The Care Quality Commission heavily criticised West London Mental Health NHS Trust today for providing standards of care that were “unacceptable in the 21st century”.
The safety of inpatients was repeatedly jeopardised by the trust’s “seriously flawed” arrangements to learn lessons from a string of serious incidents, the regulator said, which included 31 suicides and three homicides from 2005-8.
Instead, “mediocre” care was tolerated across the organisation, which runs high-security Broadmoor Hospital in Berkshire, eight other inpatient units and a range of community services, and employs more than 4,000 staff.
The Healthcare Commission, which was replaced by the CQC in April 2009, launched an investigation into arrangements at the trust from 2005-8 after receiving concerns “from a number of sources” about the trust’s response to suicides in April 2008.
Inspectors found evidence of “unacceptable practice” caused by persistent overcrowding at a number of sites, including a mental health unit in Hammersmith and Fulham. Many inpatients were forced to sleep on sofas or stayed too long in psychiatric intensive care units, posing “a significant risk” to their safety.
Buildings “not fit for purpose”
Several buildings, including Broadmoor, dated back to the 19th century and had already been described by official reports as “not fit for purpose”. One site – St Bernard’s Hospital in Ealing – had recurring infestations of vermin.
The trust suffered from persistent staffing problems, with vacancy rates as high as 36% in one inpatient ward, and widespread absence through sickness. Locking inpatients at Broadmoor into parts of the ward at night to compensate for a lack of staff became standard practice.
Staff “poorly trained”
Meanwhile less than a third of ward staff across the trust had attended mandatory training courses between 2006 and July 2008.
CQC chair Barbara Young reserved strong criticism for a culture of “complacency” presided over by the board of executives.
Handling of investigations
A review of 37 serious incident investigations found reports were often if poor quality and subject to significant delays, but this went unchallenged at board level. Timescales for producing them stretched to nearly two years, with an average of nine months.
Recommendations were often repeated, such as the removal of ligature points, which implied that lessons from previous incidents had not been learned, according to Young.
“Some of the problems were repeatedly mentioned in serious incident investigations, such as risk management, but we didn’t get the feeling they were being addressed with vigour,” she added.
The trust’s chief executive since 2004, Simon Crawford, resigned prior to the report’s publication. He has been replaced by Peter Cubbon, currently the chief executive of Cheshire and Wirral Partnership NHS Foundation Trust.
Young said there was hope for the future but stressed West London Mental Health Trust had a long way to gain registration with the CQC, when a mandatory scheme for providers comes into effect next year.