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.
Ruislip Residents' Association is a member of The Community Voice. At the meeting on 5th June 2014, Dr Shirlony Morgan, Consultant Psychiatrist, Central & North West London NHS Foundation Trust, deputised as guest speaker for Dr James Warner, who had been obliged to send his apologies. She was accompanied by Phil Bolland, Deputy Service Director Older People’s Services, CNWL. The title of her address to The Community Voice was “Dementia in the Community." Her main points are summarised below:
1. Dr Morgan started by affirming that it is possible to live well despite a diagnosis of dementia.
2. She then presented an overview of dementia, noting that it refers to disorders of cognition, including a decline in memory and orientation of time and space, as well as difficulties with planning, organisation, problem solving, and language. These symptoms are caused by loss of nerve cells due to disease, for which there may be more than 100 causes.
3. Dementia is very common and is experienced by 5% of those over 65 years and by 20% of people over 80 years. There are 812,000 cases in the UK, with several subtypes: Alzheimer's Disease - 62%, Vascular dementia - 18%, Mixed dementia – 10%, Dementia with Lewy Bodies - 5%, Other dementia including fronto-temporal dementia - 5%
4. Alzhiemers disease has an insidious onset followed by progressive decline in cognition, which begins with short term memory problems and difficulty with language, recognition, and daily tasks. The brain changes, suffering atrophy and the development of plaques and tangles.
5. Vascular dementia has a variety of causes, an abrupt onset and stepwise deterioration, with a fluctuating course. Deficits may be patchy, with better insight, but more emotional symptoms.
6. Dementia with Lewy Bodies usually involves memory loss, problems with attention span, and Parkinsonian symptoms such as tremor, slowness, muscle stiffness, also visual hallucinations, fainting fits and “funny turns”.
7. Fronto-temporal dementia may start younger, with memory intact but with personality and behaviour changes, early loss of insight, loss of the capacity to empathise, and communication difficulties.
8. Some dementias can be treated, particularly those due to vitamin B1 or B12 deficiency, infections such as syphilis, endocrine abnormalities e.g. hypothyroidism, brain tumours e.g. meningiomas, normal pressure hydrocephalus, and injury with subdural haematoma (collection of blood).
9. The national agenda is led by NICE. There have been various national initiatives - Supporting people with dementia and their carers in health and social care (2006); National dementia strategy (2009); National Dementia Declaration (2010) and the Dementia Action Alliance: Prime Minister's Challenge (2012); NICE quality standards – supporting people to live well with dementia (2013).
10. Dementia care in the community occurs in many settings, based on person centred care, targeted prevention programmes, early diagnosis and early treatment. Shared care practice involves supporting carers, supporting patient autonomy and independence, and managing crises. The cost of dementia care is very great, largely provided by families and friends. Two thirds of dementia sufferers live in their own homes and one third live alone, which brings the risk of isolation or abuse. Two thirds of people in care homes have dementia. Memory assessment services are increasingly community based and in some areas are moving more into primary care settings.
11. The NICE aim is for people to manage their own support as much as they wish, so that they are in control of what, how and when support is delivered to match their needs.
12. To prevent dementia, some risk factors can be controlled - high blood pressure, high cholesterol (hypercholesterolemia), diabetes, smoking, heavy alcohol use, physical inactivity. Other protective factors include educational attainment, improved workplace health in mid-life, supportive social interactions and lifelong learning and stimulation in later life, as well as care from services, carers and families. Action to tackle the social, economic, and environmental factors is important too.
13. Currently only 44% of dementia sufferers are diagnosed but diagnosis is important for patients, their families and carers, because it facilitates better understanding, improves access to medication, information and support, and allows better planning for future care. NHS England has prioritised dementia and aims to increase diagnosis to 60% of sufferers.
14. Basic dementia screening is completed in primary care with routine haematology, biochemistry tests (electrolytes, calcium, glucose, renal and liver function), thyroid function tests, serum vitamin B12 and folate level tests. Early referral to memory services is helpful. There are newly commissioned services in Hillingdon and Harrow. Medication is initiated by a specialist but most people then no longer require specialist input, so they are discharged back to primary care for community support.
