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The Priory Hospital North London Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 July 2018

We rated The Priory Hospital North London as requires improvement because:

  • At the previous inspection in May 2016 we found that ligature risks were present across the wards. At this inspection there were still many ligature risks, including high risk ligatures in bedrooms on the child and adolescent wards. The pace of change following serious incidents on the child and adolescent wards was not rapid enough to ensure that ligature risks were removed or minimised. Serious incidents had included a child who had died. They had used a bedsheet and been found hanging from a ligature anchor point.

  • There was a lack of clear leadership on the child and adolescent wards. At the time of the inspection neither ward had permanent ward managers available. Acting ward managers were in place, but they were unable to describe what actions were taken to ensure the safety of all young people on the wards.

  • On the child and adolescent wards, the governance and risk management systems and processes in place had not been effective. Potential risks to young people were not proactively addressed and minimised in a timely manner. The systems and processes in place to monitor care were not effective on the child and adolescent wards. Audits were not effective in alerting staff or managers to areas where there were concerns and improvements were needed.

  • At the previous inspection in May 2016 we found that there was not a full complement of nursing staff. At this inspection we found that staffing levels for nurses on the child and adolescent wards were not safe. There were numerous shifts when the number of registered nurses fell below the established level to one registered nurse on a shift. Young people did not always receive one to one nursing sessions and their escorted leave was sometimes cancelled due to staffing levels on the wards.

  • Patients' risk assessments were not detailed and risk management plans did not always identify how staff could minimise risks effectively. On the child and adolescent wards, young peoples' risk assessments did not include information about all areas of potential risk, such as their physical health needs or history of severe self harm.

  • Staff on the child and adolescent wards did not always understand what constituted restraint. Restraints of young people were not always recorded consistently on incident forms or within nursing notes. Care plans did not reflect how to support young people in the least restrictive way.

  • On the child and adolescent wards emergency alarms and call buttons were not always responded to in a timely manner. The on-call doctor was on site, but did not carry an alarm or pager. Staff may not have been able to contact the doctor in an emergency.

  • Physical health assessments of young people were not always fully completed on their admission to the hospital. Staff did not complete the paediatric early warning system correctly. This meant staff may not recognise a deterioration in a young person's physical health and report this to medical staff.

  • Staff on the child and adolescent wards did not ensure that medicines were managed safely. Medicine administration records did not always show clearly which route ’as required’ medicines should be or had been administered. Staff did not record in daily records why ‘as required’ medicines were required or how effective they had been.

  • Clients having substance misuse treatment did not have early exit plans in case they left detoxification treatment early. Early exit plans would describe to clients how they could avoid such risks when leaving treatment early, such as alcohol withdrawal seizures or overdose.

  • Clients having alcohol detoxification treatment were monitored using a validated withdrawal tool for two days. Serious complications from alcohol withdrawal treatment can occur after the first two days of alcohol detoxification.

  • On all of the wards, patients and young peoples’ care plans did not always reflect their needs. Care plans were not always personalised, holistic or recovery-orientated. On the child and adolescent wards, young people were not involved in producing their own care plans. Staff did not always understand the needs of the young people. Most patients on the adult ward did not have a copy of their care plan.

  • Young people on the child and adolescent wards told us that some staff did not treat them with respect and dignity. They found some staff patronising and unsympathetic.

  • On the child and adolescent wards, staff had not attended specialist training required to carry out their role effectively. They had not had training in epilepsy or autism, and did not have a good knowledge of the Mental Capacity Act 2005.

  • On all of the wards, there was no clear record that informal patients were told that if they were informal, they had the right to leave at any time. On the child and adolescent wards this applied to informal young people over 16 years of age. This was not in accordance with the Mental Health Act code of practice.

  • On the child and adolescent wards, information was not available in an 'easy read' format for young people with learning disabilities or difficulties.

  • There was no system to indicate to staff when equipment needed replacing or recalibrating. Physical health equipment, such as blood glucose monitoring equipment, could become inaccurate if it was not maintained properly. Only an adult blood pressure cuff was available on one of the child and adolescent wards, and some equipment was not clean or within it's expiry date.

  • The provider did not ensure that complaints were responded to within agreed time frames.

However, we also found the following areas of good practice:

  • Chronotherapy was used to treat patients’ depressive symptoms. Chronotherapy  involves a variety of strategies to control exposure to environmental factors which may influence depressive symptoms. This treatment is not widely available in the United Kingdom, but has a strong international evidence base.

  • On the adult ward, staffing levels had improved and the minimum staffing levels were consistently met or exceeded. Staff on the adult ward received regular one-to-one supervision, and had access to regular group supervision. This had improved since the last inspection.

  • Patients, young people and carers had the opportunity to provide feedback to the service in various ways. This included community meetings and periodic surveys. Young people on the child and adolescent wards were involved in the recruitment of staff.

