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The Priory Hospital North London Requires improvement

Reports


Inspection carried out on 23 & 24 October 2018

During an inspection to make sure that the improvements required had been made

As this was a focused inspection, the provider’s overall inspection rating or core service ratings were not altered.

We undertook this focused inspection of the child and adolescent wards to check the progress the provider had made in addressing the breaches of regulation identified at the previous inspection in April 2018.

At this focused inspection on 23 and 24 October 2018, we found the provider had made good progress regarding our concerns identified in the April 2018 inspection. The provider had made improvements in all 14 areas we asked them to address. We also report on additional concerns found with the safety of the clinic room.

We previously inspected this service in April 2018 as part of our on-going comprehensive mental health inspection programme. As a result of our findings at the inspection in April 2018, we provided feedback to the provider regarding our serious concerns of 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. We were assured that the action plan demonstrated risk was either removed or was being removed in a timely manner to ensure people’s safety on the on the child and adolescent wards.

At the April 2018 inspection, we found the following concerns on the child and adolescent wards:

  • Ligature risks were present on all of the wards, including high risk ligatures in young people’s bedrooms.
  • Young peoples’ risk assessments were not detailed and risk management plans did not always identify how staff could minimise risks effectively.
  • Young people did not always have a full physical health assessment on admission to the hospital.
  • Emergency alarms and call buttons were not always responded to in a timely manner.
  • Paediatric early warning scores were not completed correctly. Possible deterioration in a young person's physical health may not have been escalated appropriately.
  • Staff on the child and adolescent wards did not understand what constituted restraint. There was inconsistent recording of restraint of young people, and a lack of planning of how to support young people in the least restrictive way possible.
  • The out-of-hours doctor did not carry an alarm or pager. Staff may not have been able to contact the doctor in an emergency.
  • The prescription of 'as required' medicines on the child and adolescent wards did not always clearly describe the route for administration. There was not always a recorded rationale for the administration of 'as required' medicines.
  • The provider did not ensure that appropriate medical equipment was within its expiry date and was suitable for the client age group.
  • Young peoples’ care plans did not always reflect their needs. Care plans were not always personalised, holistic or recovery-orientated.
  • Young people told us that some staff did not treat them with respect and dignity. They found some staff patronising and unsympathetic.
  • The governance and risk management systems and processes had not been effective. Potential risks to young people had not been proactively identified and addressed. Monitoring of the quality of care on the child and adolescent wards had been ineffective.
  • Staffing levels for nursing on the child and adolescent wards were not safe. On a number of day shifts, there was one registered nurse rather than the minimum of two. 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.
  • Staff had not received suitable training to meet the specific needs of young people in their care. Nursing staff on the child and adolescent wards had not received specialist training in epilepsy, autism or eating disorders.

At this inspection, we found that the service had made the following improvements:

  • Leaders had a good understanding of the child and adolescent wards and had improved governance systems. An experienced child and adolescent service manager provided supernumerary support to the wards, and senior managers had a good oversight of the wards. There were improved systems in place to identify potential risks and to monitor the quality of care on the wards. However, the provider needed to ensure that the quality of the leadership was maintained and the implementation of the new governance systems was embedded.
  • Staff completed risk assessments that were detailed and risk management plans identified how staff could minimise risks effectively.
  • Staff completed a full physical health assessment for patients on admission to the hospital.
  • The provider regularly tested response times to emergency alarms and call buttons via a rolling programme of staff emergency scenario drills.
  • Staff completed paediatric early warning scores correctly, which ensured they were able to identify and escalate deterioration in a young person’s physical health.
  • Staff understood what constituted a restraint and they used verbal de-escalation techniques first to ensure young people were supported in a least restrictive way. Staff completed restraint records to a good standard.
  • The out of hours doctor carried a pager to ensure they could be contacted in an emergency.
  • The prescription of 'as required' medicines clearly described the route for administration. Staff always recorded a rationale for the administration of 'as required' medicines.
  • Staff ensured that young people’s care plans reflected their needs, were personalised, holistic and recovery orientated.
  • Staffing levels for the children and adolescent wards were safe. The provider had processes in place to ensure the correct number of registered nurses was on each shift.
  • Nursing staff on the CAMHS wards had received specialist training required to deliver their role safely. For example, staff had received suitable training to meet the specific needs of young people in their care, which included epilepsy, autism and diabetes.

We also found that the service needed to continue to make the following improvements:

  • The provider had addressed our previous concerns regarding the clinic room. Staff checked medical equipment was within its expiry date and was suitable for the client age group. However, we found additional concerns with the clinic room. The provider did not have a robust system in place to ensure that all clinic rooms items were within its expiry date or to ensure that the clinic room environment was cleaned regularly.

