I have responsibility for reviewing the effectiveness of the system
of internal control. My review is informed in a number of ways. The Head of Internal Audit
provides me with an opinion on the overall arrangements for gaining assurance through the
Assurance Framework and on the controls reviewed as part of the internal audit work.
5.1 Opinion on the Assurance Framework
The Internal Audit review of the organisation’s overall arrangements for gaining assurance has
concluded that:
1. The Trust must ensure that detention papers are renewed as required by the Mental Health
Act in respect of detained patients and all aspects of care is documented in the agreed
service user care plan by 31 May 2010
2.
3. The Trust must ensure it employs sufficient numbers of staff with the appropriate skills,
knowledge, experience and qualifications to meet the needs of patients at St Bernard’s
Hospital and provided evidence of this to the CQC by 1 September 2010
The Trust must ensure that appropriate systems are put in place to assess and monitor the
quality of service provision by 30th September 2010
“Based on the work undertaken in 2010/11, significant assurance can be given that there is a
generally sound system of internal control, designed to meet the organisation’s objectives, and
that controls are generally being applied consistently. However, some weakness in the design
and inconsistent application of controls, put the achievement of particular objectives at risk.
“We were requested by Management to review the controls in place which had led to a £2
million spend in excess of plan on the 2009/10 capital budget despite the programme reporting
an under spend throughout the year. The risk of breach of external financial duties was
mitigated through an approved increase in the Capital Resource Limit. Our review highlighted
a number of concerns around the authorisation of capital expenditure and the ongoing
Following the submission of evidence by the stated timeframes the CQC lifted the three
conditions in September and December 2010.
Monitoring of the Trust’s CQC Registration Status is undertaken by the Trust through the
Quality & Risk Committee, and the Trust Board.
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I have been advised on the implications of the result of my review of the effectiveness of the
system of internal control by the following committees within the Trust.
Who runs the Trust
n Audit Committee
n Quality and Risk Committee
n Finance & Performance Committee
The Board will continue to review progress as part of eliminating weakness and ensuring
that a process of continuous improvement is in place in the Trust in 2011/12 through the
following actions:
n Implementation of new governance structure
n Develop Trustwide clinical audit programme to gain further assurance on the quality of
clinical services
n Implementation of new management structure to ensure Trust fit for FT
n Trust Board development as part of FT planning
n Work towards achievement of NHSLA level 2
n Implement further actions to mitigate risk of providing inpatient services in buildings not fit
for purpose
n Continuing to monitor CQC registration framework
n Implementation of agreed carbon reduction delivery plans
n Continued implementation of capital action plan
n Timely implementation of any internal and external audit recommendations
Peter Cubbon
Chief Executive
June 2011
For 2010/11 the Trust Board
comprised:
Chairman
Mr Nigel McCorkell
Non Executive Directors
Dame Sally Powell
Mrs Ann Chapman
Mrs Christine Higgins
Mrs Barbara Kerin
Mr Geoff Rose
Mr Neville Manuel (since September 2010)
Prof Lefkos Middleton (since July 2010)
Ms Lisa Harrington (until August 2010)
Chief Executive
Mr Peter Cubbon
Executive Directors
Mrs Barbara Byrne
Director of Finance & Information
Mrs Ruth Lewis
Director of Organisation Development &
Workforce
Mr Steve Trenchard
Director of Nursing & Patient Experience
Dr Nick Broughton
Medical Director
(Acting MD from September 2010
MD from October 2010)
Miss Leeanne McGee,
Director of High Secure Services
Mr Ian Kent
Deputy Chief Executive
(until August 2010)
Dr Elizabeth Fellow–Smith
Medical Director
(until August 2010)
Other Board Directors
Ms Jean George
Interim Director of Local Services
(from November 2010)
Mr Andy Weir
Director - Specialist and Forensic Services
(from November 2010)
Mr Nigel Leonard
Director of Planning and Corporate Affairs
The Chairman and Non-Executive Directors
have been appointed by the Secretary of
State for Health, in accordance with national
procedures for appointments to such
positions, for a term of office that may vary
from two years to four years.
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2010 2011

