North East London NHS Foundation Trust

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question as good. At this assessment the rating was changed to requires improvement. We found some concerns about the processes in place to ensure the safety of patients across the wards, in breach of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In terms of the environment, the low ceilings enabling access to wiring on Ogura and Picasso wards presented significant risks to patients, and the garden on Kahlo ward had easy access to a low roof. Following the inspection the trust advised that work had been carried out to secure the wiring and the ceilings had been reinforced on Ogura and Picasso wards, to prevent access to the wiring.

We found that some patients did not have risk assessments and care plans in place for physical health conditions including diabetes, falls, epilepsy and support with a new pacemaker. Staff told us that they wanted more physical health training as more patients presented with complex needs.

Records of patient debriefs, did not include details of what was discussed, and patients we spoke with did not remember having a debrief after being restrained. We saw varying approaches to zonal observations, with some staff standing in position in their areas, to others engaging well with patients, and we found some staff undertaking intermittent observations at regular intervals, making them predictable. Following the inspection, the trust updated their policy on observations to reflect the need to vary times of observations.

Data indicated a significant reduction in the use of prone restraint across the wards. However, some records of physical restraints on each ward did not have all relevant details completed, including the position of restraint and each staff member’s intervention.

We found some issues with medicines administration including PRN (as and when medicines) records not including a reason for or limits on administration, so that promethazine was administered above the British National Formulary daily limit. We also found instances when controlled drugs were administered with only one signature on Kahlo, Picasso and Knight wards.

Staff on each ward were able to tell us about how they had taken steps to incorporate learning from incidents and there were action plans in place for all serious incidents. Staff understood the duty of candour, when things went wrong staff apologised and gave patients clear information and suitable support. Managers said they provided debriefs for staff and patients following incidents, including restraints, but these were not recorded.

Relevant health and safety environmental checks were in place across the wards and the roll out of patient call bells was underway. The wards were visibly clean, with regular hand washing and infection control audits in place. Staff were clear about how the trust’s safeguarding procedures to protect patients from abuse.

There had been significant recruitment to the wards including overstaffing on some wards as new nurses completed their induction and competency training. Almost all wards had vacancies for permanent consultant psychiatrists, with locum consultants covering, and the trust was working hard to address this. Mandatory training rates were quite high across the wards, with some gaps in staff completing fire warden training. Staff described good opportunities for professional development within the trust.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff on each ward were able to tell us about how they had taken steps to incorporate learning from incidents. They discussed serious incidents that had happened across the wards within team meetings and shared lessons learnt. There were action plans in place for all serious incidents. These actions included emergency scenario training provided regularly on all wards, and clear signs on entrance doors indicated that plastic bags were not permitted. However, we found an inconsistency on Rodney ward where the use of baths was completely stopped for patients, whilst other wards allowed patients to use baths with safeguards. We reported this to senior management, who advised that there was a plan that baths were to be removed from all wards.

Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the ward teams and wider service. They involved patients and their families in investigations, and reviewed CCTV footage where relevant. Changes made as a result of learning from incidents including the introduction of zonal observations, whereby staff monitored patients in a particular area, and introduction of some bedroom doors fitted with alarms to prevent patients tying a ligature.

Staff understood the duty of candour, when things went wrong staff apologised and gave patients clear information and suitable support. Managers said they provided debriefs for staff and patients following incidents, including restraints, but these were not recorded. Staff confirmed that they received these debriefs, but most patients we spoke with did not remember receiving these. In addition, reflective practice sessions on the wards allowed staff a space to discuss their thoughts following incidents.

Incidents reported in the last 12 months were lowest on Rodney ward with 158 (although not open for a full year) and Turner ward with 242 reported. The highest number of incidents were reported on Knight ward with 562, and Monet ward with 476. Seclusion was used 42 times within the 12 months prior to the inspection, and there was one incident of long-term segregation on Monet ward.

Overall incidents of restraints in the last year were highest on Titian ward at 319 and Kahlo ward at 266, and lowest on Monet ward at 90, and Knight ward at 135, with Rodney (which had not been open a whole year) at 32.

At the time of the inspection two of the wards were clinical decision units (Ogura and Picasso wards). Following assessment, patients transferred to other wards, or were discharged home or to other placements. Senior managers advised that this model was under review, as it led to the clinical decision units managing significantly higher acuity of patient needs as most new admissions came through these wards. This also made them more difficult and unsettled environments for new patients admitted to the wards. The trust has since updated us to advise that the clinical decision units will become acute wards and that all acute wards will align to a geography to create improved consistency of care and better patient flow along the pathway.

All wards had incorporated regular safety huddles, where staff met to discuss the safety concerns at the time. We attended some of these and found them to be very useful in ensuring the team were working effectively to address safety issues. There were systems in place to search patients who had left the unit unescorted and room searches were in place to address concerns about illicit substances being brought on to the wards.

