North London NHS Foundation Trust

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• 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.

This is the first assessment of this newly merged trust. However, these wards were inspected under their previous trusts. At our last comprehensive assessment, we rated this key question as requires improvement. At this assessment the rating has remained requires improvement.

Some aspects of the service were not always safe. Seclusion reviews and documentation did not happen in line with trust policy. Intermittent observations were not carried out in line with trust policy. There were inconsistencies in the grading of incident reports. Safeguarding referrals were not always made when needed. There were blanket restrictions, as patients did not always have free access to drinking water. Risk assessments were not always completed on admission and did not always include all identified risk. Risk management plans were not always in place. It was not always clear from documentation if staff supported a patient’s head and monitored their breathing during restraints. Staff were not always up to date with key training, specifically life support and prevention and management of violence and aggression. Fire risk assessments were not in place, and fire drills did not occur. Patients and staff told us there were not enough staff, and it often felt unsafe on the wards. Patients did not have regular one-to-one sessions with nursing staff. There were delays with maintenance requests across the hospital sites.

However, staff knew what incidents to report and how to report them. Staff involved the necessary healthcare and social care services to support patients whilst on the ward and in their discharges. Hospital seniors held daily safety meetings to review staffing and any concerns on each ward.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incidents to report and how to report them. All staff had access to the trust’s incident reporting systems and were able to report incidents when needed.

Managers reviewed all reported incidents. Incidents were discussed in daily safety huddles, as well as weekly senior staff meetings.

We reviewed incident reports and noted some inconsistencies in the ratings of incidents. Amethyst Ward had 30 outstanding incidents that required a manager review. Staff told us these had been sent back to the ward manager for review as they had not been categorised correctly. This meant there were delays in reviewing incidents and therefore implementing learning. The trust was however aware of this issue and they were supporting ward managers with reviewing and grading incidents.

We saw one example where the incident investigation took 10 days longer than the targeted timeframe.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw evidence of this in team meeting minutes and safety bulletins. However, from the team minutes we reviewed on Coral Ward they did not discuss incidents and their learning.

Most staff we spoke with were able to tell us about recent incidents and the learning that came from those incidents. For example, staff told us they were now extra vigilant ensuring garden gates were shut following an incident where a patient was able to leave the hospital grounds via the ward’s garden. However, one consultant was unable to discuss the learning from a recent death within their hospital.

We saw practice across the wards which showed learning had not been implemented effectively. For example, staff did not always carry out intermittent observations in line with trust policy.

There was evidence that changes had been made as a result of learning from incidents. For example, changes had been made in garden areas to reduce the likelihood of patients being able to climb fences. The trust also updated their Olanzapine depot protocol to include continuous monitoring of the patient following the administration of their medication. This update to policy came after a death within the trust.

Staff were debriefed and received support after a serious incident. Staff told us they had reflective practice where they were able to discuss serious incidents with a psychologist. However, some patients told us they did not have a debrief following a restraint.

In most cases, the service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. However, some staff told us they were not always told about a patient’s full risk history, which sometimes led to inappropriate admissions.

Staff involved the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We saw evidence of community teams being invited to ward rounds and discharge planning meetings. However, we saw one example on Amethyst Ward where staff did not inform the community team a patient had been discharged. This meant the patient did not have the 72-hour follow up meeting after discharge in line with national guidance.

The wards had discharge facilitators, who supported patients to be discharged once clinically suitable. This team supported patients and staff with concerns that may be delaying discharge, such as finding suitable accommodation and managing finances.

Staff received training on how to recognise and report abuse, appropriate for their role. Staff completed training in safeguarding adults, safeguarding children and PREVENT radicalisation training. Compliance figures were over 88% for these training modules. However, some specific wards had low completion rates, for example, 67% of staff on Tulip Ward and 60% of staff on Devon Ward had completed safeguarding adults level 3 training. Also, 64% of staff on Devon Ward had completed safeguarding children level 3 training.

Most staff knew how to recognise adults and children at risk of or suffering harm and worked with other agencies to protect them. The staff we spoke with told us they knew how to make a safeguarding referral and who to inform if they had concerns.

However, we saw three examples where a safeguarding referral had not been completed following a patient assaulting another patient. Two of these incidents were at Highgate West Mental Health Centre, and one incident was at Chase Farm Hospital.

