North London NHS Foundation Trust

Updated 27 January 2023

Our rating of the trust stayed the same. We rated it as good because:

• We rated two of the core services we inspected comprehensively as good overall and one as requires improvement overall. Following the inspection, seven of the trust’s core and specialist services in the trust were rated good overall and one was rated as requires improvement overall.
• We rated well-led for the trust overall as good.
• There was good, effective leadership at all levels of the organisation. The trust senior leadership team was visible across the trust and modelled openness and transparency. The board and senior leadership team had set a clear strategy and staff were aware of what it was. Since the last inspection, the trust had refreshed their strategic priorities.
• The trust worked effectively in partnership with other stakeholders across north London. It had entered a formal alliance with Barnet, Enfield and Haringey NHS Mental Health Trust, which was progressing well. It had continued to work with people using its services to develop innovative models of care. It had an excellent clinical strategy that guided its work and service developments.
• Clinical premises where patients received care were mostly safe, clean, well equipped, well furnished, well maintained and fit for purpose. The wards at St Pancras hospital did not provide a good environment for patient care, but the trust had undertaken remedial work to address risks and had plans to build new wards.
• The service had enough staff, who knew the patients and received statutory and mandatory training to keep patients safe from avoidable harm. The trust had worked hard to reduce its vacancies and develop new roles. Since the last inspection published in March 2018, the trust had reduced the size of the team caseloads in its mental health crisis services. Nevertheless, some teams and wards continued to have challenges with staff vacancies although temporary staff were used where needed.
• Staff across the trust worked hard to reduce the use of restrictive interventions. Most acute wards for adults of working age and psychiatric intensive care units had taken part in the Safewards initiative and initial data showed reductions in restrictive interventions.
• Staff provided care that was personalised, holistic and recovery-oriented. Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. Staff were proactive in involving families and carers in patient care, when appropriate.
• The trust had systems in place for escalating and gaining assurance on risk. This included the corporate risk register and board assurance framework. It had appropriate arrangements in place to oversee the management of medicines, the Mental Health Act and safeguarding.
• Services treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and wider services.
• The trust engaged positively with service users and staff. This included a wide range of co-production work. The trust was also extending the number of peer support workers. Plans were in place to develop a trust strategy for user involvement and to ensure this was embedded throughout the organisation. The trust was working to improve staff health and well-being, for which it had produced a strategy.
• Staff had been engaged in various ways to learn, improve and innovate and were given time to do this in their day to day roles. The trust was committed to delivering a Quality Improvement (QI) programme and had invested in this across the organisation. The QI programme had flourished since the last inspection and was well embedded across the trust

However:

• The trust was experiencing high demand for its acute wards for adults of working age and psychiatric intensive care units. When beds were not available, some patients had to be placed in beds in external hospitals in the private sector, which may be out of the local area, and on temporary beds that compromised their privacy and dignity.
• Patients identified as in need of a Mental Health Act (MHA) assessment were not always assessed promptly. Staff did not complete some assessments for more than four weeks due to delays in obtaining a warrant and accessing support from the police, who only provided limited time-slots to support assessments. Staff continued to monitor patients waiting for assessments and would offer more intensive support to patients where this was possible.
• Some community-based mental health services for adults of working age teams, and individual members of staff in these teams, had caseloads that were too high to allow the staff to give each patient the time they needed.
• The trust was completing serious incident investigations appropriately, but it was continuing to miss the timescales. Whilst the senior leaders were aware of this and plans were being considered to establish a central team to undertake this work as part of the alliance, these improvements were not yet taking place
• The trust had started work to meet the needs of staff and patients with protected characteristics, but more work was needed. For example, staff networks required strengthening. This work needed further promotion so that the trust could become a beacon of good practice.

Updated 6 May 2025

We carried out a comprehensive assessment of all mental health wards for adults of working age and psychiatric intensive care units (PICU) delivered by North London NHS Foundation Trust. We inspected 20 wards across 4 sites between 10 February and 4 March 2025.

The wards we visited were:

Four wards at Chase Farm Hospital

• Devon Ward (PICU)
• Dorset Ward
• Suffolk Ward
• Sussex Ward

Three wards at Blossom Court, based at St Ann’s Hospital

• Daisy Ward
• Sunflower Ward
• Tulip Ward

Three wards at the Dennis Scott Unit, based at Edgware Community Hospital

• Shannon Ward
• Thames Ward
• Trent Ward

Ten wards at Highgate West Mental Health Centre

• Coral Ward (PICU)
• Ruby Ward (PICU)
• Amber Ward
• Amethyst Ward
• Diamond Ward
• Jade Ward
• Opal ward
• Rose Quartz Ward
• Sapphire Ward
• Topaz Ward

We rated the service as requires improvement.

