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Mental Health Act Annual Statement January 2010 
 
Local Services – Ealing, Hounslow, Hammersmith & Fulham 
West London Mental Health NHS Trust 
 
Introduction 
The Care Quality Commission (CQC) visits all places where patients are detained 
under the Mental Health Act 1983. Mental Health Act Commissioners meet and talk 
with detained patients in private and also talk with staff and managers about how 
services are provided. As part of the routine visit programme information is recorded 
relating to: 
 
•  Basic factual details for each ward visited, including function, bed occupancy, 
staffing, and the age range, and gender of detained patients. 
 
•  Ward environment and culture, including physical environment, patient privacy 
and dignity, safety, choice/access to services and staff/patient interaction. 
 
•  Issues raised by patients and patient views of the service provided, from both 
private conversations with detained patients and any other patient contacts made 
during the course of the visit. 
 
•  Legal and other statutory matters, including the scrutiny of Mental Health Act 
documentation, adherence to the Code of Practice, systems that support the 
operation of the Act and records relating to the care and treatment of detained 
patients.  
 
At the end of each visit a “feedback summary” is issued to the Trust identifying any 
areas requiring attention. The summary may also include observations about service 
developments and / or good practice.  Areas requiring attention are listed and the 
Trust is asked to respond stating what action has been taken. The response is 
assessed and followed up if further information is required. The information is used 
by the CQC when verifying the NHS Healthcheck and making decisions about the 
inspection programme in both the NHS and Independent Sector. In future years it will 
be used to inform the registration decisions 
 
A list of the wards visited within this Trust is provided at Appendix A. 
 
Background 
This report draws on findings from visits by Mental Health Act Commissioners both 
under the auspices of the Mental Health Act Commission (MHAC) and those which 
took place after 1 April 2009 when the functions of the Mental Health Act 
Commission were taken over by the Care Quality Commission  
 
The Annual Statement provides an overview of the main findings from visiting, 
highlighting any matters for further attention and / or areas of best practice. It is 

published on the CQC website, together with other publications relating to individual 
mental health providers. 
 
Main findings 
Relations between Mental Health Act Commissioners and senior managers of the 
Trust have remained constructive throughout the reporting period.  This period has 
been one of considerable activity between the Trust and the Care Quality 
Commission. Much, but not all, of this has been triggered by the publication of the 
CQC report into West London Mental Health Trust.  
 
During the period, the Named Commissioner met with the Director of Ealing services 
in July and the Director of Hammersmith and Fulham in August. In September 
constructive meetings took place between the CQC Mental Health Operations 
Manager and the Director for Hammersmith and Fulham, and both he and the named 
Commissioner had constructive discussions with the Service Manager of the 
Lakeside Unit in August.  In October the CQC shared a platform with the Trust at the 
Hounslow Local Involvement Network meeting (LINks) to discuss mental health 
services 
 
Mental Health Act and Code of Practice 
The following points highlight those Mental Health Act issues raised by 
Commissioners on visits.  The detailed evidence to support them has already been 
shared with the Trust and is not rehearsed here.  For further discussions about these 
findings please contact the author of this report via the Care Quality Commission at 
the Nottingham office. 
 
Detention 
Commissioners generally found statutory documentation in order and on the 
occasions where errors have been found, they have quickly been corrected. The 
Commission has reported concerns however about whether the Trust is adequately 
staffing this service to cope with the increasing demands placed upon it. While it is 
impressed with the dedication, skill and commitment of individual Mental Health Act 
Administrators, many Mental Health Act issues raised regularly by the Commission 
could be alleviated by more robust internal audit of Mental Health Act systems. It is 
also apparent that specific Mental Health Act issues raised in one part of local 
services continue on other sites indicating a lack of overall action to address issues 
across the entire service at a strategic level. 
 
Recommendation for Action 
The Trust’s Mental Health Act Manager should review current Mental Health Act 
Administration services to confirm whether they are able to cope with increased 
demands generated by Supervised Community Treatment, the Mental Capacity Act, 
and the Deprivation of Liberty Safeguards and still fulfil existing core administration 
and audit requirements.  
  
Section 58 
Responsible Clinicians continue to fail to record assessments of capacity when 
negotiating consent to treatment. They also do not regularly demonstrate the nature 
of discussions for consent or the information provided to patients. The compliance of 
Responsible Clinicians with their requirement to record the conversation they have 

with a detained patient following the visit of a Second Opinion Appointed Doctor 
(SOAD) remains patchy as does the requirement that the other consultees also 
record their meetings. 
 
