During 2011 Central & North West London Foundation Trust moved its headquarters from Mornington Crescent to a building near Warren Street Underground Station. This serves as the hub from which over 3,000 staff are controlled. Originally the Trust provided only mental health services but it did so for a large swathe of North West and Central London, including Hillingdon and Harrow. It provides inpatient services on the Hillingdon Hospital site. In 2010 it branched out into provision of community health services. responding to the NHS requirement that Primary Care Trusts must no longer both commission and provide services. Hillingdon Community Health amalgamated with CNWL in early 2011 and subsequently CNWL also became responsible for community health services in Camden.
This page will contain items related to CNWL Board meetings and mental health services. Items related to Hillingdon's NHS community services will be shown on our Community Health Services page.
Care Quality Commission Inspection: The draft CQC inspection report had been received, and some improvements had been asked for. The report is expected to be published on 18 June.
Urgent Care: A £1.9m Business Case has been prepared to provide crisis care in the community. This is seen as the key to improved in-patient care too.
Performance: In February the Trust had over 100% use of its inpatient beds and this combined with a slow-down of discharge rates caused difficulties. It is working on all internal and external links to address these problems, including redesign of community services and review of acute care pathways. Seven day working of all services is needed.
Previous reports highlighted concern about Hillingdon Mental Health, which has recently improved.
Rates of NHS pay: The Board is concerned about the large differences between NHS rates of pay and the charges for agency staff.
Finance: The Trust ended 2014-15 with a deficit of £2.35m, compared to a planned surplus of £5.7m, caused largely by non-achievement of savings and high levels of agency use. It achieved £17m in savings, 52% of its initial target. Its Continuity of Service rating remains 3.
For 2015-16 the Trust is negotiating with 23 Local Authorities. It has submitted to Monitor a planned surplus of £0.7m, based on the sale of two properties, which hides an underlying gap of around £8m. The Trust’s cash problems are being managed on a week by week basis. Monitor now requires the Trust to provide finance details on a monthly basis, reflecting the Trust’s poor financial position.
Contracts with North West London for 2015-16: Contracts have been agreed for community services, but not for mental health services. CNWL must make savings of £10.2m during the period and has three options:
a) Accept the contracts offered (which allow the required savings) but providing only the contracted services
b) Negotiate improved financial offers to permit additional services to be provided
c) Negotiate changes in services, taking into account the CQC Report when it is published. Decisions are expected by the second week in June, or there could be arbitration.
Recruitment: The Trust recruits newly qualified staff emerging from training in September and February, but it is concerned that some qualified staff are unemployable due to lack of numeracy and literacy. A meeting is to take place with College Deans and Peter Carter, Royal College of Nursing, to discuss both quality and quantity of training. The Trust believes that numeracy and literacy should be fully addressed during basic training.
The report below is an amalgam of notes provided by representatives observing the meeting and items in the Board Papers..
Care Quality Commission Inspection:
Last week there were 120 inspectors within the Trust. This inspection will continue until the end of May 2015, with the Final Report expected in June. To date the inspection has gone well with praise for the CNWL Community Services, Mental Health Services and Hillingdon’s Colham Green Rehabilitation Centre. There have been concerns about bed pressures and some safety issues such as restraint.
In the annual NHS Staff Survey 2014 the CNWL findings were generally positive with some real improvements year on year in key areas. CNWL was rated by staff as 8th out of 54 trusts as a good employer and best in London’s mental health trusts. There has been an improvement in morale in CNWL’s Hillingdon staff.
In the Friends and Family test 63% of staff would be happy for their own families to receive the standard of care provided by CNWL, in contrast to the national average of 60%, and 56% would recommend the organisation as a place to work (national average 54%).
Hillingdon Mental Health Services showed a downward trend with too few new cases and some cross border issues, but there has been an improvement in delayed transfers of care from local Older Adults wards from 24.7% to 5.2%, although this still remains above the target of 7.5%. Work is taking place with Social Services to improve the discharge process. There were also two failures to meet the threshold for inpatient diagnosis, which caused concerns. Hillingdon Mental Health services were noted as needing to improve.