15. In UK there are 670,000 carers of people with dementia. Families provide the majority of care, which is tiring and stressful, physically, emotionally and financially. This saves the UK over £8 billion a year. Carers should have early access to community based assessments, information and support groups and access to respite care to reduces the carer’s burden and distress.
16. Decisions must be taken about dementia patients continuing to drive, about arranging Power of Attorney and advanced directives to invoke later if needed, and about end of life care.
Dr Morgan answered questions, assisted by Phil Bolland. Some audience concerns related to crisis support by CNWL but other concerns related to Social Services’ issues.
The speakers were thanked by Neville Hughes, who also praised the excellent CNWL carers’ course, from which he had benefitted, but then noted his long campaign to combat the lack of Admiral nurses in Harrow. His thanks to the speakers were endorsed by audience applause as the speakers left the hall.
Note: The notes below are not a summary of the Board meeting but comprise items of particular interest to Harrow and Hillingdon residents.
Care Quality Commission compliance problems: Draft warning notices had been received in respect of the Campbell Centre in Milton Keynes and Beatrice Place and St Charles in Kensington. Major action plans are already in place. These issues led to extensive discussion and obvious concern by the Board.
Complaints: During Quarter 3 in 2013-14 there were 132 formal complaints, which represents a 20% reduction compared with the previous Quarter. 16% of these complaints were fully upheld, and 25% were partially upheld. Details were available according to service lines, by subjects and by CCGs. In Q3 there were 15 complaints in Harrow and 9 in Hillingdon, in neither case with any obvious themes or trends.
2013 Annual Staff Survey: Results are slightly better than last year and in the top 20% of Trusts for 11 of the key findings and no scores in the bottom 20%. Action plans are being developed to address those areas where there is room for improvement.
Infection Control: Zero tolerance of Health Care Acquired Infection is a key aspect of Government and Public Health England’s quality outcomes strategy. In the Quarter from 1st October to 31st December 2013 the Trust had no cases of MRSA bacteraemia or toxin producing clostridium difficile infection.
Community Health Patient Survey Report 2013: The survey findings demonstrate that service users are very satisfied with CNWL Community Health Services in Hillingdon, Camden and Milton Keynes with 86% of respondents rating their care as good or excellent. 88% of Hillingdon respondents rated services as good or excellent, which is a slight decrease form the 2012 survey results which achieved 94% in those categories. In Hillingdon this result came from 806 completed questionnaires, a response rate of 28%.
Finance: A small profit is predicted at end of year.
Restructuring: Given the current commissioning arrangements with CCGs mirroring borough boundaries and Local Authorities playing an increasingly important role in planning and commissioning healthcare the Trust is setting up three divisions with a borough focus.
- Division A: Brent, Harrow Kensington & Chelsea, Westminster and Learning Disabilities London-wide
- Division B: Hillingdon, Camden, Children, CAMHS (Child and Adolescent Mental Health Services), Older people and healthy ageing.
- Milton Keynes, Offender care, Sexual health, Addictions, Eating disorders
Each division will be headed by a Divisional Director. Charlie MacNally will head Division A, including Learning Disability services. Marie O’Brien will be in charge of Division B and its associated services.
Key challenges over the next two years:
Driving quality and Innovation in a challenging environment
The affordability challenge
Working within the changing commissioning environment
Effective information and community technology
Demographic change – growth in the population and increased deprivation
NB Highlights only – not a summary
New Chairman: Professor Dorothy Griffiths chaired her first CNWL Board Meeting in public.
Failure to achieve the planned savings: The Chief Executive, Claire Murdoch, noted that only 50% of the planned savings in the Cost Improvement Programme had been achieved and that the need to cut costs is now urgent. A Challenge Board has been set up to address this need, which meets weekly.
Care Quality Commission compliance problems: The Board was much concerned that the CQC has identified non compliance at three of the Trust’s sites – the Campbell Centre, Beatrice Place and St Charles - and has formally indicated that it will issue enforcement notices in respect of three standards at each location. The Trust acknowledges that further improvements are needed but believes that the serving of enforcement notices is precipitous. When received the Trust will have ten days in which to scrutinise the notices for accuracy and to respond.formally. The Board is concerned about the reputational damage that the issuing of such notices could cause. All other CNWL sites are being checked to ensure that they meet CQC requirements.
