We are working hard to raise standards and improve the quality of care we provide.

Across the trust we have clear quality improvement plans to help us track our progress and to make sure we are putting our resources into the right places.

We are working with the Institute of Health Improvement – world leaders in quality improvement methodology – who are helping us to equip our staff with the skills necessary to make meaningful and lasting changes that will help us to become an excellent provider of health services.


Service line updates

Access and urgent care

The new single point of access (SPA) launched on 4 April 2016. At the end of the 4th week we received a total of 2,990 calls to the SPA and 764 referrals. The service was featured on Sky News on 17 May 2016.

To date over 85% of inpatient ward staff have been trained in the safe administration of rapid tranquilisation and the national early warning score (NEWS) for recognising and treating acute illness. The new safe management of medicines policy has been distributed to all staff and its implementation will be audited every three months.

Two thirds of the audits of physical health care documentation have been undertaken and the remainder are due at this time.

Primary and planned care

The work to redevelop the planned and primary care service line has progressed significantly and as the new model of expanded primary care services comes on stream and with the new SPA and CATT teams working effectively, areas of concern such as high caseloads in community-based recovery teams will further reduce.

Managers and staff have greatly improved performance with respect to reducing caseloads and ensuring service users have a named professional.

The launch of a workload capacity tool with senior nurse practitioners and team managers has helped and also now caseload details of allocated staff/named professionals are circulated each month and where issues arise these are promptly addressed.

We have redesigned services delivered by our community recovery teams to increase the quality of care. These pathways are now being refined in discussions with teams and will be embedded in practice by January 2017.

We have supported the development of an enhanced primary mental health service across the three boroughs so that more people with stable mental illness may be supported by their GP and the enhanced primary mental health service in the community rather than by specialist mental health services.

The evidence so far is that service users benefit from discharge into the community, their feedback is positive, and physical and mental health care is more integrated as a result of GP involvement. Already, we have discharged 1,500 service users back into primary care.

The refurbishment of Avenue House has been completed. Final work on alarms at Claybrook centre and Avenue House are to be completed.

Work in Mott House also completed.

Cherington House has been confirmed as the future base for Ealing EIS. The plan is for the team to move in by the end of June 2016.

Recovery Team staff in Ealing have received older persons training and feel more confident in working with this age group. Dates are in place for staff in H&F and Hounslow.

We are assured that there is negligible impact to the patients on Glyn ward as a result of patients from the acute wards sleeping over.

Opportunities for staff training on MCA and DOLs have been increased as a result of the introduction of an e-learning module.

Staff are being supervised more regularly and increasingly this involves the scrutiny of documentation using a structured audit tool.

Junior Doctors (CT1-3 trainees) in Hammersmith and Fulham have had their jobs reviewed so that there will be better supervision arrangements and they will work full time in one clinical team, rather than being split across inpatient and community teams.

The lone worker policy has been reviewed and redrafted and he amended policy will presented to the Team Manager group at the end of May.

Recruitment – processes continue to be employed on a 6 week rolling programme. Interviews for Band 6 CPN are due in May. Service line has agreement to adapt skill mix in one of the Recovery Teams as a pilot to explore opportunities to reduce reliance on Band 6 Nursing Posts. There’s been a slight reduction in Band 6 vacancies from 14 to 10

Liaison and long term conditions

Liaison and long term conditions service line were not inspected as part of the core standards. However, the service line is ensuring that trust wide quality improvements are being delivered in its services and implementing lessons learned.

Gender Identity Clinic CQC inspection report – we have received the draft GIC inspection report and note that many areas of good practice were identified. The report has been checked for accuracy by the service and is currently with the CQC for final amendments. The publication date is not yet confirmed. Clinical and operational managers are taking forward the actions to make improvement where necessary.

CAMHS and developmental services

We are piloting a nurse-led, out of hours liaison service for our CAMHS. This service provides specialist CAMHS nursing advice, psychiatric assessment, risk management and intervention where there is an urgent and immediate concern.

The service can be reached on 0300 1234 244, and will operate on Monday – Friday from 4.30pm – midnight, and 9.00am – midnight at weekends and bank holidays.

Staff have been trained in the Mental Capacity Act specifically in relation to CAMHS services to ensure better quality care for young people.

Staff have been involved in the restructuring of services and how this will improve patient services and guidance has been developed that specifically addresses staff workloads including supervision.

