Annual report 2012-13 - West London Mental Health NHS Trust

InformationAbout the trustStructureWest London Mental Health Trust is structuredaround three clinical service units.The three clinical service units are:• Local services.• High secure services (Broadmoor Hospital).• Specialist and forensic services.Each of our clinical service units is led by a directorwho is a member of the board, along with strongclinical leadership.We serve a diverse population and it’s importantthat we attract and develop staff who reflect thecommunities we serve and deliver services thatare culturally sensitive and appropriate. We have adedicated diversity advisory service which focuseson making diversity from both an employment andservice provision perspective, part of our day-todaybusiness.Employee relationsWe work very closely with the trade unions whorepresent their colleagues. We believe strongly inpartnership working and this is why we have atrust partnership forum, where union officers meetwith the trust’s directors and senior managers on aregular basis to discuss current staff issues.The trust provides information to its staff ina variety of ways including an intranet, chiefexecutive’s blog, quarterly magazine, monthlyteam brief and weekly email bulletin. Inaddition, monthly listening events are hosted bydirectors and ad hoc briefings are given on keydevelopments. The majority of staff have regularteam meetings with their line manager and havean annual performance development review.Where significant changes are proposed, formalconsultation is undertaken with all affected staff.ComplaintsOur central governance team provides us with avaluable source of feedback on the experiencesof our service users, carers and wider publicusing our services through the Patient Adviseand Liaison Service (PALS), complaints andcompliments. During 2012/13, we received andregistered 307 formal complaints, 1383 PALSconcerns and 34 compliments. We respondedto 89% of complaints in an agreed timeframeand shall continue to work to increase our timelyresponse rate in the coming months.The key emerging themes highlighted incomplaints were related to all ‘aspects of care andtreatment’ and ‘staff attitude’. Care and treatmentthemes cover a wide range of issues includingmedication, admission, assessments, diagnosis,detainment and discontent due to policies such asthe no smoking and room search policies. Themesrelated to staff attitudes include service userssaying they feel they are not being treated withrespect and dignity.We work to resolve such issues and, at the sametime, take action in individual cases. Such actioncould include expediting a payment to a serviceuser due to their property being lost during a wardmove or training staff. We have the mechanismsin place to learn from complaints and furtherwork is being done to make those mechanismsmore robust. At the same time, it is our priority toapologise, learn from people’s experience and doeverything we can to prevent a reoccurrence.We set targets around response times which isagreed with the complainant and learning fromcomplaints is closely monitored by the board,providing assurance that we will improve practiceand, in turn, the patient experience.CQC registrationAll West London Mental Health NHS Trust servicesare registered with the Care Quality Commission(CQC) ‘ without conditions’. This means that therehave been no formal concerns raised on the qualityof the services by the CQC.The Care Quality Commission has not taken anyenforcement action against West London MentalHealth NHS Trust during 2012/13.West London Mental Health NHS Trust has notparticipated in any special reviews or investigationsby the CQC during 2012/13. However, as partof their routine schedule of visits we receivedtwo reports from the CQC that assessed ourcompliance against the ‘Essential Standards ofQuality and Safety’.Following the visits they concluded that the trustwas not meeting the outcomes below:Outcome 07: safeguarding peoplewho use services from abuseThe CQC judged that the Limes was not meetingthis standard and that this has a moderate impacton service users using this service. CQC felt thatservice users using this service were not fullyprotected from risk of abuse because trust staffwere not always able to take reasonable steps toensure staff always responded appropriately toany allegation of abuse.The actions taken to address this issue were:• Immediate internal alert disseminated acrossthe trust to ensure all staff knew the process forhighlighting safeguarding concerns.• Focus groups were held to establish theunderlying cause of this concern.• Bespoke training was implemented withimmediate effect.• All incidents/ concerns discussed at service areaweekly meetings.• Policy reviewed, updated and staff consultationcompleted.Outcome 14: supporting workersCQC judged that people are supported bystaff who receive training to deliver care to anappropriate standard. However, staff themselvesdid not feel appropriately supported in relation totheir responsibilities, which they felt had an impacton the care people received, and could put peoplewho use the service at risk.The actions taken to address this issue were:• The development and implementation of astaff engagement programme, where feedbackis received from a wide selection of staff andcomments directly reported to the trust board.• The board agreed the implementation ofthe trustwide workforce and organisationaldevelopment strategy.• The whistleblowing policy was immediatelyreviewed, updated and reissued across the trust.These outcomes are due to be re-assessed byCQC in June 2013 to ensure full compliance hasbeen achieved.26 Annual Report 2012/201327