From September 2024 to February 2025, 108 safeguarding referrals were made to the local authorities across all wards. Of those, 75 referrals were from the 10 wards at Highgate West Mental Health Centre.

The trust had internal safeguarding leads who could be contacted for advice.

Safe procedures were in place across each site to manage children who visited the wards. A family room, which was booked in advance and away from the main ward environments, was available for young visitors to see their relatives.

The trust had some blanket restrictions in place. For example, access to drinks and snacks. There were some inconsistencies across the wards, where some had open access to cold drinks, hot drinks and snacks. On other wards, patients had to ask staff to access drinks and snacks.

We reviewed 52 care records across the trust. Whilst all records had risk assessments, these did not always contain all relevant risk information. For example, we saw four examples at Highgate West Mental Health Centre and two examples at Blossom Court where the risk assessment did not include all of a patient’s risk, such as risk to others, despite their admission assessments stating there were known risks.

We found two examples of risk assessments not being completed on admission at Highgate West Mental Health Centre. One record was completed after 11 days, the other was completed after 5 days.

We found one example where a risk from a previous admission to another hospital within the trust was not pulled through to the risk assessment at Highgate West Mental Health Centre.

Thirteen patient records across the trust did not have a risk management plan in place. We saw one example where a patient’s forensic risk history was not care planned and did not have a risk formulation plan. Following this, managers told us all new admissions at Blossom Court would have weekly senior management reviews to ensure all risk documentation had been completed.

Risk assessments were generally updated after incidents. However, we saw two records where risk information was not updated.

Staff told us they avoided using restraint by using de-escalation techniques and restrained patients only when these failed and when necessary to keep the patient or others safe. Between September 2024 and February 2025, there had been 103 incidents of prone restraint across all wards. Of these incidents, 22 occurred on Suffolk Ward and 13 were on Diamond Ward. Staff told us they knew to move the patient to a safer position as soon as possible. We observed good use of de-escalation skills by staff.

On Sunflower Ward we saw two instances of restraints being used, with no recorded evidence of staff supporting the patient’s head or monitoring breathing. Following the inspection, managers told us they had reminded staff of the correct monitoring procedures and policy.

We spoke with patients who had been restrained. Three patients told us they felt their restraints were rough and heavy handed. One patient told us they had been injured in a restraint and had reported this to the police.

Across the trust staff were involved in quality improvement projects to reduce or improve restrictive practise and we saw these taking place. For example, Devon Ward told us they had been involved in a project to reduce the use of seclusion on their ward. In 2022, the ward had 119 incidents of seclusion, following their interventions, the ward saw a reduction to 40 incidents of seclusion in 2024.

Staff on all wards received training on prevention and management of violence and aggression. However, 55% of staff had completed this on Dorset Ward. Compliance figures for this training at Highgate West Mental Health Centre were low, with the exception of Jade Ward. On Rose Quartz Ward, 31% of staff completed this training, on Topaz Ward 38% of staff have completed this training and on Amethyst Ward 58% of staff completed this training. Managers told us extra training had been put on specifically for this hospital and compliance figures were improving. Senior staff told us a number of staff on Dorset Ward were exempt from this training due to health reasons, and the remaining staff had been booked onto upcoming sessions.

From September 2024 to February 2025, there had been 149 incidents of seclusions. Of those incidents, 30 were on Coral Ward and 16 were on Ruby Ward, which were two of the trust’s psychiatric intensive care units.

Seclusion records were not always clear and detailed. Seclusion reviews did not always happen in line with Trust policy. For one record at Chase Farm Hospital there was no evidence from CCTV footage to confirm nursing reviews took place at the recorded times. There was no evidence of staff accessing the seclusion area to carry out nursing reviews on all 7 randomly chosen times.

Following us raising concerns, managers reviewed 36 records of the two hourly nursing reviews at Chase Farm Hospital. Nine of these reviews were not completed overnight and four reviews were not completed during the day.

At Highgate West Mental Health Centre, we found four examples of medical and nursing reviews not occurring at the times set out by the trust’s policy. Staff told us there were often challenges in organising staff members for each review, especially out of hours.