None of these sites is in the area covered by the Community Voice. The Campbell Centre is in Milton Keynes and faced major problems prior to it becoming the responsibility of CNWL, leading to it being placed in a special measures programme, which CNWL is trying to rectify, but the CQC re-inspected before completion of the Trust’s action plans. Beatrice Place is a Child and Family Centre in Kensington; it is subject to an accelerated improvement programme, but here too the CQC re-inspected before action plans were completed. St Charles Hospital is also in Kensington.
Complaints: Of complaints received in October 2013 only 51% received a response within 25 working days which the Chief Executive, Claire Murdoch, noted need to be improved - the range was 9% to 100%.
Physical restraint of patients: The higher national profile currently given to the use of restraint in mental health services has led to the recent publication of a consultation document by the Department of Health. As a result of this ongoing national consultation concerning the minimisation of and alternatives to restrictive practices in health and adult social care, CNWL is reviewing its own procedures.
Response to the Francis Report: The Trust is introducing a list of actions subsequent to the Francis Report, including additional training for front line staff, directors and governors, and further work on ward staffing levels.
Emergency readmissions: Work to support discharge from hospital and to prevent readmission is taking place. There are ongoing issues in Harrow about patients with personality disorders, which continues to be one of the main reasons for readmissions. Some Hillingdon patients cause similar problems.
Patients who do not attend: Reminder text messaging is underway, but some patients appear not to understand the impact of non-attendance. Analysis of reasons for non-attendance is being used to address the problem and to seek improvements.
CNWL provides mental health services for a wide area of London and southern Counties and also provides community health services for Camden, Hillingdon and Milton Keynes. This report covers only references that are clearly related to our own area of North West London - it is not a summary of the meeting.
Dame Ruth Runciman chaired her last CNWL Board Meeting in public.
Reduction in medication errors:
This is regarded as a priority issue. Within staff induction in Hillingdon Community Services, there is awareness training with respect to insulin and heparin administration. All relevant staff receive medicine management training.
Quarterly reporting identifies trends in causes, which has led to changes in district nursing care documentation. In Hillingdon there was a reduction of 11% in recorded pressure ulcers in 2012/13 compared to the previous year.
Hillingdon Community Health activity and complaints:
The Home Treatment Team for drug and alcohol misuse experienced high volumes of activity in September. There were no particular themes in the seven complaints received in Quarter 2, nor in the 29 PALS queries over that period.
Looked After Children in Hillingdon (LAC):
Once in care, LAC is four times more likely than their peers to have a mental health, emotional, or behavioural problem, engage in substance misuse, and to become a teenage parent. The profile of such children in Hillingdon reflects the national picture.
On 4th January 2013, 361 children were looked after by the London Borough of Hillingdon, which is down from the corresponding 420 in 2010. Over the past few years the numbers of children seeking asylum have fallen due to more stringent immigration measures to ensure only genuine unaccompanied children seeking asylum are allowed to enter the country. However many of those now accepted have a more complex and challenging history prior to arrival. The children come from 23 countries of origin, many coming from countries of conflict where health needs are unlikely to be met. It is therefore a challenge to identify their health needs and to provide adequate interpreting services.
This is a women’s prison. CNWL provides primary care, substance misuse and mental health care for the prisoners.
Emergency care is provided on the day, urgent care within two days and routine care within five working days from referral. To achieve this, the team works with other custodial and community health care professionals, probations officers and case managers.
A questionnaire in May 2013 was distributed to 70 prisoners to assess their knowledge and experience of the services provided, with 40% responding. The Service User Survey Report will be repeated in summer 2014, but surveys will be handed out to users discharged throughout the year.
This report covers only highlights of the meeting, it is not a summary.
New Chairman: Dame Ruth Runciman is retiring as Chairman. Professor Dorothy Griffiths, currently a Non-Executive Director, will become chairman on 1st January 2014.
Presentation on Organisational Learning: It was noted that the number of formal complaints relating to Hillingdon services had increased slightly from 25 in 2011/12 to 28 in 2012/13. Poor communication appeared a causal factor. Particularly with regard to poor patient hospital discharge.
