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Mental Health Act Annual Statement January 2010 
 
Broadmoor Hospital 
West London Mental Health NHS Trust 
 
Introduction 
The Care Quality Commission 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 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.  
 
•  Commissioners use the Guiding Principles in the Code of Practice (Published 
2008) to inform opinions about the quality of care provided by the hospital.  All 
decisions must be lawful informed by good practice and consistent with the 
Human rights Act 1998.  Commissioners expect these principles to underpin all 
decisions and clinicians and managers and all those involved in providing care 
balance application of the principles to provide the most effective and sensitive 
care to individuals.  
 
At the end of each visit a “feedback summary” is issued to the provider 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 provider 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 Annual Healthcheck and making decisions 
about the inspection programme in both the NHS and Independent Sector.  From 
April 2010, the Mental Health Act Commissioners’ findings will inform the Care 
Quality Commission’s assessments of organisations in relation to registration 
requirements, through evidencing ongoing compliance with the Mental Health Act 
and the Code of Practice. 
 

During the reporting period a number of changes took place in the Commission team 
visiting Broadmoor Hospital. The previous Area Commissioner was appointed to 
Chair the Board of the Mental Health Act Commission from November 2008 until the 
Commission became part of the Care Quality Commission on 1 April 2009. This had 
the result that he was no longer able to act as Area Commissioner. During this period 
the Mental Health Act Commission’s Regional Director took on the responsibilities of 
the Area Commissioner. 
 
Since the inception of the Care Quality Commission the previous Area Commissioner 
has returned to his responsibilities at Broadmoor Hospital as the Named 
Commissioner. In addition, part of the allocated time of two other Commissioners has 
been devoted to visits to Broadmoor Hospital resulting in a total allocation of funding 
to cover three days of visiting per month to this hospital. 
 
A list of the wards visited within the hospital during the reporting period is provided at 
the Appendix A. 
 
Background 
Broadmoor Hospital provides specialist high secure care for male patients from 
London and the South of England, it also has one of the units that provides a service 
for the treatment on a national basis of Dangerous and Severe Personality Disorder 
(DSPD). 
 
This statement draws on findings from visits by Mental Health Act Commissioners 
both under the auspices of the Mental Health Act Commission and those which took 
place after April 1 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. 
 
In contrast to Annual Reports of the previous Mental Health Act Commission, this 
Annual Statement aims to address issues at a higher level rather than to deal with 
specific matters in detail. This is on the basis, as noted above, that at the end of each 
Commissioner visit a Feedback Summary is issued dealing with detailed points that 
have arisen during the visit. 
 
In addition to taking part in undertaking the programme of visits to wards and 
departments as set out in the appendix to this report, the Named Commissioner has 
also undertaken the following: 
 
• 
Attended meetings of the Seclusion Monitoring Advisory Group. 
• 
Attended a meeting of the National Forensic Audit Group. 
• 
Attended meetings of the Incident Monitoring and Review Group. 
• 
Held a discussion with the Chair of the Trust. 
• 
Held a discussion with the Chief Executive of Trust. 
• 
Held discussions with the Clinical Director (Broadmoor SDU). 
• 
Held discussions with the hospital’s Performance Improvement Manager. 

• 
Held discussions with Service Directors for the London, South of England and 
DSPD services. 
• 
Held discussions with Independent Mental Health Advocates concerning 
specific patient issues. 
• 
Attended a number of ward community meetings. 
• 
Provided an interview to the Editor of the Broadmoor Chronicle. 
• 
Attended an Inquest into the death of a Broadmoor patient. 
 
Main findings 
Relations between Mental Health Act Commissioners and senior managers of the 
hospital have remained constructive throughout the reporting period.  The final 
Annual Report of the Mental Health Act Commission was received positively by the 
Trust Board and an appropriate action plan published.  This has been monitored by 
Mental Health Act Commissioners on their visits during the reporting period and 
progress has been noted in a number of areas. 
 
Detention 
The Care Quality Commission is impressed with the diligence of the Mental Health 
Act Managers and the staff of the Mental Health Act office in ensuring that all 
detentions are lawful.  On the rare occasions where errors in the recording of 
detention have been found, they have quickly been corrected and steps taken to 
ensure that they are not repeated. There still appears to be a less than complete 
recording of ethnicity in patient notes. 
 
Section 58 
Responsible Clinicians continue to fail to record systematically assessments of 
capacity when negotiating consent to treatment. They also do not regularly 
demonstrate that they have discussed consent and assessed capacity during the first 
three months of detention. 
 
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 entry in the patients’ notes by 
statutory consultees. 
 
A serious error concerning the use of Section 62 was drawn to the attention of the 
Trust resulting in the instigation of a level 3 investigation, the outcome of which is 
awaited. 
 