Highgate West Mental Health Centre carried out a monthly seclusion audit, which showed Ruby Ward had a 69% compliance with policy in February 2025 and a 73% compliance in January 2025. Coral Ward had a 97% compliance with policy for both January and February 2025.

One seclusion record at Blossom Court did not state which staff were completing the observations. Staff also did not complete non-contact observations when the patient was sleeping.

Senior leaders within the trust were made aware of these concerns surrounding seclusion. They told us they would increase the frequency of CCTV reviews of clinical practice and night visits from members of the senior leadership team will now include reviews of staff’s understanding of seclusion.

Staff carried out different levels of observations, determined by assessed need. These observations were not always carried out in line with trust policy. For example, we found intermittent observations being carried out at pre-determined intervals on Thames Ward, Shannon Ward, Daisy Ward, Sunflower Ward and Sussex Ward.

On Topaz Ward, the patient observations sheet should have been signed by two staff members at 7:30 and 19:30. There were seven occasions from 1 February 2025 to 25 February 2025 when there was a single signature.

On Sussex Ward, we observed a staff member mistakenly observing and recording information on the wrong patient.

The wards had items which were not allowed to be brought onto the wards. However, on Sapphire Ward, the bin in the dining room was noted to have a plastic bag in it, which was a contraband item on the ward.

Multidisciplinary staff met with patients weekly to discuss their care and treatment. In most cases, within 72 hours of being admitted patients had a formulation meeting with the multidisciplinary team to discuss their care and treatment plans.

Staff completed and updated risk assessments of all ward areas. They removed or reduced risks they identified. For example, ensuring rooms with ligature points were used under staff supervision. However, we saw one incident where a patient was able to tie a ligature in a doctor’s office as the door was left unlocked.

The wards had blind spots. These risks were reduced by having convex mirrors, staff observations and closed-circuit television (CCTV). Live CCTV was accessible to staff in the nursing office. CCTV was also recorded and used to support investigations. However, on Shannon Ward there were blind spots which did not have convex mirrors. Managers told us these mirrors had been ordered but were unsure when they would be delivered. Whilst staff observations were used to reduce the risks on the ward, we noted many wards did not have staff in communal areas.

Staff carried out daily checks to ensure the safety of the ward. These checks included making sure all doors were secure and fire exits were clear. However, Amethyst Ward did not always carry out these checks in full.

In general, patients told us they felt safe on the wards. However, four patients told us they did not feel safe. These patients told us they had been attacked or felt intimidated by other patients on the ward. In these cases, they did not feel staff supported them to feel safer and felt staff did not intervene promptly in these situations.

Wards across the trust had undergone maintenance work to replace bedroom doors to new anti-ligature doors. An alarm would ring if a patient attempted to use these doors as a ligature point. Staff told us these were introduced following a serious incident.

Some wards across the trust were mixed-sex. Most wards complied with guidance, however on Dorset Ward, the laundry room was in the male-only area and the clinic room for medicines was in the female-only area. This meant there was a mix of genders in all areas on the ward. Senior staff told us males were escorted by staff when using rooms in the female areas. Following this assessment, Dorset Ward became a male only ward.Staff were not required to complete mandatory sexual safety training.

Staff on the wards carried alarms. Staff were able to call for assistance from other wards through the hospital alarm system. However, not all patient rooms had working alarms. For example, the nurse call systems on Coral Ward, Ruby Ward and Amethyst Ward did not work in all bedrooms.

All sites had access to a seclusion room. Most seclusion rooms allowed clear observation and two-way communication and had toilet facilities and a clock. However, on Devon Ward the digital clock displayed an incorrect time.

When Trent Ward was last inspected in 2021, there was a breach of regulation surrounding the dignity of patients using the seclusion room. At this inspection, the same seclusion room was still in use, but with extra curtains to improve patients’ dignity. Works had just begun to create a new seclusion room on the ward.

At Blossom Court, we were informed the flats opposite could see into patient bedrooms and communal areas. The windows did have some privacy screens; however, they were not across the whole window. This issue was on the hospital’s risk register and was being addressed.

Patients told us and staff their rooms were cold. This was evidenced in community meeting minutes. However, there did not appear to be any actions to follow this up after patients raised these concerns. We did see evidence of staff providing extra blankets to patients when asked.

