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Priory Hospital Enfield Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 June 2018

We rated The North London Clinic as requires improvement because:

  • The senior leadership team of the hospital had been unstable since the hospital’s merger with another provider in December 2016, which meant there had been inconsistent leadership. Although there was a governance framework in place, new systems and processes had not yet been fully embedded since the merger, and staff could not always find key information to help them deliver their role effectively.

  • There had been a high turnover of ward managers, which meant there was a lack of leadership and experience at ward level. Most deputy ward manager posts were vacant, which meant ward managers did not always have sufficient leadership support on the wards. Staff morale was low.

  • There was a high vacancy and turnover rate for the nursing teams across the hospital. This had led to an over reliance on bank and agency staff.

  • Physical healthcare monitoring was not being carried out consistently to meet the individual needs of patients. There was no effective oversight of physical health monitoring systems within the hospital.

  • The hospital did not have enough personal alarms for all staff and external visitors, and they were not all in working order.

  • The hospital did not ensure there were effective systems in place for all staff to hear about and learn from incidents and complaints. Team meeting minutes did not demonstrate that they happened every month as managers said they should. Care record audits were not being carried out.

  • Patients who were detained had limited access to an Independent Mental Health Advocate.

  • The wards did not always promote patient recovery. The wards were not well maintained and did not provide a therapeutic environment. The hospital did not ensure staff engaged with patients following a seclusion episode, which meant patients were not provided with a de-brief and offered any additional support they may have required.

  • Carer needs were not always being met. Carers reported that communication could be improved between carers and staff at the hospital.

We found these areas of good practice:

  • There was a proactive approach to anticipating and managing individual risks for patients. Up-to-date risk assessments and management plans were in place for all patients. There were systems in place for safeguarding patients.

  • Patients’ needs were fully assessed. Care plans were comprehensive, holistic and person centred. Patients co-produced their care and risk management plans. The hospital provided a range of psychological therapies and interventions recognised by guidance from the National Institute for Health and Care Excellence.

  • The hospital was good at involving patients in their care and treatment. There were opportunities for patients to feedback on the services they received at the hospital.

  • Patients were supported with their recovery journey. There was an extensive programme of individual and group activities that reflected patients’ individual needs and preferences.

  • The hospital’s risk register matched staff concerns and our concerns found during the inspection. Detailed plans were in place to make improvements and senior management discussed the risk register regularly. Leaders had recognised the recent hospital merger had been a challenging time for staff, and had been proactive in engaging with staff and working to improve morale.

Inspection areas

Safe

Requires improvement

Updated 22 June 2018

We rated safe as requires improvement because:

  • The hospital did not ensure there were effective systems in place for learning and dissemination of incidents and complaints to all staff. The hospital did not ensure staff engaged with patients following a seclusion episode. This meant patients were not provided with a de-brief and offered any additional support they may have required.

  • Not all of the personal alarms were working on the first day of inspection and where staff had highlighted alarms were not working, these had been sent for repair. Staff had been reminded to escalate where alarms were not working.

  • The wards were not well maintained and did not provide a therapeutic environment for patients. Wards required redecoration, some items were broken and furniture was in need of replacement. This issue was already highlighted on the hospital’s risk register and an estates plan was in place to make improvements to the environment.

  • There was a high vacancy rate for registered nurses and a high turnover rate for the hospital. This had led to an over reliance on bank and agency staff. Patients said agency staff did not always understand their specific needs. Three patients and one staff member said that sometimes patients did not get a fresh air break due to short staffing or agency usage.

However:

  • Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs. Staff across the wards carried out checks to ensure equipment was clean and well-maintained and staff checked emergency drugs daily.

  • There was a proactive approach to anticipating and managing individual risks for patients. Up-to-date risk assessments and management plans were in place for all patients.

  • Seclusion rooms met the design requirements of the Mental Health Act Code of Practice. Staff used seclusion appropriately and conducted the appropriate nursing and medical reviews whilst a patient was in the seclusion room. The hospital participated in a restrictive interventions reduction programme and only used restraint after de-escalation had failed.

  • Good systems were in place for safeguarding patients. The hospital had a safeguarding tracker system and proactively monitored the progress of safeguarding investigations.

Effective

Requires improvement

Updated 22 June 2018

We rated effective as requires improvement because:

  • Physical healthcare monitoring was not being carried out consistently to meet the individual needs of patients effectively, particularly in the management of patients with diabetes. There was no effective oversight of physical health monitoring system within the hospital.

  • Patients who were detained had limited access to an Independent Mental Health Advocate (IMHA). An IMHA provides an additional safeguard for patients who are subject to the Mental Health Act and helps them to understand their position including their rights and aspects of their treatment.

  • Team meeting minutes did not demonstrate that they happened every month as managers said they should.

  • Physical health monitoring and care record audits were not being carried out.

However:

  • Patients’ needs were fully assessed. Care plans were comprehensive, holistic and person centred. Patients co-produced their care and risk management plans.

  • An effective multidisciplinary team, who worked in collaboration with other organisations and agencies, supported patients.