These issues, were addressed in the response to the 2008 MHAC Annual Report 
where the Trust wrote: 
 
“It is agreed that we have more work to do to improve our performance and 
documentation. In relation to documentation following second opinion visits, a 
letter has gone out to all relevant staff from our Medical Director formally 
reminding them of the requirements of both the RMO and the statutory 
consultees. In our forensic wards where there is greatest use of Part IV of the 
Act, each one has now identified a person to check consent to treatment 
documentation on a regular basis. In addition there is a Trust-wide quarterly audit 
on consent to treatment for detained patients, the findings of which go to the 
Divisional Clinical & Research Governance Groups for action and to the Trust 
Clinical & Research Governance Executive for monitoring. We will also be 
sending the audit reports to the Commission. The West London Forensic Service 
proforma for documenting statutory duties in respect of Form 38 and Form 39 has 
been updated for use across the service. This has been widely consulted on 
across the services and will be rolled out for use shortly. The new proforma aims 
to ensure consistent practice and comprehensive compliance. In addition, 
completion of the proforma will be made subject to a rolling audit programme. 
The audit process will be introduced in the Induction programme for Junior 
Doctors and form part of their routine job plan.  
 
Local services are considering the appropriateness of adopting this proforma for 
use in acute wards in London. A number of other local initiatives to monitor and 
improve compliance are underway Trust-wide. We believe that training which will 
inevitably be rolled out to clinical staff in the run up to the Amended Mental Health 
Act will provide an excellent opportunity to formally update knowledge on 
compliance with consent to treatment and second opinion requirements.”  
 
The findings of Commissioners in this regard are supported by the findings of the 
recently published Acute Inpatient Survey where West London scored in the lowest 
20% on two key questions: 
 
•  Did the hospital staff explain the purpose of this medication in a way you could 
understand? 
•  Did the hospital staff explain the possible side effects of this medication in a way 
you could understand? 
 
Recommendation for Action 
The Medical Director is asked to address Consent to Treatment issues with medical 
staff and instigate effective audit systems to address this matter across all services. 
 
Section 132 
Commissioners found deficiencies in this area on a regular basis. This has included 
poor evidence of compliance to inform patients of their rights. Patients have also 

shown little understanding of their rights leading to questions as to the effectiveness 
of current methods taken to discuss rights with those who are detained. 
 
Recommendation for Action 
The Director of Nursing is asked to address with ward managers the requirements of 
Section 132 of the Act and ensure effective understanding of both the underlying 
ethic and the administrative requirements. 
 
Other Issues Raised 
 
Mental Capacity Act 
The lack of use of the Mental Capacity Act remains a recurring issue. Staff often said 
they had received training but there was little evidence of its use by medical, nursing 
or other health staff on wards. This is important when a patient is detained and is a 
statutory requirement when patients who lack capacity are staying on wards and are 
not detained under the Act.  
 
Recommendation for Action  
The Trust reviews its implementation of the Act and develops a system to audit the 
current lack of use across wards to ensure compliance with this legislation. 
 
Coordination between services 
The Commission is aware of raising a number of issues on different wards on a 
regular basis over time and finding that they recur both on other wards in a local area 
or on wards in other local areas. It appears that coordination between wards and all 
local services is not clear enough to ensure strategic action is taken to tackle an 
issue uniformly across all local services.  
 
Recommendation for Action 
The Trust and local service directors should consider how issues raised by the CQC 
in one area are benchmarked across other areas. 
 
Nursing staff 
Nursing staff have been praised in many reports and patient comments have often 
been positive, however, a recurring theme has been concern expressed by patients 
about poor interactions with nursing staff. From being too busy to talk to them to 
more negative comments, this issue is central to the patient experience of care.  
 
This feedback is confirmed by the results of the Acute inpatient survey where the 
Trust scored in the lowest 20% of all Trusts on the questions: 
 
• 
Did the nurses listen carefully to you? 
• 
Were you given enough time to discuss your condition and treatment with the 
nurses? 
• 
Did you have confidence and trust in the nurses? 
• 
Did the nurses treat you with respect and dignity? 
 
Indeed it would appear that the Trust’s score on ‘Did the nurses treat you with 
respect and dignity’ at 57% is close to the lowest score in the country 
 

Recommendation for Action 
The Director of Nursing takes action to address poor patient experience. The 
Commission is aware of the Time to Care initiative and hopes the Trust will 
effectively audit its implementation to ensure ongoing improvements. 
 
Informal patients 
Ensuring informal patients understand their rights to leave wards etc has been raised 
on a number of occasions. The Trust should consider a uniform approach across all 
three boroughs to address this matter including an informal rights leaflet and signs by 
exit doors explaining rights. The issue also connects to assessment of patients in 
terms of capacity to consent to their admission or continued stay on a ward and 
potential Deprivation of Liberty indicators. 
 
Recommendation for Action 
The Trust develops measures to address the rights of informal patients across all 
local services.  
 