Staff told us there were often delays for maintenance issues. For example, on Trent Ward the kitchen shutter had been broken for 1 year. Staff were therefore locking the dining room outside of mealtimes, this meant patients did not have free access to the dining room facilities. This had been reported to the hospital’s maintenance team. Staff told us the water dispenser on Sapphire Ward had been broken for more than 1 year, meaning patients did not have free access to water. The water dispenser had been fixed by the end of our inspection activity.

The water dispenser on Trent Ward was also broken. There were two toilets on Thames Ward and two toilets on Trent Ward that were out of use. Maintenance staff had attended the ward to fix the toilets whilst inspectors were onsite.

Wards did not have fire risk assessments. Wards were not able to provide evidence of fire drills occurring. This was raised with senior staff within the trust. Senior managers told us they had put inpatient ward’s fire safety on their risk register and were now implementing a programme of fire drills. Staff completed training in fire safety. At the Dennis Scott Unit, Blossom Court and Chase Farm Hospital staff had training every 2 years. All wards had a compliance rate of 80% for this training. Wards at Highgate West Mental Health Centre had training every year, all wards had a compliance rate of 78% for this training.

Some multidisciplinary staff at Highgate West Mental Health Centre told us there was not enough space for them to work in the office. They told us there were around 40 staff members, but only 20 chairs and workspaces, meaning they often had no place to work.

Eighteen patients told us there were not enough staff. Patients said this was particularly an issue at the weekend. Patients told us staff were busy, which meant their escorted leave was often delayed, and staff were not able to support their requests. Most patients told us they did not have one-to-ones with staff and were not aware who their named nurse was.

Staff told us they often felt short staffed, even when meeting the required staffing numbers. On many wards we observed there to be no staff visible in communal areas.

Some staff told us they felt unsafe with the staffing levels, particularly on night shifts. Staff told us they had completed incident reports when staffing felt unsafe.

The ward managers could adjust staffing levels according to the needs of the ward and patients. For example, when more than one patient was being nursed on enhanced observations.

Staffing vacancies varied across the wards. Some wards had no vacancies for registered nurses or healthcare assistants, other wards had high vacancy rates. For registered nurses, Diamond Ward had 27.3% vacancy, Ruby Ward had 25.8% vacancy, Devon Ward had 22.7% vacancy and Dorset Ward had 19.2% vacancy. For healthcare assistants, Diamond Ward had 28% vacancy, Amethyst Ward had 26.9% vacancy, Sapphire Ward had 25.6% vacancy and Dorset Ward had 23.8% vacancy.

Bank usage for nursing staff was high across all wards. For example, bank staff were used 50% in September 2024 on Coral Ward, 50% in October 2025 on Ruby Ward, 47% in January 2025 on Sapphire Ward and 47% in January 2025 on Tulip Ward.

Agency usage was generally low. Most wards did not use agency staff, however there was some usage, mostly for the wards at Chase Farm Hospital.

Managers made sure all bank and agency staff had a full induction and understood the service before starting their shift. However, not all managers were able to show us how many staff had completed their induction.

Whilst the service attempted to fill vacant shifts with bank and agency staff, there were shifts which could not be filled. For the 6 months between July 2024 and December 2024 there were 33 unfilled healthcare assistant shifts and 70 unfilled registered nurse shifts. Staff told us ward managers and staff from other wards would help where they could. Staff on Sapphire Ward told us gaps from staff annual leave was not covered by managers until the day of leave, leading to unfilled shifts.

The trust monitored the turnover of staff. In January 2025, turnover ranged from 0% on Amber Ward to 22.6% on Sapphire Ward. Staff told us staff often left the ward for promotions or professional development.

Sickness levels across the wards in January 2025 ranged from 1.1% on Shannon Ward to 13.7% on Ruby Ward,

The hospital held safety meetings each morning where seniors and the nurses in charge of the wards came together to report on any concerns, including their staffing levels. If a ward required more staff, staff on other wards were able to move to the wards where support was needed.

There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency. There was one consultant vacancy on Daisy Ward. Staff on Daisy Ward told us a community consultant covers one day per week. There were resident doctor vacancies on Jade Ward, Opal Ward and Ruby Ward. Across the trust five consultants were agency or locum.