  • The hospital provided a range of psychological therapies and interventions recognised by guidance from the National Institute for Health and Care Excellence.

  • New staff received an induction. Staff had access to mandatory and specialist training for their roles.

Caring

Good

Updated 22 June 2018

We rated caring as good because:

  • We observed most staff interactions with patients were kind, positive and responsive.
  • Staff supported patients to understand their care and treatment, and most patients said they felt involved in their care.
  • The hospital was good at involving patients in their care and treatment. Patients chaired daily morning meetings to plan their activities for the day and developed their care plans with staff. Patients worked with the occupational therapist to develop their activities timetable.
  • There was a service user liaison role at the hospital. Patients in this role sat on the hospital reduce restrictive practice group.

However:

  • Some carers reported that the communication with hospital staff was poor.

Responsive

Good

Updated 22 June 2018

We rated responsive as good because:

  • Patients were supported with their recovery journey. There was an extensive programme of individual and group activities that reflected patients’ individual needs and preferences. Patients accessed a dedicated recovery college, which supported them with their rehabilitation and discharge plans.

  • Staff supported patients to maintain contact with their families and carers.

  • Patients spoke positively about the choice and quality of food, which met their religious, cultural and dietary needs.

  • Information on how to make a complaint was displayed throughout the service. Patients were able to give feedback on the quality of their experience and their concerns and complaints were addressed.

However:

  • Ward environments were not well maintained and did not promote a therapeutic environment to support recovery.

  • Staff did not receive feedback on the outcome of complaints investigations.

Well-led

Requires improvement

Updated 22 June 2018

We rated well-led as requires improvement because:

  • The senior leadership team of the hospital had been unstable since the Priory Group merger in December 2016. There had been a high turnover of senior managers, which meant there had been inconsistent leadership.

  • The hospital had a governance framework in place, however, due to the recent hospital merger, the framework was still not yet fully embedded to ensure it was fully effective in identifying risks and areas of improvement. Staff were still getting used to the new IT systems, and did not always know how to access key information, such as complaints or ligature risk assessments.
  • There had been a recent turnover of ward and deputy managers. Ward managers were inexperienced in the role or new to the organisation. Whilst the organisation was recruiting to the deputy posts at the time of the inspection, ward leadership and support was not robust

  • Confidential papers were not always secured securely on the wards.

  • Staff did not undertake regular and systematic audits to monitor the quality of care records and physical health support.

  • Staff morale was low. Staff said this was due to low staffing levels on the wards, high turnover of staff and the recent merger with another provider. This had been highlighted on the hospital’s risk register and plans were in place to improve morale.

However:

  • Leaders were visible and approachable, and they attended regular staff and patient meetings.

  • Leaders had recognised that the hospital merger had been a challenging time for staff, and had been proactive in engaging with them to gain their feedback and improve morale via the recent introduction of ‘you say’ forums.

  • The hospital’s risk register matched staff concerns and our concerns found during the inspection. There were detailed plans in place to make improvements. Senior management reviewed and updated the risk register in clinical governance meetings, and had developed an improvement plan to address the areas identified on the risk register.
Checks on specific services

Forensic inpatient or secure wards

Requires improvement

Updated 22 June 2018

Long stay or rehabilitation mental health wards for working age adults

Updated 28 July 2015

The long stay/rehabilitation mental health wards for working-age adults were safe, effective, caring, responsive and well-led. Patients had up to date risk assessments and were involved in writing these. Actions were taken to minimise the risks to patients. Emergency equipment was accessible and being checked regularly by staff. There were enough staff to care for patients safely. Staff knew how to recognise different forms of abuse and how to report it in order to keep people safe.

Comprehensive and detailed assessments of patients' mental and physical health needs were carried out. Care plans were up to date, holistic and recovery orientated and addressed any needs identified. Patients received good physical health care and had access to a physical health nurse and GP when required. Staff received appropriate training, supervision and appraisal. Patients had good access to psychological therapies. The service had a strong multi-disciplinary team who worked very well together. Staff showed good understanding of the Mental Health Act 1983 and the Mental Capacity Act 2005. Patients had their rights explained to them on a regular basis. There was a good range of group and individual activities available. Everyone had an individual activities and therapies timetable. Staff promoted community integration and social inclusion and supported patients to use local community facilities to support their recovery.

Staff were positive, kind and caring. Staff knew about the holistic care needs of individual patients and how best to work with them. Patients were routinely involved in their care planning, ward rounds and CPA reviews. Families and carers were welcome on the ward and involved in care planning and decision making. Patients were treated respectfully by staff.

The meals that were provided were of good quality. Many patients prepared their own meals, some with support from staff. Patients knew how to make a complaint and these were responded to appropriately. Patients and staff were actively encouraged to record all complaints, even minor ones, so that improvements could be made.

Staff understood and shared the values of the organisation. They were committed and passionate about the work they did. The ward was well-led. There was an open culture and staff felt able to raise any concerns they had. They were encouraged to put forward their ideas for improvements and share learning. There was clear a commitment to continual improvement.