Staff said that they made every attempt to avoid using restraint by using de-escalation techniques. Data indicated that there had been a significant reduction in the use of prone restraint across the wards used at a rate of approximately 4% of all restraints over the last year. The highest use of prone restraint was on Ogura ward with 18 occasions in the last year. Overall, this was a significant reduction since the previous inspection in 2022, with figures for 6 months indicating 17% use of prone restraint. However, when comparing data sets year on year, use of all types of restraint appeared to have increased overall. Increases in patient acuity and changes to reporting systems may have contributed to this overall rise.

Some records of physical restraints on each ward did not have all relevant details completed, including the position of restraint and each staff member’s intervention. Records of patient debriefs, did not include any detail of what was discussed, and patients we spoke with did not remember having a debrief after being restrained.

On some wards zonal observations were being piloted. We saw varying approaches, from some staff standing in position in their areas, to others engaging well with patients. We observed different staff practices regarding undertaking intermittent observations. Whilst staff on some wards were clear that these should be varied in timing, we found staff on Ogura and Turner ward were carrying these out at exactly 15 min intervals, making them predictable. These were breaches of Regulation 12 (2)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection, the trust updated their policy on observations to reflect the need to vary times of observations.

Managers noted that there had been some cases of drugs and alcohol being brought onto the wards. They were addressing the issue with routine searches and would bring in dog units to look for contraband when they had concerns that they may be hidden.

Staff understood how to protect patients from abuse and the service worked with other agencies to do so. There was high compliance with staff mandatory training in safeguarding adults and safeguarding children at level 2 and 3. Training was above 90% on all wards, with 100% achieved on several wards. Staff also had training in PREVENT to identify patients at risk of being radicalised. They understood how to recognise and report abuse or concerns about radicalisation.

Staff knew to how make a safeguarding referral and who to inform it they had concerns. The trust had a safeguarding team who could be contacted for advice.

There were systems in place to safeguard children who visited, using a family room which could be booked in advance and was away from the wards.

Some patients and relatives/carers described concerns for their safety from other patients on the ward, following incidents of assault between patients. When these incidents occurred, staff took action to protect patients as far as possible, moving patients between wards if necessary.

Staff demonstrated some understanding of individual patient risks. The multidisciplinary team reviewed the risks presented by patients daily in handover meetings and safety huddles. Plans to manage or mitigate individual patient risks were in place. However, we found that some patients did not have risk assessments and care plans in place for physical health conditions including diabetes, falls, epilepsy and support with a new pacemaker. This was in breach of Regulation 12 (2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Several staff reported wanting to have more physical health training, as they had seen an increase in the number of patients presenting with complex physical health needs.

Staff training in risk assessment was above 85% on all wards except Knight ward (77%). Staff completed risk assessments with each patient on admission, and reviewed risk regularly including after incidents. Risk was discussed at handover and multidisciplinary team meetings including ward rounds involving individual patients and their family/carers if appropriate.

The ward environments in some parts of the hospital presented risks to patients. The low ceilings enabled access to wiring on Ogura and Picasso wards. The garden on Kahlo ward meant that patients had access to a low roof and needed increased supervision. We observed a number of maintenance issues such as three chairs taped up on Monet ward, the screen in front of the TV on Turner Ward was scratched, and the washing machine on Rodney ward had been out of order for over 6 weeks. These issues were in breach of Regulation 12(2)(d) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following the inspection the trust advised that work had been carried out to secure the wiring and the ceilings had been reinforced to prevent patients accessing the wiring.

As recommended at the previous inspection published in June 2022 Picasso ward was now a single gender (female) ward, in line with Department of Health and Social Care guidance and planned works to extend the patient call alarm system across all patient rooms were underway.

Staff completed and regularly updated risk assessments of all ward areas, mitigating any risks identified, such as ensuring that rooms with ligature anchor points were used under staff supervision. Staff were aware of environmental risks on each ward and described ways of working that took these into account. These included regular observations, health and safety environment checks, and retrospective review of CCTV in communal areas following incidents. There was a detailed fire risk assessment and evacuation procedures including personal emergency evacuation plans for patients with mobility or other relevant needs.

There was a seclusion room on Titian ward (the male psychiatric intensive care unit). It allowed clear observation, 2-way communication, and had patient access to a toilet and shower, and clock. The seclusion room included a physical health monitoring system which helped staff monitor for any deterioration in patients’ health, but staff also took manual physical health observations. When a female patient required nursing in seclusion, the section 136 suite was sometimes used, whilst a suitable psychiatric intensive care bed was located.

At the time of the inspection, wards had enough staff on each shift to keep patients safe and to carry out any physical interventions safely. There had been significant recruitment to the wards including overstaffing on some wards as international nurses completed their induction and competency training. There had been months with high staffing turnover on some wards including Knight and Monet wards, and use of bank/agency staff was particularly high on Picasso and Knight wards. With recent successful recruitment across the service, this was decreasing. Staff were aware that they needed to ensure sufficient experienced staff on all wards, whilst new staff gained the experience and competencies they needed.

The highest number of vacancies were 26% vacancies for nurses on Monet ward, which had been recruited to all except for one band 5 nurse position, and 10% vacancies on Knight ward, with 2 band 5 nurse positions to be filled. However, 5 wards were overrecruited to, with 124% staffing on Rodney ward, and 112% staffing on Turner ward.

