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Provider: Barnet, Enfield and Haringey Mental Health NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 25 September 2019

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

  • We rated effective, caring, responsive and well-led as good. We rated safe as requires improvement. In rating the trust, we took account of the ratings of the six services inspected previously. After this inspection, nine of the trust services were rated good, two were requires improvement and two were rated outstanding.

  • Since the last inspection, there had been a new chair and chief executive. One new non-executive director had joined the board. The director of nursing and chief operating officer were also recent appointments. The trust had an ambitious board, with a wide range of skills and experience. The board had tremendous energy and commitment and the new membership had provided an opportunity to review how they carried out their business and make changes.

  • Although there was still more work to do, the trust had improved its services since our previous inspection, especially in its community services. Teams we had previously raised concerns about, such as the Haringey West locality team and the Enfield Crisis resolution and home treatment team, now provided safe and effective care. The trust had also addressed our concerns about its community health inpatient service and its specialist eating disorder service. Where further improvements were needed, the trust was approaching this with thoughtfulness and seeking external advice where needed. This gave confidence that the improvements would bring real benefits to patients and staff.

  • The trust leadership team knew the main challenges facing the trust and had started to make plans to address them. The trust faced significant challenges in ensuring all adults of working age with an acute mental illness who would benefit from admission could access a local bed promptly. The trust was proactively trying to improve this situation. It planned to open a new ward in autumn 2019 and had also commissioned a review of its acute care pathway.

  • The trust was working hard to improve the quality of the buildings in which it provided care to patients. This included the redevelopment of St Ann’s hospital, which would replace outdated and inappropriate provision. Other wards had also been refurbished. An ongoing estates strategy was in development looking at the options for the redevelopment of the trust’s other estate. Dormitories would be eliminated from the Haringey and Barnet sites by the end of 2020. Further work was needed to eliminate the few remaining shared bedrooms on the Chase Farm site. There was also ongoing work to improve the seclusion facilities and reduce ligatures.

  • Staff assessed the physical and mental health of most patients on admission and developed plans to support patients manage risks. Staff in most teams worked together with patients to develop care plans reflected the assessed needs. Although some teams needed to improve, many staff develop personalised, holistic and recovery-oriented plans with people. Staff supported many patients safely in the community.

  • The trust had begun work to ensure it provided good services in the future. It had developed a new strategy, ‘fit for the future’, collaboratively with patients, carers, staff and external stakeholders that reflected local and national health and care priorities. It was actively involved with other local health providers in the sustainability and transformation plans, and it was actively participating in the development of new models of care. It was, for example, leading the North London Forensic Service, which was developing a new care model across north London for secure services. It had agreed a strategic alliance with Camden and Islington NHS Foundation Trust to explore ways in which they could work more closely together.

  • The trust was working to improve the staff culture but recognised there was more to do. The board members were open and transparent in their manner and reflected the values of the organisation. A programme of executive roadshows had enabled members of the executive team to meet over 500 staff. Multiple other forums provided opportunities to listen to staff. However, the staff survey showed that improvements needed; high numbers of staff continued to report experiencing bullying and harassment and violence and aggression. This said, the overall culture of the trust was very patient centred, and this was under-pinned by the promotion of the trust values. Staff we met cared deeply about delivering the best care possible for their patients.

  • Since the last inspection, the trust had made significant progress in addressing its financial challenges. For 2018/19, the trust met its control total it had agreed with NHS Improvement.

  • The trust was strengthening its leadership structures and governance arrangements. The trust had moved from having four to five divisions to enable the community services in Enfield to have more focused attention. A triumvirate leadership team was being put into place in each division. The governance structures and accountability frameworks were being reviewed across the trust to provide improved clarity and consistency. The quality governance processes were being refreshed to provide improved assurance

  • The trust had begun work to use quality improvement (QI) in its work, which it recognised was integral to changing the culture of the trust and empowering staff and patients to identify and make improvements, but it had more work to do to emend this approach. The trust had prepared a QI strategy, was recruiting a small team to support the work and had plans to train more staff and embed the work in the divisions. Since the previous inspection progress had stalled, but work was underway to re-invigorate the work.