Hillingdon Community Health incidents: 301 incidents were reported in Q1 2013/14, a decrease compared with 419 in the same period last year. The incidents included 84 pressure ulcers, 33 medication problems, 28 accidents, 25 patient care incidents and 22 communication difficulties.
Of the eight grades 3 and 4 pressure ulcers, two incidents were deemed avoidable.
There are three insulin prescriptions with similar names and several incidents where GPs prescribed the wrong type
Finance: There is still a shortfall on cost improvement plans that the Trust expects to remedy but overall the Trust is slightly ahead of plan.
Chief Executive’s Report: It was noted that Hillingdon Council has declined to participate in the NW London integrated care pilot, but that Hillingdon has established a Hillingdon Integration Group to focus locally on integration of health and social care. However, CNWL has not been included in the work group established for implementation of that purpose. It was also noted that:
- 72,000 Hillingdon residents were supported with their physical healthcare by CNWL;
- 117,000 visits were made to people by district nurses;
- 94,000 health visiting contacts;
- 81% of people at the end of life were helped by CNWL teams to die in their place of choice.
- 4,000 admissions were prevented by CNWL’s Rapid Response Team
- 87.2% of teenage girls were vaccinated for HPV by school nurses
- 10,000 individuals were supported with mental health and substance misuse needs
- 14,000 referrals were received for assessment
- 100% of service users with dementia on psychotic medicine had 3 monthly review
- 95% of people with their first presentation of psychosis were supported by CNWL’s Early Intervention Team
Hillingdon Diagnostic Review: This review of adult mental health services investigated the interface between three service lines and how patients are manage when in crisis, particularly bottlenecks for managing complex cases. The service lines were Assessment and Brief Treatment (ABT), Psychological Medicine (A&E Liaison) and Acute Services (Home Treatment Team). Issues were highlighted and addressed, with agreement that there should be a single point of access, a triage function and ideally extended hours for the ABT team from 8am -8pm.
Hillingdon Wellbeing Centre: Following a review of the centre and its activities the centre was closed. It never fulfilled the original vision, despite trying to attract members of the public without success. The cost became unsustainable and was not considered good use of resources. The closure was discussed with partner organisations before implementation. There have been no complaints about the closure.
Control and Restraint – MIND Report: The June 2013 MIND report on restraint in mental health facilities in England is to be reviewed by a sub group of CNWL Governors, who will report to the Governing Body in December.
This report is based on the Board papers and a report from Martin Plummer who attended the meeting.
Chief Executive’s report: For the second meeting in succession this report was scheduled within Part II of the meeting. There was no CEO overview in public
Other items taken within Part II more usually taken in Part I:
- Serious Incidents Report
- Patient survey action plan / Investment Committee report / Informatics Committee report / Audit Committee including Annual Report
- The Carers Council: This identifies carers, the support carers need, and staff training with respect to carers. Representatives include Harrow Young Carers and Hillingdon Rethink.
- The Think Family Project: This has ten work streams to focus staff attention on the needs of families of patients
- The Carers Research Project: This study, in Brent, will focus on 12 carers, users and staff, working in collaboration with Lancaster University.
- Key 2013-14 carer developments: These include the Triangle of Care Assessment, Good Practice Guide for Sharing Information and the Carers Film Project.
CNWL Urgent Advice Line:
This crisis line operates from St Charles Hospital Mental Health Unit, 5pm – 8am Monday to Friday and 24 hours at weekends and Bank Holidays. From launch on 25th February to 14th April there were 725 calls from the six London Boroughs covered, highest usage was from Hillingdon, 27%, with lowest from Brent, 12%. Brent previously had a similar service and is the only Borough with a 24 hour Home Treatment Team, which may account for the low usage. All these calls were entered on the JADE patient database. The philosophy is to resolve callers’ problems without increasing the workload for other CNWL services. Most callers received advice or the patient’s care co-ordinator was informed – only 50 of the 725 calls were referred to other health personnel, including those who were told to call an ambulance or to go to A&E. There were also 43 anonymous calls, including one woman who calls most nights and sometimes makes several calls!
Acquisition of the in-patient services at the Cambell Centre in Milton Keynes:
Formal acquisition was in April 2013, making CNWL “the largest community facing Trust in England”, caring for people with a wide range of physical and mental health needs, with a total income of £420m and 7,000 staff providing healthcare to a third of London’s population and across wide geographical areas including Kent, Surrey and Hampshire. Previously the CQC found the Campbell Centre non-compliant with eight assessed standards – it is therefore now on the Special Measures Programme. A number of senior CNWL staff are now involved in dealing with this problem.