North London NHS Foundation Trust was formed in November 2024 following the merger of 2 former trusts: Barnet, Enfield and Haringey Mental Health NHS Trust and Camden and Islington NHS Foundation Trust. Prior to the official merger, they operated under a joint leadership team called the North London Mental Health Partnership.At the time of the inspection the organisation was implementing its three year plan for the new trust, in collaboration with the Institute for Healthcare Improvement, to promote quality improvement throughout the organisation.

Barnet, Enfield and Haringey Mental Health NHS Trust was last inspected between October and December 2021. At this inspection we issued 3 requirement notices for breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to the mental health wards for adults of working age and psychiatric intensive care units (PICU). They were, that the trust must ensure action is taken to protect the privacy and dignity of patients using the seclusion room on Trent Ward. The trust must ensure that staff working on acute wards and PICUs that need immediate life support training complete it. The trust must continue to take action to address the high rates of unfilled staff shifts on acute and PICU wards, particularly on Devon, Trent and Daisy wards.

Camden and Islington NHS Foundation Trust was last inspected in November 2022. At this inspection we issued 1 requirement notice for a breach of the Health and Social Care Act (Regulated Activities) Regulations 2014 relating to the mental health wards for adults of working age and psychiatric intensive care units (PICU). That was, the trust must ensure that there are sufficient staff assigned to all wards to ensure the safety of patients and quality of care.

We carried out this comprehensive assessment due to the number of serious incidents and a number of deaths noted within the trust’s inpatient wards. The assessment followed up the themes from these deaths. Between April 2022 and March 2024, there had been 8 deaths in Barnet, Enfield and Haringey Mental Health NHS Trust and there had been 5 deaths in Camden and Islington NHS Foundation Trust.

In the 6 months between September 2024 and February 2025, there had been 4 deaths within the acute and PICU wards.

At this assessment we found areas that needed to be improved. Seclusion reviews did not always happen at the scheduled frequencies. Patient observations across the wards were not always being carried out in line with trust policy. Fire drills and fire risk assessments were not in place across all sites. There were low compliance rates for key training, such as life support and prevention and management of violence and aggression. Staff did not always receive regular supervision and appraisals. Team meetings were not always happening each month. Patients and staff told us there were not enough staff working on the wards. Wards did not use outcome measures to track patient outcomes.

We did find several areas of good practice, including, the majority of staff were positive about working for the trust, and the support they received from their managers. There was good career development for staff and access to further training. Most patients and carers said staff were kind and caring. There were quality improvement projects across the trust, which staff were passionate about. Managers were receptive to feedback from the inspection team and worked to create action plans and solutions.

During this assessment, the inspection team:

• visited 20 wards, including 1 unannounced visit in the evening
• reviewed the environment on each ward and observed staff supporting patients
• spoke with 58 staff including registered nurses, healthcare assistants, activity co-ordinators, psychologists and occupational therapists.
• spoke with 29 ward managers, senior managers, matrons, associate directors of nursing, and a Mental Health Act administrator.
• spoke with 7 pharmacists
• spoke with 12 doctors
• spoke with 56 patients
• spoke with 32 carers
• reviewed the care and treatment records for 52 patients
• reviewed 76 prescription and administration records and associated care records
• attended handover meetings, safety huddles, multidisciplinary team meetings, a formulation meeting, an activity group and community meetings
• reviewed other documents, performance data and policies relating to the running of the service

Action we have taken

We found 13 breaches of the regulations in relation to safe care and treatment, person centred care, staffing and governance.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Mental Health Act and Mental Capacity Act Compliance

Mental Health Act

Most staff were trained in and had a good understanding of the Mental Health Act 1983, the Mental Health Act Code of Practice and the guiding principles. Overall, 83% of staff had received training in the Mental Health Act. However, compliance in this training varied across wards. For example, 100% of staff on Rose Quartz Ward had completed this training, compared to 67% of staff on Devon Ward.

Staff had easy access to administrative support and legal advice on implementation of the Mental Health Act and its Code of Practice. Staff knew who their Mental Health Act administrators were and how to contact them.