Staff were required to complete mandatory training. All wards had an overall compliance figure over 75%. Staff completed immediate life support training, however five wards had low compliance between 46% and 67%. Staff were required to complete basic life support, however nine wards had low compliance between 40% and 70%. When we last inspected Barnet, Enfield and Haringey Mental Health NHS Trust in 2022, there was a breach of regulation for staff not completing immediate life support training. This continues to be an area for improvement.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.

Ward areas were clean, had good furnishings and were well-maintained, although Ruby Ward had some furniture that was older and needed to be replaced. We saw housekeeping staff cleaning ward areas throughout the day.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

However, on Sapphire Ward there was a large paper bag being used as a bin, lying on the floor. This was both in the dining room and the lounge.

On Sapphire Ward there was a wash basin in the dining room, but there was no soap to wash your hands.

We saw graffiti on Thames Ward and Daisy Ward, which people could find offensive. On Daisy Ward the graffiti was in a communal area and on Thames Ward the graffiti was in a bedroom. Following the assessment, the graffiti on Daisy Ward was painted over. Thames Ward planned to repaint their patient’s bedroom once the patient’s mental state improved.

Wards were due to complete monthly infection prevention and control audits. All wards found over 80% compliance with policy. However, Sapphire Ward had not completed this audit since August 2024.

There were policies and processes in place which supported staff to give medicines safely, however these were not always being followed. People were sometimes being given medicines which were not included on their relevant Mental Health Act consent to treatment documents. When people are detained under the Act, these documents ensure treatment is given in line with people’s consent, or where they lack capacity, to ensure treatment is offered in the person’s best interests.

When medicines were prescribed, information was sometimes missing, ambiguous or not in line with recognised practice. For instance, on Trent ward we observed that a rapid tranquilisation intra-muscular injection had been prescribed for insomnia. This is not common practice. At Highgate West Mental Health Centre hospital, medicines usually prescribed to manage anxiety and agitation were prescribed for ‘sedation’. It was not clear if medicines were prescribed for managing anxiety/agitation, insomnia or both.

When a medicine was given ‘when required’ (PRN) as rapid tranquilisation, staff did not always complete, or record required post-dose physical health monitoring to ensure the patient was kept safe. We also saw multiple records where the indication for a prescribed PRN medicine, the minimum time between doses or the maximum daily dose were missing. There were times where PRN medicines were given more than the maximum amount allowed in a 24-hour time frame.

When PRN medicines were used, staff did not routinely record why the medicine had been given or if it had been effective. We saw some instances where medicines were used for reasons other than the one indicated on the prescription. For example, one person was prescribed promethazine for agitation, however, staff were administering the medicine to help the person sleep.

We saw an example where staff were working collaboratively with the specialist diabetes team to manage a patient with complex diabetic needs. However, we also saw an example where staff had not followed a diabetic treatment plan, or administered the insulin as per the prescriber’s instructions, which had placed the person at risk of harm. We raised this at the time of the inspection with staff.

The trust did not make use of topical administration records and did not record the placement, removal or rotation of topical pain patches. This placed people at risk of adverse reactions or potential overdose. For people prescribed paraffin-based skin products, fire risk assessments were not completed to ensure they were kept safe whilst using these products.

Staff reviewed people’s medicines and their side effects regularly. Staff used national recognised rating scales to monitor side effects of medicines.

People on high-risk medicines, for example, clozapine, had care plans in place to guide staff to support people with their physical health needs.

There was a process in place to report medicines incidents and share learning trust wide. Staff were provided support and training after serious incidents involving medicines.

We were not assured that staff on Devon Ward fully understood the risks to patients following an Olanzapine depot. Staff were carrying out vital checks every 15 minutes following the medicine, as opposed to 3 hour continual observations. This was despite additional training and internal bulletins following the death of a patient in the trust.

Following the merger of the Trusts some audits were being completed to ensure good medicines optimisation.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff generally checked regularly. However, we found some of these checks had been missed on Daisy Ward.

All 3 wards at Blossom Court had out of date Flumazenil in the emergency bags. This medication was not listed in the contents on the check forms. We were later informed this medicine was no longer meant to be in the emergency bags.

Staff told us a full check of the emergency bag contents took place monthly and took around 2-3 hours to complete. However, on Sunflower Ward, an electronic check record showed it took staff less than 5 minutes for the full check to be completed.