  • The provider needed to complete its planned work to reduce potential ligature anchor points. Since our last inspection, the provider had removed high-rated risks, but they still had environmental work to complete to minimise all of the ligature points. The provider needed to ensure that they met the timescales for this work.
  • Young people told us that agency staff did not always treat them with dignity and respect, but told us permanent and bank staff were caring and understanding. At the last inspection, young people told us that staff did not always treat them with respect and dignity. At this inspection, all six patients were positive about how permanent and bank staff treated them. However, three out of six patients told us that agency staff did not always treat them with dignity and respect. Particularly agency staff did not always knock on their toilet door before entering.
  • The provider needed to ensure that staff worked with young people to understand their rights as an informal patient.

Inspection carried out on 30 April - 2 May 2018

During a routine inspection

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 carried out on 26-27 April and 9 May 2016

During a routine inspection

We rated the Priory Hospital North London as good because:

  • The hospital wards were clean and well-maintained. There was a fully equipped clinic room on each ward which had emergency resuscitation equipment. Medical equipment was serviced and cleaned regularly.
  • A risk assessment was carried out on admission and reviewed throughout the patient’s stay in hospital.
  • There were sufficiently skilled and qualified staff to provide a safe, caring and therapeutic environment.
  • There was an extensive programme of therapies including cognitive behavioural therapy (CBT), exposure therapy, music imagery, yoga, self-acceptance groups, relaxation therapy, dialectical behaviour therapy (DBT), mindfulness, anxiety management programmes and medicines. Treatment for addictions followed a 12-step programme with CBT and family therapy.
  • There was extensive use of outcome scales to monitor patients’ progress.
  • Throughout our interviews, staff consistently demonstrated positive attitudes towards the people they worked with. Patients spoke positively about their experiences of staff, care and treatment. A satisfaction survey was completed by patients at the end of their admission. Responses were very positive.
  • An extensive menu of healthy food was available for each meal. The menu included dishes that were clearly labelled as being dairy free, gluten free, vegan and free from genetically modified ingredients.
  • Staff spoke positively about the way the hospital was managed and consistently told us that they felt supported in their roles. We found a positive attitude that was caring and supportive to patients. Staff spoke positively about team work and mutual support. Staff told us that they valued the opportunities for working and learning together with colleagues at training days and group supervision sessions.
  • Staff spoke positively about the hospital director and the ward managers. All staff knew who the hospital director was and said that they were visible and frequently visited the ward.
  • Governance of the hospital was provided through the monthly clinical governance meeting. Patients were invited to participate in these meetings.
  • The child and adolescent mental health service wards were part of the Quality Network for Inpatient CAMHS (QNIC).

However,

  • There were ligature points throughout the hospital. Two bedrooms designated as safer rooms still had significant ligature risks. The patients had unrestricted access to a laundry room with did have ligature points including electric plugs, cables and exposed pipes. This room was not included in the ligature audits.
  • There was a high use of temporary staff to cover for staff vacancies.

Inspection carried out on 20 - 21 January 2015

During a routine inspection

The Priory Hospital North London is registered to provide the following regulated services / activities:

  • Accommodation for persons who require treatment for substance misuse
  • Treatment of disease, disorder or injury
  • Assessment or medical treatment for persons detained under the 1983 Act
  • Diagnostic and screening procedures

It provides a range of specialisms including caring for children, caring for people whose rights are restricted under the Mental Health Act, people with mental health conditions, and people with substance misuse problems.

The service has three wards:

Birch Ward

Core service provided: Child and adolescent mental health wards

Male/female/mixed: Mixed

Capacity: 13 beds

Oak Ward

Core service provided: Child and adolescent mental health wards

Male/female/mixed: Mixed

Capacity: 9 beds

Lower Court

Core service provided: Acute wards for adults and Substance misuse services

Male/female/mixed: Mixed

Capacity: 28

The inspection found that the service provided by The Priory North London had many good aspects. The service followed national guidance, developing clear therapy programmes, which were delivered in the most part by skilled staff. Most aspects of people’s care was planned for in a holistic manner. When incidents occurred these were reported by staff and learning points were identified and acted upon by management. The service had had a high level of nurse staffing vacancies, but had ensured that staffing levels were maintained at safe levels by using bank and agency staff.

However, we found some areas the service needed to improve: People’s mental capacity to consent to each aspect of care and treatment was not always being assessed robustly; the Lower Court ward was not managed in a manner which ensured it followed single gender guidance; and there were some maintenance concerns in the child and adolescent wards.

Inspection carried out on 25 February 2014

During an inspection to make sure that the improvements required had been made

We undertook this inspection to check whether improvements had been made since our last inspection in April 2013. At the inspection in April 2013 we found many care plans had not been reviewed within expected timescale and there was a risk that care plans did not address patients’ current needs. In addition, information recorded in patients’ electronic records sometimes conflicted with information given to staff about their care needs and status under the Mental Health Act 1983.

At this inspection we found that improvements had been made. We reviewed the health care records of eight young people admitted to the adolescent unit and found that most care plans and risk assessments were up to date and had been reviewed in accordance with specified dates. This ensured care plans reflected the current needs of patients. Patient records were accurate and fit for purpose.