Patients and some carers told us that patients were not always able to take their agreed escorted leave due to staffing priorities. We were unable to evidence this from records, and staff told us that whilst leave might be delayed it would take place on the same day.

Average staff turnover in October 2024 was at 3.97%, highest on Knight ward at 11.7% then Monet ward at 6.98%, with no turnover on Rodney, Ogura and Turner wards. Over the last 12 months from November 2023 the highest staff turnover was in November 2023 at 9.58% and the lowest was in June at 3.44%.

Use of bank and agency staff was highest in May 2024 at 462 shifts and remained over 330 between November 23 to June 2024. Following this it reduced significantly so that just 6 shifts in October 24 were provided by bank or agency staff. Staff sickness was highest on Titian at 11% in September 2024, and lowest on Rodney ward at 2%. In the last year it was highest on Monet ward at 15% in October 2023.

Almost all wards had vacancies for permanent consultant psychiatrists, which was being mitigated by the use of regular locum consultants. The trust was working hard to recruit and retain permanent consultants. However, this had an impact on the culture of the wards. There were vacancies for 2 permanent consultant psychiatrists on Monet, Turner, Kahlo, and Picasso ward, for one consultant psychiatrist on Rodney and Knight ward, and for one specialty doctor on Ogura ward. Although a shortage of consultant psychiatrists was a national issue, the trust had plans in place to address this shortage, including setting up a bespoke careers fair.

Other multidisciplinary team vacancies were for a clinical psychologist and assistant psychologist on Picasso ward, and a part time OT position on Rodney ward. There were vacancies for 2 administrative staff on Knight ward.

Mandatory training compliance was above 90% on all wards, ranging between 99% compliance on Rodney ward and 91% on Picasso and Knight wards. Staff described good opportunities for professional development within the trust. Training in immediate life support was above 90% on all wards. Oliver McGowan training on each ward was above 90% on all wards. Lowest compliance was in prevention and management of violence and aggression (PMVA) and fire warden training. Compliance with PMVA training (a face-to-face course) was at 74% on Turner ward, and 84% on Picasso ward. Fire warden training compliance was at 54% on Turner Ward and 65% on Knight ward.

The ward environments were clean and this was also reflected in the most recent PLACE scores. Regular hand washing, and infection control audits were taking place. Current cleaning records were kept and housekeeping staff were present on the wards through on day.

We observed staff following infection control principles including appropriate handwashing techniques, use of personal protective equipment and hand sanitiser.

Staff training in infection control was above 90% on each ward. PLACE scores from 2023, for cleanliness were highest on Knight ward at 100% and Picasso at 95%, and lowest on Ogura ward at 86%. Scores for condition and maintenance were highest on Knight ward at 74.1% and lowest on Kahlo ward at 50%, with the poor condition of the bathrooms noted.

Medicines were stored in automated medicines cabinets. The ambient room and fridge temperatures were monitored electronically with alerts of temperature breaches sent to pharmacy and the ward manager for action. Emergency medicines were kept in the treatment room and locked with tamper evident seals. We saw records of daily checks of all emergency medicines and emergency equipment. Oxygen was available and appropriately stored.

We found some issues with medicines administration including PRN records not including a reason for or limits on administration, so that promethazine was administered above the BNF daily limit. We also found instances when controlled drugs were administered with only one signature on Kahlo, Picasso and Knight wards. This was in breach of Regulation 12(2)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff reviewed patients’ medicines regularly and patients received routine physical health monitoring. Side effects of medicines were discussed regularly and monitored by staff. Patients on High Dose Antipsychotic Treatment (HDAT) were monitored in line with national guidance. Patients at risk of developing blood clots had venous thromboembolism (VTE) risk assessments completed. Staff were aware of the impact of high-risk medicines on physical health. Risk management plans were in place. For example, staff ensured that patients on clozapine received regular monitoring of their stools / bowel movements.

Positive behaviour support plans were in place to help care for patients with autism. Patients were given ‘when required’ (PRN) medicines to manage agitation as a last resort. However, the documentation of reasons and outcomes from PRN medicines in patient records was inconsistent.

Staff were able to contact the out of hours pharmacist and had access to medicines when the pharmacy was closed. Staff told us there had been issues with supplies of medicines from an external contractor which dispensed medicines and delivered to the wards. During the inspection, medicines dispensing was brought inhouse and it was anticipated that this would improve the timely access of medicines for patients.

Staff said that the use of electronic prescribing and medicines administration had reduced medicines errors. Staff were aware of medicine incidents both on their own wards and trust wide. Staff told us there was a supportive culture around reporting and learning from medicines incidents.

Staff followed national guidance to monitor physical health and ensure patients were kept safe following administration of rapid tranquilisation via the intramuscular route. Patients detained under the Mental Health Act had relevant documentation available, and medicines had been legally prescribed and administered.

Prior to discharge, staff reviewed benzodiazepines prescribed to patients. This was to avoid long term use of benzodiazepines in the community.