Ellern Mede Barnet

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant people were safe and protected from avoidable harm. However, there were improvements needed to the hospital environment and recording of strategies for risk management.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness. They listened to concerns about safety and reported and investigated safety events. Lessons were learnt to identify and embed good practice.

Staff knew what incidents to report and how to report them. Staff we spoke with shared examples of learning from recent incidents, both internal and external to the service, and changes made as a result. For example, changes were made to searches and restricted items following recent incidents.

Most incidents related to planned nasogastric feeding and deliberate self-harm. All nasogastric feeding activities were reported as incidents. Learning included personalised holds following a patient reporting pain after being restrained by staff.

Patients who had been restrained told us that staff had done so safely. There were reports of debriefs and psychology support following restraint incidents.

We reviewed the last 6 months of incident records across the wards. These were thorough and demonstrated an appropriate level of detail and actions taken. Managers reviewed incidents in line with the provider’s policy. We saw evidence that staff and patients were offered post-incident debriefs.

Support was available to staff following incidents, including psychology and management support. The service had a dedicated restrictive practices trainer who supported staff and patients with anticipated incidents and with post-incident debrief and reflection.

Staff and managers discussed incidents and learning in a number of forums, including individual supervision meetings, daily meetings, and clinical governance and the managers’ meetings. Monthly newsletters were shared and learning from incidents was part of mandatory e-learning. Managers noted that they were providing staff with training in Dialectical Behaviour Therapy (DBT) to meet the more complex needs of patients being admitted to the service.

The duty of candour is a statutory duty that requires registered providers to act in an open and transparent way with people receiving care or treatment. This includes specific requirements for certain notifiable safety incidents. Staff completed mandatory training in duty of candour, with 100% compliance.

The service had recently adopted the PSIRF (Patient Safety Incident Response Framework developed by the NHS). A dedicated patient safety lead oversaw incidents which met the PSIRF thresholds.

We scored the service as 3. The evidence showed a good standard. The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. They made sure there was continuity of care, including when patients moved between different services.

The hospital received referrals from national NHS commissioners, as well as from overseas. The service’s referral and admission processes ensured that all essential information about the patient was received to determine if their needs could be met safely. Staff discussed upcoming admissions and discharges in daily meetings and managers attended weekly patient flow meetings with local system partners.

Decisions about the most appropriate ward for admission were made by the multidisciplinary team. Patients needing a higher level of physical health support were usually first admitted to Rowan ward (previously a ward for young people).

Staff involved relevant health and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. These included the local acute hospital, GPs, and community teams. Staff worked closely with the NHS commissioners who provided input and support.

In the care and treatment records we reviewed, we saw evidence of effective discharge planning. Discharge plans were discussed in pre-admission meetings and throughout the treatment journey.

Due to the level of complexity involved and appropriate support required on discharge, lengths of stay at the hospital varied. Carers we spoke with said they found the discharge planning process clear.

We scored the service as 3. The evidence showed a good standard. There were clear safeguarding processes in place with all concerns taken seriously and addressed promptly. The service worked to improve patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service had established robust safeguarding systems. All staff were trained in safeguarding adults and children up to level 3, with managers completing training up to level 5. All staff were trained in PREVENT (training aimed at safeguarding people from the risk of radicalisation and extremism) and professional boundaries. Staff received safeguarding supervision every 4 to 6 months.

The service had a dedicated social worker safeguarding lead who was embedded in the multidisciplinary team and easily accessible to staff and patients, alongside the hospital director clinical services manager and medical director. The lead attended safeguarding, risk and handover meetings and offered individual support sessions to staff. Learning from the outcomes of safeguarding cases was shared with staff as part of mandatory training. Records on the safeguarding log were comprehensive and up-to-date. There were regular safeguarding audits that supported identifying themes and monitoring safeguarding supervision and training compliance.