We launched a specialist service for children and young people with eating disorders in April, with a single point of access for referrers as well as young people who have concerns about themselves. This new service will improve access and waiting times as urgent referrals will be seen within a week and routine referrals within four weeks.

A dedicated Clozapine clinic for young people has been set up in Ealing with specific guidance for prescribing in children, protected clinic time for young people and child-friendly leaflets produced.

The CAMHS environments have been reviewed for soundproofing and appropriate operational systems to call for assistance and these are in order.

Specialist training for all clinicians in the Mental Capacity Act and Deprivation of Liberty standards has been organised and is being delivered.

Cognitive impairment and dementia

Progress includes:

  • recruitment of Band 6 nursing staff which will facilitate caseload reduction
  • consultant psychiatrist recruited
  • a revised patient information leaflet, easy-read name badges and an information video
  • introduction of the dementia link worker role as the point of contact for all patient and carer queries which is having a positive effect on reducing the stress of knowing where to go for advice
  • advanced moving & handling training has increased staff confidence and capability in planning care for patients with mobility issues
  • MSNAP accreditation of 2 community teams has improved morale

Reducing restrictive practice

Work is also progressing in the Cognitive Impairment & Dementia Service (CIDS). Issues of concern are less focussed on the more prominent practices such as seclusion and rapid tranquillisation and more related to issues around locking doors, standardised routines (bed time, getting up time, meal times), covert medication etc. Training in and use of DOLS has helped but staff did not routinely recognise some areas of practice as restrictive and, therefore, report it as such. As a result, guidelines have been drafted and an audit of restrictive practices will be undertaken.

West London forensic services

A guide and training package was co-produced with patients and staff on recovery focussed care planning and its use is being regularly audited.

Ligature anchor point audits have been completed throughout the forensic services and training has been provided where needed such as in the Orchard


The HealthRoster report is operational and gives clear measures of KPIs on staffing levels, shift monitoring, sickness and absence rates. It is reviewed monthly.

Restrictive practice

Initiatives such as the SafeWards project which had been piloted and rolled out, as well as PMVA training, security liaison and practice development are taking place to reduce restrictive practice.

Brent ward is piloting use of an Exchange tool to record segregation; Lea and Berry wards are piloting reduction of specific blanket restrictions with a view to evaluating and rolling learning and better practice out to other wards.

Change is evident in staff attitude and understanding.

Medicines management

An updated high dose antipsychotic therapy (HDAT) procedure has been implemented and includes flagging patients prescribed HDAT by pharmacists and a monitoring form for each patient on HDAT to enable doctors and nurses to record results and highlight when monitoring is next due.

We have updated the rapid tranquilisation policy and included a flowchart outlining the medical and nursing responsibilities in relation to rapid tranquillisation (RT) including post RT monitoring. A sample of RT incidents is now reviewed every month to ensure documentation and monitoring has been completed.

We are in the process of implementing a new procedure for all inpatient wards on the safe management of medicines. It outlines requirements, responsibility and how management of medicines on wards will be monitored, i.e. through self-assessment, regular senior nursing and pharmacist checks and annual auditing.

Physical healthcare

A programme to ensure clinical staff are aware of new admissions and an assessment of physical health and care needs is made in 72 hours is being embedded with assessment results recorded on EMIS and RiO. CPA health assessment reports are recorded every six months and where necessary referrals are made to dieticians, nurses etc.

Patients are invited to multi-disciplinary team ward rounds and it is now recorded whether they can attend or not.

Ligature anchor points

We have developed a new ligature anchor point policy and have trained all of our ward managers and estates staff in the use of an updated ligature assessment tool, as we work to ensure the safety of patients in our services.

By the end of May 2016, all of our in-patient areas will have gone through a thorough ligature assessment and as mentioned already the first phase of a ligature removal programme has been completed this year.

Therapeutic engagement

Policy 01 Therapeutic Engagement and Supportive Observations has now been issued and is available on the Exchange. Staff are beginning to document using the language of the policy “TESO” for example as opposed to EEOs

The aim of the new therapeutic engagement and supportive observation policy is to actively engage with service users in a positive and compassionate way. By developing a caring and supportive rapport with service users, staff create a meaningful two-way relationship which is grounded in trust. This is important in assessing service users, encouraging them, and reducing risk.