Good performance is evident in Harrow Adults’ Services. Both CNWL’s Harrow services and its Hillingdon Community Health services met all their targets.
However, both Hillingdon Mental Health and Hillingdon Community services had high staff sickness rates in January, both above 4%, and Hillingdon was one of the areas with a higher than average proportion of complaints, 2.3 per 1000 patients.
The Trust’s Business Plan is to be published in April 2015. The year end forecast is a deficit of £1.1m, which is £3.3m behind the recovery plan and £6.8m behind original plan.
Monitor’s Continuity of Services rating remains at 3.
The Trust expects to achieve £17.2m savings in 2014-15 against a target of £32.7m . There remains a significant gap in identified savings for next year
Notes below are simply items of particular interest – not a summary of the meeting.
Closure of Max Glatt Unit: This is a ward with 15 beds in the South Kensington and Chelsea Centre for Mental Health, for drug and alcohol treatment for patients with complex physical and mental health problems. Patients come from across North West London, including Harrow and Hillingdon, their care commissioned by their Borough Councils.
The Unit has been under public consultation since last September because it has run at a loss for the last two years and a loss of over £650k is forecast this year.
The Board reluctantly agreed that closure cannot be avoided, although the Unit is highly regarded for its skills and clinical effectiveness. There was concern that alternative provision for these patients does not exist and that they are likely to turn to local acute hospitals, which cannot meet their needs.
The Unit will close on 31st March 2015 unless contracts are then in place to keep it open.
The CEO stressed that there will be no redundancies and the Trust will retain the staff expertise in the hope of again providing the service at a later date.
Chief Executive’s Report: This verbal report noted that consultants brought in by North West London have found no clear link between the cost and quality of services provided by the Trust, noting the difference in input from different London Boroughs for similar services, quoting Hillingdon as paying much less than others.
The Chief Executive, Claire Murdoch, noted the need for a health and wellbeing five year strategy for mental health in North West London, including prevention as well as treatment.
She was hopeful that a sustainable strategy may emerge from work which has now started.
CQC Inspection: A full inspection of the Trust’s services starts on 23rd February. It was stressed that preparations for this inspection should focus on what is done for patients, rather than on impressing inspectors. Staff should be honest about shortcomings and problems but also unafraid to rejoice at what is done well.
Finance: the Trust recorded a deficit of £4.8m for the first eight months of the year. Its best forecast for year end is a surplus of £2. 4m, which is £3.3m behind plan.
Monitor’s Continuity of Service rating is 3.
The Trust expects to generate £17.3m savings in 2014-15 against a target of £32.7m.
- Child and Adolescent Mental Health Services (CAMHs) Out of Hours Services: The current out of Hour’s services to support young people with mental health problems is acknowledged as very limited. A pilot approach to implementation of agreed improvements is planned for 2015/16 funded by the 8 NW London CCGs. Key changes include moving from telephone access to Adult Mental Health Services to a help line to a CAMHs specialist, which eventually should operate a full out of hours service 5pm – 9am seven days a week.
- North West London funding problems: CNWL has been providing services for which it has not been paid, which cannot continue. There are great differences in the funding provided by the five London Boroughs that CNWL serves - services available in Westminster are not available in Hillingdon, or are only partly available eg Hillingdon provides £14 per day for the care of psychosis patients but Westminster provides £34. Radical transformation is unavoidable for 2016-17 and the Trust is seeking external help to develop a five year NW London Mental Health and Wellbeing strategy, but the next 18 months pose immediate issues which must be resolved.
- Closure of Ealing Hospital’s Maternity, Gynaecology and Paediatric Departments: Ealing CCG will decide when these departments will close. A date in early 2015 is expected, dependent on surrounding hospitals being ready to receive Ealing patients.