Staff explained to patients their rights under the Mental Health Act in a way that they could understand and repeated this as necessary. Most records showed staff recorded when and how they shared the information with patients, and this was done regularly. We reviewed 52 care records across the trust, and we found 6 examples where patient’s rights were not being read regularly.

We saw examples across the trust where patients had been administered medicines that had not been in line with the Mental Health Act consent to treatment authorisations. This was found on Trent Ward, Thames Ward, Sussex Ward and Sapphire Ward.

Staff supported patients to take Section 17 leave (permission for patients to leave hospital) when this had been granted. However, patients and staff told us there were often delays in using escorted leave due to staffing pressures.

Staff requested an opinion from a second opinion appointed doctor when necessary.

Staff stored copies of patients' detention papers and associated records correctly and they were available to all staff that needed access to them.

Patients had access to information about independent mental health advocacy, such as posters on notice boards. However, 12 out of the 56 patients we spoke with said they were not aware of what an advocate was or how to contact them.

Mental Capacity Act

Most staff had completed training in the Mental Capacity Act. Overall, 81% of staff had completed this training. However, some wards had a lower compliance, for example, 56% of staff on Tulip Ward and 60% of staff on Topaz Ward and Devon Ward had completed this training.

For patients who may have had impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. We saw evidence of these assessments in patient’s care records.

Updated 21 June 2016

Overall we rated community mental health services for people with learning disabilities and autism as ‘good’ because:

• Staff undertook comprehensive assessments and developed high quality care plans. The assessment and resulting care plans were personalised and holistic and included the physical health of the patient. Staff made individualised risk assessments at the point of referral to the service, updated these regularly and developed good crisis and contingency plans for each patient. The care plans included the views of the patient.
• Staff followed best clinical practice. They took account of guidelines from the National Institute for Health and Care Excellence (NICE) and used a range of nationally recognised outcome tools.
• Staff worked well as a team and were well supported by their managers. Multi-disciplinary team meetings took place on a regular basis. Staff received regular supervision and 94% of staff had attended their mandatory training; with 96% having attended safeguarding training.
• The service managed referrals and allocations well. There was a single point of referral, all teams met the target for maximum waiting times and a senior nurse monitored the caseloads for each member of staff. Caseloads ranged from eight to 24 patients.
• Patients and carers had a positive experience of care. Staff treated patients with care, compassion and communicated well. The service ensured that patients and their carers know how to make a complaint. Information leaflets were available in both easy to read and standard formats.
• Staff described the electronic system to report incidents and their role in the reporting process.

However:

• Staff reported that they did not have access to lone worker devices.
• There were two electronic recording systems in operation in each team that did not link to each other at all, meaning that information may be entered twice on some occasions or being recorded on one system but not the other. Protocols were in place to address this issue.

Updated 21 June 2016

We rated Camden and Islington NHS Foundation Trust Community-based mental health services for older people as good because:

• Most staff completed a risk assessment of every patient at the beginning of treatment and updated them regularly. Care records reviewed all contained up to date, personalised, holistic, recovery-oriented care plans.
• All care records reviewed all contained up to date, personalised, holistic, recovery-oriented care plans.
• Staff followed National Institute for Health and Care Excellence (NICE) guidance when prescribing medication. Service users within the Camden team had a least two NICE informed interventions on their care plans which included psychological interventions.
• We observed staff interactions with service users and their families in a variety of settings, found that they were responsive, respectful, and provided appropriate practical and emotional support. Staff were committed to working in partnership with people to ensure that the service users felt supported and safe.
• Staff supported families and carers to be involved in the service users’ care. Staff offered families and carers' access to psychological therapies.
• Staff were committed to improving the service by participating in research. They had been innovative in implementing a ‘brain food’ group that was making a positive difference to service users.
• Staff assessed and recorded a person’s capacity to consent following every appointment.
• Team managers assessed and managed caseloads to ensure that all service users were allocated care co-ordinators.
• Team managers had recruited to all qualified nursing posts.They were actively recruiting to fill other vacancies within the multidisciplinary team.
• A duty team was in place across the service to monitor the waiting list. Staff monitored the waiting list to detect service users’ increase in risk or to respond promptly to a sudden deterioration in their health.
• The provider used balance score cards to gauge the performance of the team. The scorecards were available in an accessible format.
• Team managers had a risk register for the service, which they completed and monitored in monthly senior management meetings.
• Across the service, there was 100% compliance for staff attending monthly clinical and managerial supervision.
• Staff reported that they enjoyed their roles and that morale within the team was good.