Inspection carried out on 18 April 2013

During a routine inspection

During this inspection we visited the adolescent unit and the addictions treatment programme. We spoke with several young people who were admitted to the adolescent unit. Most patients were satisfied with the care and treatment provided. One patient told us that their care was “good” and staff were “nice.” Comments from patients who had completed patient satisfaction questionnaires on the adult ward and from those taking part in the addictions treatment programme included “I felt safe, secure and cared for” and “very caring and committed staff.”

Patients were satisfied with the environment in which they received care, although the adolescent ward was described as generally quite hot and lacking ventilation. Appropriate arrangements were in place to ensure that medicines were managed safely. Complaints about the service were investigated and managed appropriately.

However, we found that not all care plans and risk assessments were reviewed in line with specified review dates in order to ensure that patients’ individual needs were being met. Records kept in respect of patients’ care and treatment were not always accurate and could not always be located promptly. Information provided to staff about patient care, legal status and capacity to give consent was sometimes contradictory or was not always immediately available to them.

Inspection carried out on 13 November 2012

During an inspection to make sure that the improvements required had been made

We carried out this unannounced inspection to check if the provider had made improvements on the adolescent unit following an inspection of the service in May 2012. There were 13 young people admitted to the unit on the day of our visit.

During this inspection we observed that the young people on the unit were provided with education, individual and group therapy and recreational activities throughout the day and evenings. These mostly took place as planned. However, one young person told us, “weekends are long and boring; those are the two days I hate.”

Staff received appropriate training and support to enable them to deliver the care to the young people that they needed. Most staff we spoke with demonstrated a detailed understanding of the individual needs of the young people they supported. There were sufficient numbers of staff available to care for the young people on the unit.

A detained patient we spoke with understood their legal status and rights under the Mental Health Act 1983 and records pertaining to their detention were located promptly and were accurate.

Inspection carried out on 28 May 2012

During a routine inspection

During our visit to The Priory Hospital North London we visited the adolescent unit. We spoke to four of the 18 young people who were patients on the unit at the time. The young people said they did not feel safe or protected particularly from some of the other young people. Staff were described as ‘not in control’ of the unit and they felt that concerns for their personal safety were not taken seriously by staff. The young people told us there were not enough activities provided for them, particularly at the weekends. Those that were scheduled often did not take place. One young person described the weekends as ‘awful’.

Three of the young people we spoke with told us there were usually not enough staff on duty to meet their needs. This meant that they were often unable to go outside for a walk. Those not receiving one-to-one care had little time with staff and their needs were not always met.

We found that agency staff did not always receive an adequate induction when they came to the ward. An agency nurse induction checklist had been prepared by managers but was not yet in use. A typical comment we received from one young person was, ‘agency staff don’t know about young people’. This meant there was a risk that agency staff were not appropriately supported to enable them to deliver care to the young people safely.

Evidence of the legal detention of one young person in the hospital could not be located on the day of our visit. This could have resulted in a failure to uphold the person’s rights under the Mental Health Act 1983.

Inspection carried out on 21 July 2011

During an inspection to make sure that the improvements required had been made

Patients told us that they were happy with the care they received at the hospital. Group and individual therapy was provided on a regular basis. Staff were described as ‘sincere, kind-hearted and genuine’. Young people on the adolescent unit took part in regular activities and school work and were enabled to keep in contact with their families. Plans of care and treatment were individualised and patients were agreed their weekly programme of activity with staff. Treatment, including medication, was explained in ways that could be easily understood by patients. Patients felt that staff had time for them. One comment we received typified this: ‘staff always want to know how you are doing; they stop and ask you how you are feeling’.

Inspection carried out on 21 October 2010

During an inspection in response to concerns

We visited two wards in the hospital, the adult Ward and the adolescent Ward. Young people on the adolescent Ward told us they took part in a range of therapies and activities. One said they had found the therapy ‘very helpful’ and commented that ‘staff don’t push too much and also don’t let me sit back either’. They said that therapy had helped them to express their feelings more and they liked the support they got from other young people. One said ‘it feels like being part of a family’. They told us that a community meeting was held every morning for staff and young people and that at the meeting the ‘young people can have their say’ and their views are ‘taken on board by staff’.

Negative comments we received from the young people included ‘we don’t get talked to enough’ by staff and some staff interact with the young people whilst others do not. One young person said that they sometimes found it hard to approach staff directly and would like staff to take the initiative more in approaching them. One young person said that staff ‘say they can’t take you out because they are too short staffed’; and another told us ‘when things get out of control there are never enough staff’

The patients we spoke to on the adult Ward told us that ‘staff are responsive’ and ‘it is like a hotel here.’ They also said they had regular sessions with a psychologist and that staff ‘are knowledgeable and capable’ and ‘there are loads of activities’ including meditation and board games. Patients said staff were respectful and sensitive in their approach towards them and took notice of patient preferences. Patients on both wards described having a choice of food at meal times including a salad bar and said the food was generally, ‘good’ and ‘properly prepared’

Reports under our old system of regulation (including those from before CQC was created)


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.