The Physical Environment 
Concern over ward environments was raised on a number of visits from lack of 
cleanliness, mice and cold bedrooms to general repair issues.  The Commission is 
aware of the involvement of the Healthcare Associated Infection Team of the Care 
Quality Commission and hopes that after many years of campaigning about the issue 
of vermin on the Ealing site, progress is beginning to occur.  The Commission is also 
aware that many sites are undergoing considerable physical changes at present or in 
the near future and hopes that this will resolve many of these issues.  
 
Recommendation for Action 
The Trust ensures that environmental issues raised during visits are tackled 
promptly. 
 
Police  
The Commission is concerned about police not taking action to charge patients with 
offences such as serious assault (resulting in forensic MHA detention) and instead 
using civil admission (Section 2 or 3). This can remove patients from the oversight of 
forensic services that are better equipped to provide assessment and treatment and 
also places undue pressures on local services potentially increasing risk levels in 
areas less able to deal with this. The Commission welcomes the Designated Police 
Officer project at Ealing that has started resulting with an officer (Andy Fox) being on 
site and hopes this project will address our concerns. 
 
Recommendation for Action 
The Trust takes forward this issue with the police and monitors cases where action is 
not taken. 
 
Phones 
The Code of Practice states: 
 
“16.3 Hospitals should make every effort to support the patient in making and 
maintaining contact with family and friends by telephone and to enable such calls 
to be made with appropriate privacy. Most wards contain coin-operated and card-


operated telephones. Hospital managers should ensure that patients can use 
them without being overheard. Installing booths or hoods around them may help 
to provide the necessary level of privacy. 
 
16.4 The principle that should underpin hospital or ward policies on all telephone 
use is that detained patients are not, of course, free to leave the premises and 
that individual freedom to communicate with family and friends should therefore 
be maintained as far as is possible. Any restrictions imposed should be the 
minimum necessary, so as to ensure that this principle is
 adhered to.”  
 
This issue was raised across the service and unfortunately remains unresolved. 
 
Recommendation for Action 
The Trust reviews all wards to quickly address this matter in local services. 
 
Smoking 
The Commission is aware of proposed changes to the Trust’s smoking policy but it 
notes that many visits have contained negative comments on the impact of the 
existing policy of not allowing any smoking on the hospital sites. This evidently 
creates considerable patient frustration and annoyance which impacts on staff.  The 
Commission looks forward to monitoring future developments in this area. 
 
Forward Plan 
 
•  Mental Health Act Commissioners will continue to visit the Trust in the coming 
year to monitor the operation of the Act and to meet with detained patients in 
private. 
 
•  They will work with other colleagues in the Care Quality Commission to develop 
an integrated approach to the regulation of the Trust’s services. 
 
•  During the year they plan to meet members of the Mental Health Law committee 
to review progress on the issues raised in this report. 
 
 
 
 
 
 
 
 
 
 
 

Appendix A 
 
Commission Visit Information for  
West London Mental Health NHS Trust Local Services  
Covering the period between  
1 November 2008 and 19 January 2010 
 
 Det. 

Pats. 
  Records  
Date 
Ward 
seen 
checked 
Lakeside Unit 
25 Nov 2008 
Kingfisher Ward 


1 Dec 2008 
Dove Ward 


 
Grosvenor Ward 


25 Jun 2009 
Finch Ward 


19 Aug 2009 
Kingfisher Ward 


25 Aug 2009 
Kestrel Ward 


27 Oct 2009 
Dove Ward 


Total for Lakeside Unit 
27 
24 
Hammersmith & Fulham Mental Health Unit 
10 Nov 2008 
Avonmore Ward (Was Area 2) 


26 Nov 2008 
Lilly Ward (Was Area 4) 


6 Feb 2009 
Askew Ward (Was PICU) 


13 May 2009 
Meridian Ward (Was Area 3) 
10 

15 Jul 2009 
Ravenscourt Ward (Was Area 1) 


26 Oct 2009 
Lilly Ward (Was Area 4) 


13 Jan 2010 
Meridian Ward (Was Area 3) 


Total for Hammersmith & Fulham Mental Health Unit 
39 
24 
Ealing Local (Non Forensic) 
27 Jan 2009 
Beverley Ward (Non Forensic) 


7 Feb 2009 
Coniston (Non Forensic) 


 
Windermere (Non Forensic) 


15 Feb 2009 
Windermere (Non Forensic) 


31 Mar 2009 
Campion Ward (Non Forensic) 


30 Jun 2009 
William Sargent 


1 Jul 2009 
Blair (Non Forensic) 


18 Jul 2009 
Mary Seacole (Non Forensic) 


31 Oct 2009 
Conway (Non Forensic) 


5 Dec 2009 
Beverley Ward (Non Forensic) 


11 Dec 2009 
Coniston (Non Forensic) 


Total for Ealing Local (Non Forensic) 
42 
45 
 
Total Number of Visits: 23 
Total Number of Wards visited: 25 

Total number of Patients seen: 98 
Total Number of documents checked: 93