However

• The recovery team did not update risk assessments when service users were admitted to the service.
• No compliance rates were available for Mental Health Act training.
• Only 34% of staff had completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards.

Updated 28 January 2020

Our rating of this service stayed the same. We rated it as good because:

• We rated effective, caring, responsive and well led as good. We rated safe as requires improvement.
• The service provided safe care. Clinical premises where patients were seen were safe and clean and the physical environment of crisis resolution and home treatment (CHRT) teams and Crisis House were fit for purpose. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• 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 and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The mental health crisis service was easy to access. Those who required urgent care were taken onto the caseload of the crisis teams. Staff completed most initial assessments within two days. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
• The service was well led, and the governance processes ensured that service procedures ran smoothly.

However:

• The Crisis resolution and home treatment teams did not have a robust system in place to keep an audit trail for medicines in stock. Staff did not always count and record the medicines the teams had received and dispensed, which meant they may not always have an accurate oversight of the medicines for which they were responsible.
• There were high levels of staff turnover and all the CRHT’s had vacancies. However, there was ongoing work on recruitment and retention of staff and where needed temporary staff covered vacant posts.
• Staff working for the mental health crisis teams did not always provide copies of care plans for patients.
• Arrangements for safe lone working needed to be strengthened further. Staff were being provided with new personal alarms to call for help if needed during a home visit. However, staff were still receiving training to use this new equipment and were not yet confident. Other arrangements to ensure safe lone working were in place such as carrying out visits in pairs where needed and maintaining a calendar of staff visits.

Updated 12 January 2018

We did not rate this service as this was a focussed inspection.

We found the following issues that the service provider needs to improve:

• Although Camden and Islington hadengaged with the three acute trusts, the Whittington the Royal Free and UCLH, to develop a joint action plan following a serious incident involving the death of a patient, there were some areas where the actions were not fully embedded. Camden and Islington had not effectively assured themselves that necessary actions were being carried out.At the Whittington Hospital ED, the assigned acute staff did not attend to their observation duties consistently. These are responsibilities to observe patients with mental health problems who have been assessed by the liaison team as having a risk of self-harm. At the Royal Free and UCLH, security staff, rather than clinical and adequately trained staff, observed patients whilst mental health nurses were requested.

• Camden and Islington needed to continue their work with the Whittington, to ensure the assessment rooms in the ED offered appropriate levels of privacy and provided an environment where patients could wait in comfort. There were plans to make improvements by December 2017.

• Camden and Islington was not making improvements in response to some feedback from inspections and peer review visits. For example the provision of information about services and legal rights under the Mental Health Act 1983 and Mental Capacity act 2005 and the completion of comprehensive patient records.

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

• Liaison staff assessed most patients promptly within their target of one hour after they arrived at the ED.
• At all three acute trusts, liaison staff delivered regular training sessions to acute staff working in ED to develop their knowledge of mental health patients.

Updated 28 January 2020

Our rating of this service stayed the same. We rated it as good because:

• The service provided safe care. The ward environments were safe and clean. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and 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 cared for in a mental health rehabilitation ward and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing 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.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

Updated 21 June 2016

Overall we rated wards for older people with mental health problems as ‘good’ because:

• The wards were safe, visibly clean and well maintained. Clinical areas and ward environments were bright, airy and hygienic. Furnishings were of good quality and homely. Up to date cleaning records showed that the wards were cleaned regularly. Handrails helped patients to maintain their balance while walking around the wards. There were wheelchairs and bathing facilities specific to the needs of older frail people. The clinic rooms were fully equipped. Resuscitation equipment was accessible and regularly checked. Nurse call bells were in every bedroom, bathroom and communal area. Staff carried alarms to summon help.

• The provider managed risks to patients well on both wards. There were clear lines of sight from the nursing offices. Where there were blind spots, a convex mirror was used to help staff observe the ward. There was a robust policy on the use of patient observations in place. Environmental ligature points (fittings to which patients intent on self-injury might tie something to harm themselves) were mostly addressed and the provider was taking steps to mitigate the risks from these by using the guidance of the trust observation policy.

• Both wards met the Department of Health guidance and Mental Health Act 1983 Code of Practice in relation to the arrangements for mixed sex accommodation.There was a female only lounge on each ward. Every bedroom had its own basin, shower and toilet. Continence equipment was available.

