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Priory Hospital Enfield Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 13 December 2021

Our overall rating for the service stayed the same. We rated it as Requires Improvement because:

There were lots of staff vacancies and the services relied on temporary staff to ensure the wards were safely staffed. This affected the continuity of care for patients, who reported that they were not always familiar with the staff who cared for them.

Staff on the forensic wards did not always make the necessary physical health checks when patients had received medicines by intramuscular rapid tranquilisation. This meant that potentially harmful physical health deterioration may not be identified and acted on by staff.

Staff had not taken any action to escalate problems with emergency alarms not working in two bedrooms on Coleridge ward a forensic service. This meant that staff or patients requiring assistance in an emergency in these rooms would not be able to call for assistance.

Patients on Blake ward, the acute ward for adults of working age, reported that there were not enough therapeutic activities to keep them occupied and they did not have access to support from an occupational therapist. Patients on the forensic wards reported that there were not enough activities to keep them occupied during evenings and at weekends.

The forensic mental health ward environments were not therapeutic in nature and the provider had made very limited progress in improving the ward environments since the last inspection.

The service had not yet made much progress with its approach to reducing restrictive interventions, like restraint and seclusion. The reducing restrictive interventions project group was newly formed and was not systematically reviewing themes and trends from data about the use of restrictive interventions.

Some concerns identified during the inspection had not been identified by the provider through their internal governance assurance processes.

However;

The ward environments were clean. Blake ward had recently opened as a new acute mental health ward. The provider had completed a robust programme of environmental works to ensure the ward was fit for its intended use.

Patients told us they had good therapeutic relationships with the regular staff who worked on the wards.

Patients were encouraged to give feedback on their experience and the quality of the service. They also contributed to discussions about their care and treatment and were given treatment options where appropriate.

A positive staff culture meant that staff felt well supported in their roles and could access support from colleagues. Leaders were committed to delivering a high-quality service and supporting staff. They managed to provide enough support to staff and oversight of wards despite some ward manager posts not being filled at the time of the inspection.

Improvements had been made since the last inspection. These included learning from incidents, patients knowing how to access IMHA, and access to personal emergency alarms.

Different members of the multi-disciplinary staff team were dedicated to supporting patients in their recovery. They explained how they tailored their approach to individual patients and supported patients to re-integrate to the community and boost their skills and experience where appropriate.

Staff held close professional links with colleagues in other agencies and teams which helped them plan for effective patient discharge.

Inspection areas

Safe

Requires improvement

Updated 13 December 2021

Effective

Good

Updated 13 December 2021

Caring

Good

Updated 13 December 2021

Responsive

Requires improvement

Updated 13 December 2021

Well-led

Good

Updated 13 December 2021

Checks on specific services

Wards for people with a learning disability or autism

Updated 28 July 2015

Forensic inpatient or secure wards

Requires improvement

Updated 13 December 2021

Staff did not always monitor patient’s physical health to detect potential deterioration when they had received medicines by intramuscular rapid tranquilisation. We identified one example where a patient living with a significant long-term physical health condition had not been subject to routine physical health monitoring after receiving antipsychotic medicine via intramuscular rapid tranquilisation.

Staff had not taken any action to escalate problems with emergency alarms not working in two bedrooms on Coleridge ward, despite them being checked and recorded by staff as not working for weeks before the inspection. This meant that staff or patients requiring assistance in an emergency in these rooms would not be able to call for assistance if needed.

Challenges with staff recruitment and retention were ongoing. Some staff and patients reported that Section 17 leave was often re-arranged at short notice because staff were too busy to facilitate it as planned. Staff shortages were identified during the last inspection in April 2018 and this continued to be a challenge. Leaders were working hard to reduce the number of vacant posts across the hospital.

The ward environments continued to appear sterile and were not therapeutic in nature, despite this being identified as needing attention during the last inspection in April 2018. This issue continued to feature as one of the top risks on the hospital risk register and not much progress had been made.

The service had not made much progress with its reducing restrictive interventions programme. The reducing restrictive interventions project group was newly formed and was not systematically reviewing themes and trends from data about the use of restrictive interventions.

Some patients reported that there were not enough activities to keep them occupied at evenings and weekends.

Some issues identified during the inspection had not been identified by the provider’s internal governance assurance processes. These included discrepancies with patient risk assessments, emergency alarms not working, inconsistencies with how general observations were recorded and an issue with medicines storage.

However,

Some improvements had been made since the last inspection. Staff now systematically learnt from incidents and complaints, patients knew how to contact the independent mental health advocate and there were now enough personal emergency alarms for staff to wear.

The ward environments were safe and clean, and staff followed good practice with respect to safeguarding. Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice.

Although the ward teams had access to the full range of specialists required to meet the needs of patients on the wards, there were some staff vacancies within these specialist disciplines, such as occupational therapy and psychology. This meant that these staff needed to carefully prioritise their workloads and work across multiple wards. Managers ensured that staff received training, supervision and appraisal. All staff worked well together as a multidisciplinary team. Staff worked very closely with colleagues at other providers through the North London Forensic Consortium, to help plan for discharge and aftercare. Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Face to face feedback clinics had been introduced by the complaints manager, which has improved patient satisfaction and resulted in a reduction in formal complaints. Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason. Staff supported patients to integrate with the wider community and supported patients to develop their skills and experience to help them secure potential employment in future.

The service was led by a dedicated and skilled senior team. Senior staff were dedicated to supporting ward staff as best as they could whilst arrangements were being made to cover the ward manager posts on Byron and Coleridge ward. The staff culture was positive. Staff reported that they enjoyed working at the service, felt well supported and valued by their colleagues and were able to raise concerns without fear of retribution.

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

Good

Updated 13 December 2021

Blake Ward had been refurbished to a high standard prior to reopening as an acute ward for working age adults in the summer of 2019.

Staff spoke positively about the practical and emotional support provided by staff and support to understand and manage their own care, treatment or condition.

Patients said staff treated them well and behaved kindly and they felt safe on the ward. Patients told us that staff listened to feedback.

Staff recorded detailed, comprehensive, and holistic care plans and risk assessments for patients on the ward, with some evidence of patient involvement. Staff identified patients’ physical health needs and monitored patients’ physical health using National Early Warning Score charts, identifying when specialist input was required, for example a dietitian to ensure that dietary and hydration needs were met.

Staff spoke positively about support from senior managers and the ward manager and deputy, and they described good multi-disciplinary team work on the ward.

Staff were able to tell us about learning from incidents on the ward, and within the wider provider organisation.

We spoke with one family member of a patient on the ward, who spoke positively about their involvement in their relative’s care, and inclusion in ward meetings via a video call.

However:

The service did not provide enough therapeutic activities for patients. There was no occupational therapist in place at the time of the inspection and patients complained that they were often bored. There were also no group psychology sessions in place and patients did not have routine access to a computer with internet access.

There were significant staff vacancies on Blake Ward although there was an ongoing recruitment programme in place, leading to some difficulties finding substantive staff cover for the ward at all times.

A large quantity of a controlled medicine was identified on Blake ward that should have been safely destroyed when it was no longer required, approximately two months before the inspection. Not all staff were aware of the provider’s procedures for the safe destruction of controlled medicines. The medicine had been stored safely and was destroyed promptly when we notified the provider.

There were problems with the ventilation on Blake Ward which had led to the ward being overly hot during the summer months.

Staff did not always record that they had repeated rights under Section 132 of the Mental Health Act to patients after their admission, as necessary to ensure that they had understood them, or best interest decisions for patients who lacked capacity to consent to treatment.