Purposeful Activity 
The Commission continues to be concerned about the limited extent to which some 
patients appear to be engaged in purposeful activity. Whilst it is recognised that 
patients in some wards (especially the higher dependency wards) will not be able to 
have access to the same range of activities that may be available to patients in other 
parts of the hospital, the Commission considers it inappropriate that some patients on 
assertive rehabilitation wards are not more actively encouraged to rise from their 
beds before the middle of the day and become involved with activity. 
 
The Commission has been impressed with work done by the Occupational Therapy 
Department, together with the active involvement of a number of patients, to 

undertake an audit of the actual amount of purposeful activity engaged in by patients 
in assertive rehabilitation wards. The results appear to demonstrate that this is an 
area that requires further attention and investment. The Commission is equally 
impressed with the attempts that are in the process of being made, again with the 
active participation of a number of patients, to ascertain the views and wishes of all 
patients on assertive rehabilitation wards in determining the nature and range of 
activity options that are available. 
 
Patient Deaths 
The Commission shares the concern shown by the hospital management about the 
recent high incidence of patient deaths. The Commission welcomes the preparation 
of the thematic review of four of these deaths and hopes to be able to join with the 
hospital management in giving this challenging matter further attention in the hope 
that learning may be acquired so as to lead to a reduction of deaths of this nature in 
the future. The Commission is pleased to note that the hospital is cooperating with 
the work of the Independent Advisory Panel to the Ministerial Council on Deaths in 
Custody. 
 
The Commission also welcomes its continuing involvement in the hospital’s Incident 
Monitoring and Review Group where each incident that occurs is scrutinised and the 
implementation of action plans is monitored. The Commission is pleased to see the 
investment being made into suicide awareness training and the work towards the 
provision of links with the Samaritans. In this respect it is encouraging to note the 
way in which the hospital is prepared to work with other organisations in the local 
community, clearly there is a good deal of mutual benefit that can accrue from such 
cooperation. 
 
Patient Community Meetings 
The Commission is pleased to have been invited to attend meetings of the Hospital 
Users’ Forum. Whilst it will not be possible to attend every meeting, it will provide an 
important opportunity to assess the ‘temperature’ of patients’ views about issues that 
affect the way in which their lives can be lived whilst in hospital. 
 
The Commission has noted the results of a recent audit of ward community meetings 
and welcomes the action plan that emerged from this work and in particular the 
finding that this had been a ‘rich and positive experience from service user 
experience’. It is the Commission’s firm view that it is vital to give to patients the 
opportunity and responsibility to take an active part in shaping the way in which their 
respective ward communities are run. 
 
The impact of the publication of recent adverse reports 
It is recognised that the Trust has had to deal with the consequences of the 
publication of the Care Quality Commission report of the investigation into the West 
London Mental Health Trust and the publication of the Report of the Independent 
Inquiry into the Care and Treatment of PB and RL. The findings of each of these 
reports raise serious concerns about aspects of the way in which Broadmoor Hospital 
is run. The Commission will monitor with interest the responses that are made to the 
recommendations contained in these reports. 
 

It is evident that these publications have the potential to seriously to undermine the 
confidence and morale of staff at all levels within the hospital. Whilst recognising the 
seriousness of the issues that have been raised, the Commission will want to play its 
part in counteracting any such lack of confidence and helping the hospital 
management to address the issues that require attention. 
 
In this context it was gratifying on a recent visit to Luton Ward, the scene of the 
homicide which was the subject of one of the reports, to be able to say in the 
Feedback Summary: 
 
“The visiting Commissioner would like to commend the ward staff and in 
particular the Clinical Nurse Manager for the very positive attitude that is 
apparent on the ward... It is clear that there is a great deal of energy on the 
ward which evidently is the result of positive and motivational leadership. It is 
understood that the ward has been the focus of attention both within the 
hospital and also beyond in recent times, especially with the publication of the 
homicide report; the way that this has been engaged with and used as a 
positive force rather than a negative influence is to be commended...” 

 
It is hoped that good practice such as this can be appropriately recognised by 
hospital management. 
 
Staffing issues 
It is evident that all too often there is very considerable pressure on ward staff 
resulting from staff shortages. It is understood that the hospital is making a concerted 
effort to recruit additional staff up to the proper and necessary establishment. Visiting 
Commissioners all too often are confronted by patients and ward staff alike with 
concerns about the extent to which patient and staff safety is in danger of being 
compromised as a result of inadequate staffing. The Trust is urged to redouble its 
efforts to address this vitally important issue. 
 