• The wards supported patient recovery. There were easy read signs at eye level height that used both words and symbols. The dining rooms were spacious and welcoming and encouraged people to talk to each other. There were menu options that included the needs of a culturally diverse group of patients. Food was available in pureed, finger and other forms to meet patient need. Mealtimes were protected from distracting ward activities such as medicine rounds and meetings.

• Care records included comprehensive assessments and care plans. Falls prevention plans were in place, both wards used the ‘Fallstop’ guidance. Pressure ulcer care was led by a tissue viability nurse. Staff used the ‘Modified Early Warning Signs’ tool to monitor and assess physical health. There was secure and easily accessible patient information stored on electronic systems. Learning from incidents was shared at handovers and team meetings.

• Managers and clinical staff engaged well with patients and carers. Staff spoke kindly with patients and responded to patient needs with discretion and respect. Carers told us they were supported and welcomed onto the wards. Staff knew what potential abuse was and what to do if they had any safeguarding concerns.

• Ward Managers engaged well with their staff. Staff felt supported to raise concerns without fear of victimisation and told us that morale and job satisfaction was good. Staff had regular supervision and an annual appraisal. The ward managers had sufficient authority to run the ward and administrative support to help them. Staff were provided with opportunities for leadership training at ward management level and staff sickness and absence rates were low.

However:

• Staff told us that more staff were needed. There was an unfilled psychology post.

• Staff said they did not know much about the most senior trust managers.

• Some staff did not know where the ligature cutters (equipment to cut safely through materials used to self harm) were kept.

• Some patients said that the behaviours of other patients at times made them feel unsafe.

On Garnet ward;

• Tablet crushers were found with residue from previous medications. Four more sets of tablet crushers were immediately ordered.

• Patient names could be identified on the spines of files from outside the nursing station.

On Pearl ward;

• Some patients said staff occasionally responded to them in ways that were not helpful or kind.

• The clinic room and fridge temperature records showed gaps in recording, the worst being a week of no monitoring between 15 February 2016 and 22 February 2016.

• Compression stockings prescribed from 21 January 2016 were marked as unavailable. No alternative had been provided.

Updated 21 June 2016

We rated substance misuse services as requires improvement because:

• Staff did not complete and update paperwork appropriately. Assessment, mental health, physical health and safeguarding documents contained blank pages. Staff did not routinely update risk assessments when a person’s situation changed. Recovery plans did not outline goals that were holistic and addressed a variety of needs alongside drug and alcohol misuse.

• Managers had not addressed issues with the electronic record system in a timely way. Information about risk had not transferred from the previous system in full and this made information about a client difficult to navigate. The new system was implemented in September 2015 and the issues had not been resolved in full and there was no long term plan to address this.

• Staff did not see clients for appointments as outlined in recovery plans and did not review clients’ medication regularly. Staff did not fully complete medication records and information was missing about client allergies

• Managers did not record specialised training completed by staff that supported them to work with this client group. Supervision records were poor quality. Managers did not record that staff were given the opportunity to discuss their individual development needs. Managers did not record training that staff had attended.

However:

• Medical professionals assessed physical health at the start of treatment and referred people for appropriate tests prior to starting medication. Medication was stored and managed well across all services and prescriptions were stored securely.

• Staff worked with clients in a positive and supportive way. They spoke to clients with respect and people told us that they felt safe using the service. People said they staff treated them as individuals.

• Staff dealt well with complaints and resolved them at a local level. Managers apologised to clients when things went wrong. Staff escalated complaints to the trust complaints team if clients were unhappy with the local outcome.

Updated 28 January 2020

Our rating of this service stayed the same. We rated it as good because:

• Our overall aggregated rating did not change in this inspection because we did not inspect Effective, Caring, Responsive and Well-led. In these key questions, our ratings for from our previous inspection published in March 2018 remain unchanged. At that inspection, we rated the trust’s community-based mental health services for adults of working age as good for caring, responsive and well-led. We rated it as outstanding for effective.

However, our rating of Safe went down. We rated Safe as requires improvement because:

• Patients identified as in need of a Mental Health Act (MHA) assessment were not always assessed promptly.

• The number of patients on the caseloads of some teams, and of individual members of staff in these teams, was too high to allow the staff to give each patient the time they needed.

• Nevertheless, the service provided safe care to most patients. Clinical premises where patients were seen were safe and clean. Staff managed most waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.