  • Staff were supported following serious incidents. Staff were given the opportunity to reflect on incidents and identify changes that could be made to the service to prevent similar incidents re-occurring. Learning was identified following incidents and complaints, and was used to improve the service.

  • Clients having substance misuse detoxification were monitored using validated withdrawal tools. Staff were knowledgeable regarding substance misuse and had received specific training.

  • On the child and adolescent wards, the staff team provided a weekly programme consisting of education, therapy and activity-based groups.

  • All patients and young people received a welcome pack when they were admitted to the hospital. Families of young people also received a welcome pack. This included information on how to make a complaint. Carers had access to a monthly carers group. They could meet other carers and discuss any issues or concerns that they may have.

  • Adult patients having acute mental health or substance misuse treatment reported that staff had positive attitudes and treated them with respect. Staff worked hard to meet the individual needs of patients, and supported them with areas such as religion and gender identity.

  • On the child and adolescent wards, young people were expected to attend education that was provided on the ward. Staff supported young people to be reintegrated back into their local school or college provision.

  • Staff supported young people to maintain contact with their families and carers. Families and carers were encouraged to attend ward rounds and care programme approach meetings. Where this was not possible staff gave other opportunities such as attending by conference call. Staff encouraged young people to maintain relationships with people that mattered to them.

  • Staff found that the senior staff team were supportive and visible. Following a recent serious incident staff had received counselling and additional support.

During and following this inspection, we provided feedback to the provider regarding our concerns, and specifically our serious concerns regarding young peoples' safety on the child and adolescent wards. The provider immediately transferred an experienced child and adolescent service manager to provide leadership to the child and adolescent wards. The provider also developed a detailed action plan to address our concerns.

Inspection areas

Safe

Inadequate

Updated 17 July 2018

We rated safe as inadequate because:

  • At the previous inspection in May 2016 we found that ligature risks were present across the wards. At this inspection there were still many ligature risks. These were in communal areas and in clients' bedrooms. Some high risk ligatures were in young peoples' bedrooms on the child and adolescent wards. We highlighted the potential ligature risks on the child and adolescent wards with the provider during our inspection. The provider took immediate action to mitigate these risks.

  • At the previous inspection in May 2016 we found that there was not a full complement of nursing staff. At this inspection we found that staffing levels for nurses on the child and adolescent wards were not safe. There were numerous shifts when the number of registered nurses fell below the established level to one registered nurse on a shift. Young people did not always receive one to one nursing sessions and their escorted leave was sometimes cancelled due to staffing levels on the wards.

  • Patients' risk assessments were not detailed and risk management plans did not always identify how staff could minimise risk effectively. For clients having substance misuse treatment, the multidisciplinary team did not discuss potential risks effectively. On the child and adolescent wards, young peoples' risk assessments did not include information about all areas of young peoples’ potential risk, such as their physical health needs or history of severe self harm

  • Staff on the child and adolescent wards did not always understand what constituted restraint. Restraints of young people were not always recorded consistently on incident forms or within nursing notes. Care plans did not reflect how to support young people in the least restrictive way.

  • On the child and adolescent wards emergency alarms and call buttons were not always responded to in a timely manner.

  • On the child and adolescent wards staff had not completed paediatric early warning system records correctly. This meant that staff may not be alerted to a young person’s physical health deteriorating. This also meant that deterioration in young peoples’ physical health may not be escalated appropriately.

  • The provider had an out of hours doctor on site. However, the doctor did not carry an alarm or pager so staff may not have been able contact the doctor immediately in an emergency.

  • Staff on the child and adolescent wards did not ensure that medicines were managed safely. Medicine administration records did not always show clearly which route ’as required’ medicines should be or had been administered. Staff did not record in daily records why ‘as required’ medicines were required or how effective they had been.

  • Clients having substance misuse treatment did not have early exit plans in case they left detoxification treatment early. There are specific risks to people if they leave alcohol or opiate detoxification treatment early, such as alcohol withdrawal seizures and overdose, which can be fatal. Early exit plans would describe to clients how they could avoid such risks.

  • On all of the wards, informal patients were not consistently informed that they had the right to leave at any time. On the child and adolescent wards this applied to informal young people over 16 years of age.

  • The provider did not have a system to alert staff working on the ward to the need to either replace or recalibrate physical health monitoring equipment. This presented a risk that physical health monitoring readings, such as blood glucose monitoring, could become inaccurate if equipment was not maintained appropriately. On the child and adolescent wards, only an adult blood pressure cuff was available on one ward and some equipment  was not  clean or within its expiry date.

However, we also found:

  • During our inspection in May 2016 we identified a high number of staff vacancies and use of temporary staff. On the adult ward, this had improved and the minimum staffing establishment was consistently met or exceeded.

  • Staff were supported following serious incidents. Staff were given the opportunity to reflect on incidents and identify changes that could be made to the service to prevent similar incidents re-occurring.