However:

  • The trust needed to continue to review the governance systems to ensure that it always identified and addressed areas of concerns, shared learning between teams effectively and make sure important changes following incidents had been embedded. We found areas that required improvements that had not been identified and addressed in the wards of older people with mental health needs and the mental health crisis services.

  • The trust continued to experience pressures on its services, which meant that acutely unwell mental health patients sometimes did not get promptly assessed and cared for in local high-quality services. It had to place many patients in external services that may be a long way from where they lived, and many patients experienced long waits in the trust’s health-based place of safety. In addition, many patients were waiting too long to have a Mental Health Act assessment when this was felt to be clinically needed to maintain their own or other people’s safety.

  • The trust did not have enough permanent nursing and care staff, particularly on the acute inpatient wards, who knew the patients. This impacted on their ability to form the professional relationships needed to understand and support each patient consistently with their individual needs. This was leading to instances of violence and aggression that might have been managed better by permanent staff. The trust knew it needed to address its ongoing workforce challenges and had plans to support the recruitment and retention of staff. It monitored whether the wards achieved safe staffing levels and had completed a nursing skill mix review to assess its nursing requirements.

  • The trust still needed to implement a system to automate the production of live business information. The trust had arrangements in place in the interim to generate accurate data and had made improvements in how this was presented, but the overall process was cumbersome.
Inspection areas

Safe

Requires improvement

Updated 25 September 2019

Our rating of safe stayed the same. We rated it as requires improvement because:

  • At this inspection, we rated safe as requires improvement in three of the six core and specialist services we inspected. We rated the community based mental health services for adults of working age as inadequate for safe. We rated safe as good in the other two core services. When these ratings were combined with the other existing ratings from previous inspections, four of the trust services were rated requires improvement, one was rated as inadequate and seven were rated good.

  • The service did not have enough permanent nursing and care staff, particularly on the acute inpatient wards, who knew the patients. This impacted on their ability to form the professional relationships needed to understand and support each patient consistently with their individual needs. This was leading to instances of violence and aggression that might have been managed better by permanent staff. The trust knew it needed to address its ongoing workforce challenges and had plans to support the recruitment and retention of staff. It monitored whether the wards achieved safe staffing levels and had completed a nursing skill mix review to assess its nursing requirements.

  • The trust had not ensured that teams shared lessons learnt with each other - especially with teams in different boroughs. In some areas, such as the mental health crisis services, the trust had also not ensured that important changes had been embedded following incidents. The trust had identified this as an area to improve and had plans in place to support staff to share lessons learnt more easily.

  • Patients identified as in need of a Mental Health Act (MHA) assessment were not always assessed promptly and there were significant delays to MHA assessments. Delays in completing assessments could mean that people may be at risk of harm. Staff across all adult community mental health teams told us that MHA assessment delays was a significant issue for their team, and told us of incidents where patients’ safety had been compromised whilst waiting for a MHA assessment. Despite the delays in MHA assessments being completed, the trust was working closely with other agencies, including the police and social services, to address these delays.

  • Whilst the completion of mandatory training had improved, and was 89% overall, there were still some courses where further improvement was needed. This included training which needed to be delivered face to face. However, the trust was monitoring this closely through their ‘brilliant basics’ programme and were providing bespoke training to teams where needed.

However:

  • The trust was working hard to improve the quality of the buildings in which it provided care to patients. This included the redevelopment of St Ann’s hospital, which would replace outdated and inappropriate provision. Other wards had also been refurbished. An ongoing estates strategy was in development looking at the options for the redevelopment of the other trust estate. Dormitories would be eliminated from the Haringey and Barnet sites by the end of 2020. Further work was needed to eliminate the few remaining shared bedrooms on the Chase Farm site. There was also ongoing work to improve the seclusion facilities and reduce ligatures.

  • The trust had continued to improve in how staff assessed and monitored risks to patients. Although some teams still needed to embed further improvements, most teams in the community-based mental health services for adults of working age and mental health crisis services assessed and managed most risks to patients well, enabling people to live safely in the community. There were still some teams where further improvements were needed. For example, on the wards for older people with mental health problems, staff did not always record patients’ physical health observations accurately and had not completed physical health monitoring of patients’ vital signs after every use of rapid tranquilisation. Staff in the Barnet mental health crisis services did not clearly record the risk management plans for patients when their risk level had changed.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • Staff had easy access to clinical information and it was easy for them to maintain high quality clinical records – whether paper-based or electronic.