Security issues 
It is, of course, recognised that matters of security are of primary concern at 
Broadmoor Hospital and the Commission would not in any way wish to detract from 
the importance of this. However, visiting Commissioners do find on occasion that at 
ward level there can be a very rigid adherence to the letter of the law rather than, 
when appropriate, the possibility of being guided more by the spirit of the law. This 
inevitably leads to frustration and tension resulting in greater difficulty in managing 
volatile situations. The Commission hopes that ward staff take particular care to 
ensure that over zealousness in this respect is avoided and that proper discussion 
takes place with patients so that there is a clear understanding of the rationale 
behind the implementation of security measures. This is perhaps of greatest 
significance in the Dangerous and Severe Personality Disorder (DSPD) Unit. 
 
The Commission is aware that its predecessor body had made previous comments 
about the balance between therapeutic input and custodial care. Clearly in a high 
secure hospital both considerations need to be accommodated. However it is hoped 
that the welcome trend towards a greater emphasis on the therapeutic value of time 
spent at Broadmoor Hospital can continue. It is clear that for some patients, 
especially in the DSPD unit, the considerable value of the therapeutic programmes 

can sometimes be eroded by all that is necessary in the provision of high secure 
care.  
 
The physical environment 
The old Victorian wards of the hospital are recognised by all as no longer fit for 
purpose.  Visiting Commissioners are aware of the programme of work to upgrade 
the older parts of the building stock. However it is apparent that there is only so much 
that can be done in this respect and it is often only work of a relatively superficial 
nature is possible. This means that more major work, for example the provision of en-
suite facilities in bedrooms, is not tackled. The Commission has been pleased, 
however to note progress on the long overdue work to remove ligature points in 
patient areas in the older parts of the hospital. 
 
The Commission continues to note the progress, slow as it inevitably is, towards 
obtaining approval for the redevelopment of the hospital as a whole. However the 
Commission is concerned that the prospect of this will be the cause a ‘planning 
blight’ on more substantial upgrading work for the considerable period of time before 
a new hospital is commissioned. It is unacceptable to continue to house patients in 
accommodation that is not fit for purpose. 
  
Recommendations for Action 
• 
The Trust should as a matter of urgency institute effective governance 
arrangements to ensure that there is an improvement in compliance with 
Section 58 of the Mental Health Act at Broadmoor Hospital. 
 
• 
The Trust should ensure that adequate financial resources are allocated to 
maintain the fabric of Broadmoor Hospital at levels consistent with ensuring 
patient safety until it is redeveloped. 
 
• 
The Trust should ensure that the current staff recruitment campaign is 
maintained, and if necessary stepped up, until all wards and departments at 
Broadmoor Hospital are properly and safely staffed, however care should be 
taken to avoid the risk of sacrificing the quality of the staff recruited simply in 
order to acquire the right quantity. 
 
• 
The Trust should ensure that the work on seeking to understand and reduce the 
incidence of suicide of patients is continued and that the findings are 
promulgated as soon as possible. 
 
Forward Plan 
• 
Mental Health Act Commissioners will continue to visit Broadmoor Hospital 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 hospital’s staff to review 
progress on the issues raised in this report. 

Appendix A 
 
Commission Visit Information for  

West London Mental Health NHS Trust Forensic Services  
Covering the period between  
1 November 2008 and 19 January 2010 
 

 Det. 
Pats. 
  Records  
Date 
Ward 
seen 
checked 
Broadmoor Hospital 
4 Nov 2008 
Kempton 


5 Nov 2008 
Dunstable Ward 


10 Nov 2008 
Churchill 


22 Nov 2008 
Ascot 


9 Dec 2008 
Luton Ward 


30 Dec 2008 
Henley Ward 


17 Feb 2009 
Chepstow 


19 Feb 2009 
Windsor Ward 


24 Feb 2009 
Dorchester Ward (Now Closed) 


10 Mar 2009 
Harrogate 


11 Apr 2009 
Taunton Ward (Now Closed) 


12 May 2009 
Dover Ward (On Leeds) 


16 May 2009 
Isis Ward 


27 May 2009 
Sheffield Ward 


3 Jun 2009 
Ascot 


15 Jun 2009 
Banbury Ward 


7 Jul 2009 
Churchill 


27 Jul 2009 
Chepstow 


7 Aug 2009 
Oakley 


14 Sep 2009 
Henley Ward 


28 Sep 2009 
Milton 


9 Oct 2009 
Luton Ward 


 
Sunningdale Ward 


24 Oct 2009 
Harrogate 


2 Nov 2009 
Dunstable Ward 


27 Nov 2009 
Epsom 
13 

Total for Broadmoor Hospital 
115 
106 
 
Total Number of Visits: 25 
Total Number of Wards visited: 26 
Total number of Patients seen: 115 

Total Number of documents checked: 106