Staff we spoke with knew how to recognise individuals at risk of suffering harm and were aware of the risks specific to their patient group. Staff gave examples of how to protect patients from discrimination, including those with protected characteristics under the Equality Act 2010, For example, autistic patients. Staff escalated concerns appropriately to managers and when required, worked in partnership with the local authorities and police. The service had effective mechanisms to link with the relevant authorities when patients were admitted from out of area or overseas.

Stakeholders from partner agencies were positive about the safeguarding arrangements within the service, noting that the service was an active partner in the Barnet Safeguarding Partnership Board.

The service maintained a blanket restriction register and reviewed it monthly. Restrictions in place were proportionate to maintain a healthy and safe environment. For example, items known to be a risk of causing harm were not permitted on the ward.

We scored the service as 2. The evidence showed that there were areas for improvement in staff recording of observation, assessment and management of risks to patients and themselves. We also found several areas of good practice. Staff followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint only after attempts at de-escalation had failed. Staff participated in the provider’s restrictive interventions reduction programme.

We reviewed 6 care and treatment records. Each contained a personalised risk assessment completed on admission and reviewed regularly thereafter, including after incidents. However, 4 of 6 patient risk formulations we viewed did not lead to a clear strategy to manage identified risk. Without a management strategy, there is risk that not all staff would know how to manage a risk and/or triggers in a timely and consistent way.

We found that several psychology action plans and personal emergency evacuation plans contained standardised information rather than personalised information about the support each patient would need.

Staff carried out different levels of observations and reviewed these based on individual need and risk. We reviewed a sample of observation records which contained comprehensive details of patients’ presentation at each observation point. However, we found some variation in how staff completed intermittent observations, with some randomised and some recorded at set intervals, meaning they were predictable. This was in contrast to the provider’s policy on Therapeutic observations (Feb 2026), which required staff to carry out observations at randomised times.

We found several areas of good practice. We spoke with 7 patients and 5 carers, who told us that they, or their relatives, felt safe at the hospital. Staff we spoke with demonstrated a good understanding of each patient and their individual risks. They discussed risks, and any changes to risks daily.

There was evidence of patients’ voice in the records we viewed.

Staff we spoke with demonstrated commitment to reducing restrictive practices and using restraint only as a last resort. For example, introducing food exposure, and naso-gastric feeding ‘holidays’ (a planned break from any restraints to provide naso-gastric feeding.) Regular audits covered incidents requiring restraint and staff restraint training. There was no use of chemical restraint, seclusion or long-term segregation. A dedicated restrictive practice trainer supported staff and patients with de-escalation and identifying the least restrictive interventions to use. Restrictive practice meetings were held twice monthly to review incidents and practice.

Patients we spoke with who had been restrained during nasogastric feeding told us they understood the reason for this and said that staff had done so safely.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Staff completed regular risk assessments of the care environment. Staff completed relevant mandatory training, with 100% compliance in health & safety and fire safety training.

Staff had access to alarms and patient rooms had nurse call systems. Staff completed risk assessments for potential ligature anchor points and mitigated the risks adequately.

Most bedrooms were single occupancy and all bedrooms had an en-suite bathroom. Two bedrooms were dual occupancy. One bedroom was fitted with padding for the protection of patients at high risk of self-harm.

Clinic rooms were equipped with appropriate equipment that was checked and calibrated regularly. However, the clinic room was too small for naso-gastric feeding to be carried out safely without removing several large items. Bedrooms were also small for this purpose, but were used for most patients requiring this intervention. One patient told us that they were unhappy about receiving naso-gastric feeding in their own bed.

CCTV was in operation in communal and clinical areas. CCTV records were used to review incidents.

A fire risk assessment was last carried out in September 2025 and the most recent fire evacuation drill was carried out in March 2026. Staff completed personal emergency evacuation plans (PEEP) for relevant patients, but these were found to be standardised rather than specifying the support each patient needed to evacuate the hospital. Although there were stoppers available on each door, staff allowed several patients’ doors to be propped open with objects, which we highlighted to staff during the inspection as a potential risk to fire safety.