Notes below are simply items of particular interest – not a summary of the meeting.
Increased provision of services in the home: As feedback from patients, a video was shown of a Hillingdon couple, both of whom would previously have been admitted to hospital, but who had avoided admission by receiving enhanced care at home. The husband had pneumonia and the wife had had a serious fall – conspicuously she had two very black eyes. They were both full of praise for the kindness and effective support they had received from Hillingdon Community Health, a branch of CNWL.
Chief Executive’s Report: The signing of this year’s North West London contract was not completed until the end of October, due to fundamental differences between the Trust and the Commissioners with respect to funding. It was jointly agreed to work with Carnall Farrar to review the partnership, including funding, activity, service outcomes and plans for urgent care and this has now been extended to include West London Mental Health Trust to enable a whole sector approach. The CEO, Claire Murdoch gave lengthy background details, noting:
- CNWL has been providing services for which it has not been paid, which cannot continue
- There are great differences in the funding provided by the five London Boroughs that CNWL serves
- Hillingdon provides £14 per day for the care of psychosis patients – Westminster provides £34
- Services available in Westminster are not available in Hillingdon, or are only partly available.
- Radical transformation is unavoidable for 2016-17 – but the next 18 months pose immediate issues.
- Clinical outcomes are important, but not the only issues. Access / waiting times must be considered.
- CNWL has tried to assist Comissioners – they have saved £22m by bringing back patients formerly cared for at a distance.
- Early findings of Carnall Farrar are already leading to dialogue with the Commissioners.
- The sector is hoping, in two or three months, to appoint an external organisation to support the development of a five year Mental Health and wellbeing strategy for North West London.
Divisional Restructure: The new locally focussed divisional structure will go live on 15th December. New Borough Directors have been appointed – Natalie Fox for Brent, Tanya Paxton for Harrow and Kim Cox for Hillingdon. A management saving of £1.27m is expected.
Finance: The Trust has recorded a deficit of £3.5m for the first six months of the year and its year end forecast is a deficit of £2.5m, which is £8.3m behind plan.
Friends and Family Test: Of the 2947 patients who responded, 94% reported that they would be likely or extremely likely to recommend CNWL services. Of the 523 staff who responded 70% said they would recommend CNWL to their family and friends. These results are similar to the previous Quarter.
Monitor targets: In September the Trust maintained compliance with all required standards.
Delayed transfer of care of older adults in Harrow and Hillingdon: In August and into September there was underperformance due to difficulty in finding suitable placements as well as delays in arranging funding for placements.Waiting times for dementia diagnosis: This issue was not raised at the Board Meeting but questions were put informally to Robyn Doran, Chief Operating Officer, based on a BBC television programme on 13th October which quoted that Harrow and Hillingdon were the worst Boroughs in London for long waits for dementia diagnosis. .She provided the following information:
- The national average wait is 4/5 weeks
- The wait in Harrow is 14 weeks
- The wait in Hillingdon is 7 weeks
Notes below are simply items of particular interest – not a summary of the meeting.
- Communication and information sharing during handover, discharge or transfers of care, internally and externally
- Risk assessment, risk management and mitigation through care planning
- Understanding and managing patient and family expectations
- Workforce and leadership, especially clinical leadership.
CQC’s special measures: All warning notices have been lifted from the Campbell Centre in Milton Keynes and from Beatrice Place in London.
Expected CQC inspection: As many as 150 inspectors are expected, probably early in 2015. The CQC has experienced difficulty in recruitment of so many inspectors. The Trust expects challenges in providing for the needs of so many people including providing transport to locations and to central points for the inspectors to confer. Providing access for the public to liaise with the CQC will also create challenges. The Trust is already preparing for the inspection but it faces many pressures including the national problems of recruitment, particularly at the matron and consultant levels, as well as pressures on beds and environmental issues. The Trust is liaising with other Trusts already inspected. to learn from their experiences.