  • The trust managed most patient safety incidents well. Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support. While there was ongoing work to improve the timeliness of incident investigations, the reports were completed to an appropriate standard.

Effective

Good

Updated 25 September 2019

Our rating of effective improved. We rated it as good because:

  • At this inspection, we rated effective as good in all six core and additional services we inspected. When these ratings were combined with the other existing ratings from previous inspections, 11 of the trust’s services were rated good and one was rated outstanding.

  • Staff assessed the physical and mental health of patients on admission. They developed individual care plans for most patients, which they reviewed regularly through multidisciplinary discussion and updated as needed. Staff in most teams developed care plans reflected the assessed needs and were mostly personalised, holistic and recovery-oriented. Some teams still needed to make some improvements in ensuring that staff developed individualised and holistic plans with patients in all cases.

  • The trust continued to make improvements in the physical health care it offered patients with mental health needs. It had held trust-wide learning events and some adult community mental health teams had established clinics to support patients. Further work was required to ensure that the trust delivered good support to all patients with their physical health needs as there were still variations between teams. The trust had also sought to improve its links to primary care services. In Barnet, they had developed a GP link-working service, which ensured that every GP practice had direct access to a dedicated mental health professional.

  • The trust provided a range of care and treatment interventions suitable for the patient groups and mostly consistent with national guidance on best practice. They ensured that patients had good access to physical healthcare and supported patients to live healthier lives. Staff in the Haringey community-based mental health services for adults of working age and mental health crisis teams had begun to use the Open dialogue model in some of their care, which plans care around the person and their social network.

  • The trust recognised the importance of having a strong programme of quality assurance. This included clinical audits, where during the year 2018-19 the trust participated in 11 national clinical audits, two national confidential enquiries, 86 trust-wide audits and 11 local audits.

  • The trust made sure staff were competent for their roles. The trust had systems in place to induct and deliver ongoing training to ensure staff had the range of skills needed to provide high quality care. They supported staff with appraisals and opportunities to update and further develop their skills.

  • The trust ensured that staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

  • Staff supported patients to make decisions on their care for themselves. Most staff understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

However:

  • The trust had not made sure that all staff consistently received all the support they needed. At the time of the inspection, whilst most staff said they had access to supervision and reflective practice, the trust did not have a robust system to monitor the delivery of this, although plans were in place to acquire a system to provide this management information. Across the trust, we found some teams in which supervision rates needed to improve. We also found large variations in the quality of team meetings. Some teams did not complete regular and meaningful team meetings that covered all relevant topics. The trust had recently put in a framework for ward meetings, but this needed to embed.

Caring

Good

Updated 25 September 2019

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

  • At this inspection, we rated caring as good in all six core and specialist services we inspected. When these ratings were combined with the other existing ratings from previous inspections, 10 of the trust’s services were rated good and two were rated outstanding.

  • Across all services, staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Whilst there were some exceptions, most staff cared about patients and supporting them well.

  • Staff involved patients in care planning and risk assessment and actively sought their feedback on the quality of care provided. They ensured that patients had easy access to independent advocates.

  • The trust promoted the involvement of patients. Since the last inspection, the trust had developed a patient engagement strategy. Staff in wards for older people with mental health problems had set up improvement meetings, involving a range of staff, patients and relatives/carers, to gather the views of people and improve the service.

  • Staff informed and involved families and carers appropriately. They supported carers to complete a carers’ assessment. They provided opportunities for carers to become better informed or participate in the service such as through carers groups. The community-based mental health services for adults of working age early intervention services facilitated a carer group each month, where staff provided support and information to carers and encouraged them to provide mutual support for each other.

Responsive

Good

Updated 25 September 2019

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

  • At this inspection, we rated responsive as good in four of the core and specialist services we inspected. We rated responsive as good in the other two core services. When these ratings were combined with the other existing ratings from previous inspections, nine of the trust’s services were rated good, two were rated outstanding, and two were rated as requires improvement.