Annual Plan 2013-16
There are three challenges:
- Finding ongoing savings
- Retaining and developing a workforce for the future
- Developing information systems to meet current and future needs
The geographical area covered by CNWL is exceptionally diverse with areas of both great deprivation and affluence. There is a 16 year mortality gap across the London boroughs in the average age at death between those two extremes. An increase in older adults is expected across London in the years ahead, leading to development priorities for services for dementia, for people with long term conditions and for integration of physical and mental health services.
The Trust’s current estate comprises 113 buildings on 88 separate sites. During 2012-13 Hillingdon PCT and Camden PCT transferred freehold ownership or leases of 20 properties to CNWL including Kirk House, various health centres eg Eastcote, Harefield, Ickenham, Northwood, Yiewsley and other facilities eg Pembroke Centre, Laurel Lodge, as well as Mount Vernon in-patient Cawthorne Ward,
Quality and performance:
CNWL continues to achieve all Monitor’s targets, with a financial risk rating for 2012-13 scored as 4.15. Its Northwick Park redevelopment project cost £1.2m and various project work in Hillingdon cost £1.5m
Patient led assessment of the care environment (PLACE), early in 2012, rated both Northwick Park Mental Health Centre and Northwood and Pinner Community Unit at Mount Vernon as excellent for all three standards - environment, food, and privacy and dignity. Hillingdon Hospital Mental Health Unit was rated good for environment and food, and excellent for privacy and dignity.
The notes below are points of particular interest – they are not a summary of the meetingThe Francis Report: The Board consensus was that CNWL procedures are sufficient to protect the Trust from the risks identified in this report.
September 2012 Hillingdon Community Health Patient Experience Survey: This survey covered patients using both general health services in Hillingdon and mental health services. There were 670 responses, a response rate of 30.2%, of whom 60% were female, 65% White British and 66% aged over 51 years. Responses were very positive, with 94% rating their experience as good or excellent.
Quarterly report on complaints: There were 85 complaints, 9 referred to the ombudsman and 384 PALS queries. The majority related to care and treatment, staff attitude, communication and appointments. A few examples were provided, showing outcomes. Nine legal claims were noted, each with brief details – 8 related to Mental Health and Allied services (3 assaults on staff, 3 for unlawful detention, 2 for injury during restraint). There was also one claim against Community Services for injury caused by catching a falling patient – this claim is being reviewed.
The JADE patient records computer system: Some problems were noted which are still being addressed. The delay in getting this system in place continues to cause concern.
Performance: All Monitor targets are being met but Hillingdon had some problems with delayed transfers of care and 7 day follow-up after discharge.
Draft Annual Plan: This is being finalised for presentation to the May Board meeting
Finance: The Trust was in line with its in-year predictions and it expects to achieve its planned end-of-year targets. Two Hillingdon debts were more than 90 days overdue - £129k of disputed continuing care funding from Hillingdon Council, and £102k from Hillingdon PCT.
Draft budget: This was approved - it does not include any elements relating to the transfer of Milton Keynes Services to CNWL. It was disappointing that noting that omission was the only reference to CNWL becoming newly responsible for community health services in Milton Keynes - which is an interesting development.
National Safety Thermometer: The Trust has not achieved this target due to confusion over this metric, as was the case amongst most other Trusts in London (including The Hillingdon Hospitals Trust which was particularly cited in the Health Service Journal – to that Trust’s consternation).
New crisis telephone line for out of hours use: A new out-of hours urgent advice line was launched on 25th February – Tel: 0800 0234 650. – together with new crisis cards. Old crisis cards should be destroyed.
It appears that all 13 London Boroughs for which CNWL provides services have been given the same crisis telephone number, which has only one line, but if that line is engaged a call will be diverted to an answer-phone for someone to ‘phone back within an hour.
Millhouse, Uxbridge: This CNWL adult centre has no out-of-hours ‘phone message for anyone who ‘phones after 5pm – this problem was reported to a CNWL official after the Board meeting.