Finance: At the end of July income was better than expected due to successful negotiations, but pay was overspent by £5m due to high levels of bank and agency usage. The year end forecast based on July data is a surplus of £5m, but that depends on bringing the position broadly back to plan.
Income from the North West London CCGs for mental health block contracts is better than plan with an additional £5m in the latest offer. However, the Outer London Boroughs’ psychiatric liaison services were in jeopardy, due to £1.7m unresolved risk, and the Trust cannot provide services without payment. Also a senior Director mentioned, outside the meeting, that Hillingdon CCG is proposing to withdraw £1m from CNWL’s Hillingdon community services plus £1m from its Hillingdon mental health services.
Quality and Performance: The Trust remains compliant with all Monitor indicator targets although underperformance is reported in some service areas; its Continuity of Service rating is 3. Falls were noted in Hillingdon and underperformance in Hillingdon Adults. Harrow Adult services have shown a gradual decline over the last few months, but are still within target. Both inpatient and community diagnosis failed to meet targets.
Friends and Family Test: The outcome of the Trust’s first test, based on 2793 responses, was that 95% of patients would be “extremely likely “ or “likely” to recommend CNWL services.
Pharmacy: CNWL employs the only mental health medicines management nurse and the only consultant pharmacist for mental health in England.
CNWL has very wide responsibilities:
- West Sussex addiction services: .CNWL operates this service from five sites, each an hour or more away from the others. Recruitment is difficult. Implementation of service improvements is proving hard.
- Buckinghamshire dental services: Over a hundred staff provide these services for patients with complex needs e.g. those with dementia, learning difficulties . CQC feedback is very positive and the service is reported to be very well led.
- Possible move to Central Middlesex site: Price Waterhouse Cooper is progressing work for the business case for the possible move of the Trust’s Park Royal mental health services to this site.
Community Mental Health Patient Survey Report: The outcome of this postal paper survey late in 2013 was much better than last year, but Hillingdon was one of its three areas with significantly poorer than average results. The Trust does not yet have full data for Hillingdon but it is already addressing the issues raised and subsequent local Hillingdon surveys have been more positive.
Child and adolescent mental health Tier 4 bed pressures: The Chief Executive, Claire Murdoch, has raised concerns by writing to NHS England about the shortcoming of provisions for young people with very complex mental health needs There is national agreement that 40-50 more beds are required to meet the need, but the Tier 4 tariff does not meet the cost of providing the necessary service.
Proposed closure of the Max Glatt Unit: With much regret the Trust is preparing a public consultation on the future of this unit with the Local Authorities who commission it and other stakeholders. This inpatient unit provides 18 beds for people with medically complex addictions. It costs more to run than its contract value and has lost £600,000 per year for the last two years. Its proposed closure is expected to meet with high levels of protest.
CQC’s special measures: The Campbell Centre in Milton Keynes remains subject to a special measures programme. St Charles is making progress with its action plan. However, the Trust has been told that the enforcement notices on Beatrice Place will be lifted, but the final report has not yet arrived.
Complaints: The Board received its Annual Report on complaints. In 2013-14 it received 538 formal complaints and PALS resolved 1,153 issues for patients and their families. The Trust also received 5.843 compliments and expressions of appreciation or recommendation. Communication problems and staff attitudes were components of many adverse reports.
Clinical safety incidents: In the last financial year there were 15,267 reports of clinical safety incidents. Incident reporting has increased by 9.75% in the year, due to acquisition of services at Milton Keynes and the inclusion of incident reporting from Offender Care and small but real increases from London CNWL services attributable to staff training. Hillingdon Community Services is the only area in which incident reporting has fallen.