The new policy addresses the following key practice issues:

  • Definitions of the types and levels of therapeutic engagement and supportive observations
  • Who can implement supportive observation above a general level
  • How supportive observation is implemented and recorded
  • Who should review the level of supportive observation
  • Who can increase or decrease the level of observation
  • When reviews should take place
  • How service users’ perspectives will be taken into account

We are developing a suite of tools, including a practice audit, new leaflets for staff and service users and some training to encourage staff to engage with this new policy. The trust updated and improved this policy in line with feedback received during the CQC inspection.

Primary nursing audits are in place and reviewed monthly to discuss therapeutic activities undertaken, escorted leave, meetings and so on.

Record keeping

All clinical bank staff have been trained to use RIO and have Rio access. A small number did not attend training, and these will be picked up in normal induction training.

The Head of Mental Health Law has provided confirmation that there is process underway for monthly audit of MHA documentation as per attachment, and that this will be reported quarterly.

Incident reporting

We have reviewed and have worked with staff to improve our online reporting system.

We have seen a 25% increase this year with 12,522 incidents reported.

A new incident reporting form is being developed and will be available on the Exchange shortly. To make sure we follow up on the actions from incidents we now share lessons learnt with staff through a regular quality and safety briefing on the QI pages of the Exchange and through regular learning lesson events.

We have also improved our processes for quality checking and timeliness in reporting data. These changes have resulted in a sustained improvement in our reporting rate and number of days taken to report incidents to the National Reporting and Learning System.

A new Tab on RiO has been created, requiring the completion of a form on RiO which will be used to monitor Safeguarding Adults activity and will eventually replace the manual collection of Safeguarding activity data. This should result in more accurate and timely data being available to the central Safeguarding Team, and then back to WLFS.


Weekly visits by the clinical leads and service directors are now taking place as are ‘Back to the Floor’ sessions by senior leaders. Listening events in which staff can raise questions with senior leaders were introduced in April and a schedule of dates has been made available to forensic staff. These have all had positive feedback from staff who feel supported and reassured by leaders’ increased responsiveness and presence on the wards.

A DREEM organisational climate survey was conducted in WLFS with 121 staff responding. On average respondents agreed or strongly agreed that staff engagement, development and support, service quality and service user feedback were positive, this is particularly notable in the women’s service. Results will be fed back to staff and used to make further improvements.

The DREEM survey asked service users views about outcomes, empowerment, personal recovery and positive self-view as well as quality of life. The 52 respondents were on average positive about their experiences associated with personal recovery. Output will be used to review the therapeutic environment and the way in which care and treatment are provided.

High secure services

We now have agreed standards for transferring patients internally within the trust and clinicians now provide timely communication whenever a discharge from the high secure service is delayed.

We have:

Restrictive practices

As part of the programme of work to reduce restrictive practices, a pilot project to reduce long-term segregation on Cranfield and Epsom wards was introduced and has progressed well. The good practice from the pilot is now being embedded on four wards and will be rolled out across High Secure Services. Learning will be shared across the trust. Additional improvements have been made to the intensive care ward environments to give patients better access to more areas and facilities.

We can now clearly demonstrate that at Broadmoor patients are spending less time segregated in their bedrooms and have more access to facilities and activities.

Change is evident in staff attitude and understanding. The Restrictive Intervention & Reduction Committee monitor and review the use of seclusion, restraint and zoning (segregation). Where seclusion, rapid tranquilisation or mechanical restraints have been used, the committee ensures that the policy is followed, that there has been proper recording of the intervention and that usage is analysed.

To reduce injuries to staff and patients through use of handcuffs, the PMVA team conducted extensive research which resulted in the ending of double cuffing. New methods, found to be much safer, have been introduced to good effect, evidenced by a reduction in reported injuries.

We have developed a new ligature anchor point policy and have trained all of our ward managers and estates staff in the use of an updated ligature assessment tool, as we work to ensure the safety of patients in our services.

By the end of May 2016, all of our in-patient areas will have gone through a thorough ligature assessment and as mentioned already the first phase of a ligature removal programme has been completed this year.

Staffing shortages are being addressed through the extension to overtime and more intensive recruitment of staff. This has led to additional staff resource being available on the wards and has resulted in a reduction in cancelled patient activities with positive outcomes for patient care.

Monthly staff forums and follow up feedback to all staff in the hospital are now embedded and well attended. Staff are more able to access members of the Board as Board meetings are now regularly held at Broadmoor Hospital.

Better information sharing to ensure best practice is spread and adopted across secure services is being addressed through regular safety briefings and staff shadowing best practice.