The provider acknowledged that the hospital environment needed an uplift. There was a plan in place to renew paintwork both internally and externally and change the flooring on the main stairway. At the time of the inspection the annex was in the process of being refurbished.

Bedroom doors were not fitted with the most up to date features to support safe care in mental health settings. Only 2 patient bedroom doors had viewing panels, and no bedroom doors were anti-barricade. The provider advised that they were aware of this and were planning to upgrade the doors.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met patients’ individual needs.

The hospital was fully staffed to safely meet the needs of patients. We saw that staff were present in communal areas and engaging with patients. Despite this, some patients told us that staffing levels were not enough to support with activities when activities staff were absent.

Over the last 12 months, staff turnover had been at 15% (17% turnover of nurses) and sickness had been at 2%. At the time of the inspection there were no vacancies for nursing staff, with 2 nurses and a new occupational therapist having been recruited. Managers advised that there was overstaffing of non-registered nurses to meet a high level of enhanced observations at the time of the inspection. Managers reviewed staffing levels daily and adjusted those according to the changing needs. The service used their own part-time bank staff who were familiar with the wards. There was no agency staff use.

There was adequate medical cover day and night and a doctor could attend quickly in an emergency. Senior managers and doctors were part of the on-call rota out of hours. Staff were fully up to date with training in basic and immediate life support and first aid. There were also monthly, unannounced emergency simulation drills including resuscitation techniques and other emergency scenarios.

Staff participated in regular training, appraisal and supervision and managers monitored the completion rates. These were consistently high, with 99% overall compliance with mandatory training, and 100% with clinical supervision. Training and induction were tailored to the needs of the patient group. All staff had completed the Oliver McGowan Tier 2 mandatory training on learning disability and autism.

There were enough staff to carry out physical interventions safely. Staff had received accredited training to do so, with 100% compliance, and had support from a dedicated physical interventions trainer.

Managers ensured safe recruitment of staff. This included disclosure and barring and right to work checks, and where relevant, evidence of continued professional registration.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff adhered to infection control principles, with 100% compliance with hand hygiene and 98% staff completion of infection control training.

Wards were visibly clean and had appropriate furnishings which were well-maintained. Staff maintained clinical equipment well and kept it clean.

Cleaning records were kept up to date by the provider’s housekeeping team and demonstrated that all ward areas were cleaned regularly. Carers we spoke with described the hospital environment as clean.

The sharps bin in the clinic room was overfull at the time of the inspection. This was addressed by staff immediately.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences.

Staff followed systems and processes to prescribe and administer medicines safely. Staff regularly reviewed the effects of medicines on each patient's mental and physical health. Staff told us that the pharmacist visited the unit regularly and checked the legality of prescriptions and informed prescribers if there were any issues. We saw evidence that Mental Health Act consent to treatment forms were in place as appropriate. No patients were self-medicating at the time of the inspection.

Medicines care plans were electronically documented and were patient centred. Staff recorded the reason for the use of ‘when required’ (PRN) medicines.

Medicines were stored safely and securely within the locked treatment room. Staff had access to controlled drugs storage facilities that met legal requirements, but the key to this facility was broken at the time of the inspection. Staff had reported this issue as appropriate. There were no controlled drugs in stock at the time of the inspection.

Temperature readings for medicines storage areas were appropriately monitored and within the recommended range. Emergency medicines and equipment were in place and checked regularly.

We saw evidence of medicines competency assessments for staff responsible for administering medicines, including the management of percutaneous endoscopic gastrostomy (PEG) tubes.

The provider had a system in place to ensure staff knew about safety alerts. Staff told us that medicines related incidents were reported and investigated. The pharmacist attended the monthly governance committee meeting and produced a medicines report summary on themes and trends in incidents.

The clinic room on Ash ward was very small. As a result, stock items were stored in piles, making them difficult to locate. We found there was a tympanic thermometer that was out of date and raised this with the provider for immediate action.