Board Meetings
Our Board held eleven business meetings at
our headquarters in Southall during 2010/11.
These meetings were open to the public with
agendas and papers available in advance and
published on our website afterwards.
We also held an annual public meeting at
which we presented our annual report and
accounts. Last year’s meeting was held on
23rd September 2010.
Committees
In respect of the following committees of
the Trust Board, the Board members below
are present, either as members (M) or in
attendance (A):
Audit Committee
Christine Higgins - Chair (M)
Barbara Kerin (M)
Geoff Rose (M)
Ann Chapman (M)
Barbara Byrne (A)
Peter Cubbon (A)
Charitable Funds Committee
Barbara Kerin - Chair (M)
Nigel McCorkell (M)
Christine Higgins (M)
Peter Cubbon (M)
Barbara Byrne (M)
Ruth Lewis (M)
Steve Trenchard (M)
Dr Nick Broughton (M) (from Sept 2010)
Leeanne McGee (M)
Quality & Risk Committee
Ann Chapman - Chair (M)
Sally Powell (M)
Christine Higgins (M)
Professor Lefkos Middleton (M)
(from July 2010)
Dr Nick Broughton (M)
(from September 2010)
Steve Trenchard (M)
Leeanne McGee (M)
Jean George (M) (from November 2010)
Andy Weir (M) (from November 2010)
Dr Elizabeth Fellow-Smith
(until August 2010)
Ian Kent (until August 2010)
Any Trust Board member has an open
invitation to attend the meetings of this
committee.
Finance & Performance Committee
Sally Powell - Chair (M)
Neville Manuel (M) (from Sept 2010)
Geoff Rose (M)
Barbara Kerin (M)
Lisa Harrington (M) (until August 2010)
Barbara Byrne (M)
Ruth Lewis (M)
(+ ED Clinical Representative - alternated
between Steve Trenchard, Leeanne
McGee and Dr Nick Broughton)
Any Trust Board member has an open
invitation to attend the meetings of this
committee.
Operations board (and Clinical
Engagement & Leadership Forum)
Peter Cubbon - Chair (M)
Barbara Byrne (M)
Jean George (M) (from November 2010)
Ruth Lewis (M)
Steve Trenchard (M)
Dr Nick Broughton (M) (from Sept 2010)
Leeanne McGee (M)
Andy Weir (M) (from November 2010)
Mr Ian Kent (M) (until August 2010)
Dr Elizabeth Fellow-Smith
(until August 2010)
Mental Health Act Managers
Committee
Ann Chapman - Chair (M)
A number of lay people appointed as
mental health act managers.
All non executive directors are eligible
to be members.
Remuneration Committee
Nigel McCorkell - Chair (M)
Christine Higgins (M)
Barbara Kerin (M)
Geoff Rose (M)
Ann Chapman (M)
Sally Powell (M)
Neville Manuel (M) (from Sept 2010)
Professor Lefkos Middleton (M)
(from July 2010)
Lisa Harrington (M) (until August 2010)
Peter Cubbon (A)
Ruth Lewis (A)
Register of members’ interests
It is a requirement that the Chairman and all
board members should declare any conflicts of
interest that arise in the course of conducting
NHS business. During the year none of the
Trust board members or parties related to
any of them have undertaken any material
transactions with West London Mental Health
NHS Trust. As at 30 April 2011, the following
interests have been registered. Each director
states that as far as he/she is aware there is no
relevant audit information of which the NHS
body’s auditors are unaware and he/she has
taken all the steps that he/she ought to have
taken as a director in order to make himself
aware of any relevant audit information and
to establish that the NHS body’s auditors are
aware of that information.
Mr Nigel McCorkell
Deputy Chairman for FFAST FILL Plc
Dame Sally Powell
Councillor for London Borough of
Hammersmith & Fulham
Works for SAVP Consulting
Mrs Ann Chapman
Councillor for London Borough of Ealing
Trustee, Age Concern, Ealing (until 4th
November 2010)
Mr Neville Manuel
None
Mrs Christine Higgins
None
Mrs Barbara Kerin
Director and Company Secretary
Chiltern Citizens Advice Bureau Limited
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2010 2011

Mr Geoff Rose
Chair, Dimensions UK
Chief Executive of Breakthrough
Executive Coaching
Shadow member of Barnet, Enfield and
Haringey Mental Health FT
Non Executive Director of Dimensions
Community Enterprises
Professor Lefkos Middleton
None
Ms Lisa Harrington
Director (Non Board) in British Telecom
Mr Peter Cubbon
None
Mrs Barbara Byrne
Company Director and Trustee of the
Healthcare Financial Management
Association
Husband works for Brent MIND
Mr Ian Kent
None
Mrs Ruth Lewis
None
Mr Steve Trenchard
Chair of ISPS (International Society for the
Psychological Treatments and Approaches in
the Schizophrenias and other Psychoses)
Dr Elizabeth Fellow-Smith
Chair of the Royal College of Psychiatrists
Special Committee for Professional
Governance and Ethics
Trustee of the Royal College of Psychiatrists
Miss Leeanne McGee
None
Dr Nick Broughton
None
Ms Jean George
Governor of Further Education College
East Berkshire
Mr Andy Weir
None
Mr Nigel Leonard
None
Togetherness
Responsibility
Excellence
Caring
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2010 2011

Our values
Trust Headquarters
Tel: 020 8354 8354
Email: communications@wlmht.nhs.uk
Web: www.wlmht.nhs.uk
West London Mental Health NHS Trust
Trust Headquarters
Uxbridge Road
Southall
UB1 3EU
Togetherness
Responsibility
Excellence
Caring