Mental Capacity Act Report: The Trust received a report on this 2005 Act which came into force in 2007 and provides a statutory framework for assessing whether a person has mental capacity to make certain decisions and how to make decision on behalf of people who lack capacity. The scope of the Act covers healthcare, social care and financial affairs. It has five principles, forming a set of rights for people whose mental capacity is in doubt:
- Presumption of capacity
- Support with decision making
- People are entitled to make decisions that others may think are unwise
- Best interests decisions for those lacking capacity
- Least restrictive alternative
Infection Control Annual Report: With 300 services from 100 locations, CNWL has received CQC inspections on 12 sites, none of which had any issues concerning cleanliness and infection control. There have been no MRSA, MSSA or E.coli bacteremias within CNWL services. Two outbreaks clinically indicative of norovirus infection arose in inpatient units, causing wards to be closed for the duration of the outbreaks.
Finance: At the end of May the Trust was £1m behind plan. Its income was higher than expected due to overperformance but this did not offset the cost of high levels of bank and agency staff. The year end forecast at Month 2 was a surplus of £4.6m, £1.1m behind plan.
Hillingdon funding for mental health: A question to the Board confirmed that Hillingdon continues to be one of the lowest funded areas in the country for mental health services, but it was acknowledged that Hillingdon health economy has continuing financial problems.
This meeting was attended by Joan Davis and Martin Plummer. Notes below are simply items of particular interest – not a summary of the meeting. The Board papers ran to 449 pages!
Reporting of serious incidents: In response to a request from JD at the last meeting this issue will now be included in Part I of Board Meetings – but confidential factors will continue to be items for Part II. In Quarter 4 there were seven serious incidents, making a total of 36 in 2013-14, a marked reduction in comparison with the previous year. The largest single area of concern in Q4 related to documentation. Three problems related to communication. Clinical risk assessment and management had many identified issues.
All level 5 incidents are subject to root cause analysis. In Q4 six such incidents related to unexpected death / suspected suicides and one concerned a former patient charged with murder.
Workforce: The Trust has 6382 employees. 35% are over 50 years old plus 30% 40 – 49 years. Much discussion about recruitment and training. Healthcare assistants are to be an agenda item at next meeting. Over 80% of staff in Hillingdon Adult services and Rehabilitation work extra hours.
Response to CQC concerns: There has been much staff training and review of procedures at Milton Keynes and St Charles, London to meet CQC concerns. It was noted that some concerns related to factors that CNWL is not commissioned to provide. Measurable improvements have been made.
Safeguarding adults: In response to CQC concerns a large number of policy issues have been raised. It was agreed that the top priorities must be identified for the next meeting, as a focus for action and training. In Hillingdon the Local Authority has not devolved its responsibility to CNWL, but manages safeguarding issues with its own team. In Harrow, CNWL has greater responsibility for this issue.
Mental Capacity Act 2007: The House of Lords Select Committee recently released its report on application of this Act. Training is in progress accordingly, to ensure that patients are deemed to have capacity to decide contentious issues - such as accepting treatment, or taking medicine – except when they clearly do not have that capacity. Interventions should be minimal to ensure safety of the patient, other patients and staff.
Finance: Six weeks into the new year and finances have fallen behind plan, to the consternation of the Board. An inquiry is to be undertaken on causes and remedies.
User involvement: This issue arose across the agenda, with emphasis that users’ views and feedback must be taken into account in all issues. Two users spoke about their experiences at the start of the meeting, one with a focus on the benefits that finding employment brings to patients, and the other with a focus on carers’ issues.
Proposal to move CNWL services from Park Royal to Central Middlesex: The latter has better facilities – hence the proposal. CNWL is exploring this possibility with commissioners.
Management of allergic conditions in Hillingdon Schools: This is a School Nursing Service. Medication must be kept in an unlocked cupboard to ensure anaphylaxis treatment can be received immediately, without having to find a key.
Mind in Harrow survey findings of the Harrow User Group Review:
- From 83 responses, 65% reported that their expectations for help from mental health services were hardly, partly or not met by their care plans
- From 81 responses 66% thought their social care needs were partly, hardly or not covered in their care plans
- From 105 responses, 58% responded that their treatment and discharge plans were partly, hardly or not discussed at all with them
- From 84 responses, 32% have never received a care plan