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

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



2010 2011

Our vision

Our values





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.


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

Annual Report



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


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.”

Annual Report



2010 2011

Website re-launched

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


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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2010 2011



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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2010 2011

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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2010 2011

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


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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2010 2011

“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.”


Lovena Cenizo from our Contact Centre Team



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.

Annual Report

2010 2011


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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2010 2011

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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2010 2011

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.


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


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.


“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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2010 2011

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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2010 2011

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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2010 2011

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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2010 2011

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.


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.




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


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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2010 2011

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,

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


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.


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



2010 2011

Financial Review

for the year ended

March 2011


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








Other Expenditure

Non-pay costs 2010/11





n Primary Care Trusts 90%

n Local Authorities 2%


n Other 2%


n Education, training and research 3%


n Strategic Health Authorities 1%


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%



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



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.


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



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)



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


Overall the Trust Fixed Assets remained broadly stable in year at £344 million (£343 million


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



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


Non-current assets


31 March 2010



1 April 2009


Property, plant and equipment 343,802 342,654 356,170

Statement of comprehensive income for the

year ended 31 March 2011

31 March




31 March



Intangible assets 10 13 0

Total non-current assets 343,812 342,667 356,170

Current assets


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



2010 2011

Statement of

changes in

Taxpayers’ equity













grant reserve






£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


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



£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



31 March 2010



April 2009


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


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



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



2010 2011

Directors’ Remuneration

Salary and Pension Entitlements of Senior Managers

Name and Title


(bands of


2010/11 2009/10


remuneration Benefits Salary

(bands of



to £100

(bands of




(bands of




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


Total accrued


& related

lump sum at

age 60



transfer value

at 31 March




transfer value

at 31 March


Real increase

in cash



(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



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.


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




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



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.

Annual Report



2010 2011

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.


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


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.


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.


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.

Annual Report



2010 2011

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


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.

Annual Report



2010 2011

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



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 &


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.

Annual Report



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.


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


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


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


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


Mrs Christine Higgins


Mrs Barbara Kerin

Director and Company Secretary

Chiltern Citizens Advice Bureau Limited

Annual Report



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


Ms Lisa Harrington

Director (Non Board) in British Telecom

Mr Peter Cubbon


Mrs Barbara Byrne

Company Director and Trustee of the

Healthcare Financial Management


Husband works for Brent MIND

Mr Ian Kent


Mrs Ruth Lewis


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


Dr Nick Broughton


Ms Jean George

Governor of Further Education College

East Berkshire

Mr Andy Weir


Mr Nigel Leonard






Annual Report



2010 2011

Our values

Trust Headquarters

Tel: 020 8354 8354



West London Mental Health NHS Trust

Trust Headquarters

Uxbridge Road







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