Effective

Requires improvement

Updated 17 July 2018

We rated effective as requires improvement because:

  • Physical health assessments of young people were not always fully completed on their admission to the hospital.

  • On all of the wards, patients and young peoples’ care plans did not always reflect their needs. Care plans were not always personalised, holistic or recovery-orientated.

  • On the child and adolescent wards, staff had not attended specialist training required to carry out their role effectively. They had not had training in epilepsy or autism, and did not have a good knowledge of the Mental Capacity Act 2005.

  • Clients having alcohol detoxification treatment were monitored using a validated withdrawal tool for two days. Serious complications from alcohol withdrawal treatment can occur after the first two days of alcohol detoxification.

However, we also found:

  • Staff on the adult ward received regular one-to-one supervision. They also had access to regular group supervision. This had improved since the last inspection.
  • Clients having substance misuse detoxification were monitored using validated withdrawal tools. staff were knowledgeable regarding substance misuse and had received specific training.
  • On the child and adolescent wards, the staff team provided a weekly programme consisting of education, therapy and activity-based groups.

Caring

Requires improvement

Updated 17 July 2018

We rated caring as requires improvement because:

  • On the child and adolescent wards, young people were not involved in producing their own care plans. Staff did not always understand the needs of the young people.

  • Young people on the child and adolescent wards told us that some staff did not treat them with respect and dignity. They found some staff patronising and unsympathetic.

  • Most patients on the adult ward did not have a copy of their care plan to refer to.

However, we also found the following areas of good practice:

  • All patients and young people received a welcome pack when they were admitted to the hospital. Families of young people also received a welcome pack.

  • Adult patients having acute mental health or substance misuse treatment reported that staff had positive attitudes and treated them with respect.

  • Young people on the child and adolescent wards were involved in the recruitment of staff.

  • Patients, young people and carers had the opportunity to provide feedback to the service in various ways. This included community meetings and periodic surveys.

  • Carers had access to a monthly carers group. They could meet other carers and discuss any issues or concerns that they may have.

Responsive

Good

Updated 17 July 2018

We rated responsive as good because:

  • On the child and adolescent wards, young people were expected to attend education that was provided on the ward. Staff supported young people to be reintegrated back into their local school or college provision.

  • On the adult ward staff worked hard to meet the individual needs of patients. Staff supported patients with areas such as religion and gender identity.

  • Staff supported young people to maintain contact with their families and carers. Families and carers were encouraged to attend ward rounds and care programme approach meetings. Where this was not possible staff gave other opportunities such as attending by conference call.

  • Staff encouraged young people to maintain relationships with people that mattered to them.

  • Patients, young people and carers were provided with information on how to make a complaint.

However, we also found the following areas for improvement:

  • On the child and adolescent wards, information was not available in an 'easy read' format for young people with learning disabilities or difficulties.
  • The provider did not ensure that complaints were responded to within the agreed time frames.

Well-led

Requires improvement

Updated 17 July 2018

We rated well-led as requires improvement because:

  • There was a lack of clear leadership on the child and adolescent wards. At the time of the inspection neither ward had permanent ward managers available. Acting ward managers were in place, but they were unable to describe what actions were taken to ensure the safety of all young people on the wards.

  • The pace of change following serious incidents on the child and adolescent wards was not rapid enough to ensure that areas of potential high risk were addressed.

  • On the child and adolescent wards, the governance and risk management systems and processes in place had not been effective. Potential risks to young people were not proactively addressed and minimised in a timely manner.

  • Systems and processes were not in place to ensure that there was effective monitoring of care and treatment on the child and adolescent wards. Audits were not effective in alerting staff or managers to areas where there were concerns.

However, we also found the following areas of good practice:

  • The recently appointed hospital director was very responsive to safety concerns. They ensured that a number of environmental safety concerns highlighted during our inspection were dealt with immediately.

  • Following this inspection, the provider immediately transferred an experienced child and adolescent service manager to provide leadership to the child and adolescent wards. The provider also developed a detailed action plan to address our concerns.

  • Staff found that the senior staff team were supportive and visible. Following a recent serious incident staff had received counselling and additional support.

  • Learning was identified following incidents and complaints and was used to improve the service.

Checks on specific services

Child and adolescent mental health wards

Inadequate

Updated 17 July 2018

Acute wards for adults of working age and psychiatric intensive care units

Good

Updated 17 July 2018

Substance misuse services

Updated 29 April 2015

The Addiction Therapy Programme service was providing a good service. People using the service had their risks assessed. Care plans and their supporting assessment tools were comprehensive and complemented the group work programme. Therapy staff were skilled and experienced and facilitated the provision of a quality addiction therapy programme. However, the provider should consider whether locating the addiction therapy programme on a mixed ward appropriately meets patient needs. The provider gathers information addressing abstinence maintenance and relapse for patients who complete the addiction therapy programme, and should consider analysing this information as part of its outcome measurements. The Lower Court ward did not meet single gender standards.