  • Staff worked across teams to try and optimise the care pathway for patient. Staff from crisis and home treatment teams attended wards to help support patient discharges.

  • Referral criteria for community mental health services for adults did not exclude patients who would have benefitted from care. Staff assessed and treated patients who required urgent care promptly. Staff followed up patients who missed appointments.

  • The food on inpatient wards was generally of a good quality and patients could make hot drinks and snacks at any time.

  • The services met the needs of all patients who used the service – including those with a protected characteristic. Staff helped patients with communication, advocacy, cultural and spiritual support.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. The trust still needed to improve the timeliness of its completion of complaint responses and incident investigations although these were ultimately completed to an acceptable standard.

However:

  • The trust had not planned and provided services in a way that met the needs of local people with an acute mental illness. Some patients experienced long waits to access local services. A bed was not always available locally patients on the acute wards for adults of working age and psychiatric intensive care units (PICUs). This meant the trust placed patients in beds out of the area. During the period of the inspection, more than 20 patients were placed in out-of-area services. Patients staying in the health-based place of safety often experienced long waits, some for more than two days, to access a bed. The trust was working hard to improve its bed management. It had invested in its bed management team, it planned to open a new ward in Autumn 2019, and it had commissioned a review of its acute care pathway to see it any other improvements could be made.

  • The design, layout, and furnishings of some wards did not support patients’ treatment, privacy and dignity. Some patients had to sleep in dormitories. Most bedrooms did not have an en-suite bathroom. But the trust was redeveloping the wards at St Ann’s hospital and had refurbished other wards, such as the specialist ward for eating disorders, to provide better ward environments. Dormitories would be eliminated from the Haringey and Barnet sites by the end of 2020. Further work was needed to eliminate the few remaining shared bedrooms on the Chase Farm site.

  • In some adult community mental health teams there were long waits for specific types of individual psychological therapies. The trust had worked hard since our last inspection to reduce waiting times for psychological therapies through reviewing the service model, using locum psychologists and offering group interventions however, some patients continued to wait a long time for psychological interventions. Barnet had the highest waiting times, with some patients waiting up to 18-months for individual and specialist group psychological therapies. The trust was not always fully cited on the waiting times.

Well-led

Good

Updated 25 September 2019

Our rating of well-led stayed the same. We rated it as good because:

  • Since the last inspection, there had been a new chair and chief executive. One new non-executive director had joined the board. The director of nursing and chief operating officer were also recent appointments. The trust had an ambitious board, with a wide range of skills and experience. The board had tremendous energy and commitment and the new membership had provided an opportunity to review how they carried out their business and make changes.

  • The trust had responded positively to the previous inspection and worked to make the necessary improvements. For example, we saw progress in how individual services assessed risk and worked to promote the safety of patients. We were also delighted to see the new wards at St Ann’s being built. The trust was also looking at options for future estate modernisation.

  • The inspection took place when there was still considerable work to do, however the trust was approaching this with thoughtfulness, seeking external advice where needed and this gave confidence that the improvements would bring real benefits to patients and staff.

  • The board was cited on the areas where improvements were needed, and changes were taking place to ensure the provision of high-quality care to their local communities. For example, they were aware of the significant challenges in accessing high quality care for patients with an acute mental illness. They were opening additional beds but had also commissioned a review to look at how capacity and quality of care could be improved going forward.

  • A trust strategy had been launched ‘fit for the future’. This was developed collaboratively with patients, carers, staff and external stakeholders. It reflected local and national health and care priorities. There were four clear strategic aims that were being used to develop the business plans for the trust.

  • The trust was working to improve the staff culture but recognised there was more to do. The board members were open and transparent in their manner and reflected the values of the organisation. A programme of executive roadshows had enabled members of the executive team to meet over 500 staff. Multiple other forums provided opportunities to listen to staff. The arrangements for staff to ‘speak up’ were working well. However, the staff survey results were described by the trust as disappointing. Whilst staff engagement scores were similar to other trusts, there were improvements needed in staff experiencing bullying and harassment and violence and aggression. It was recognised that there were services where staff morale was poor. Measures were being implemented to make improvements, but it was recognised that more time was needed to ensure these were embedded and individual staff had an improved experience.

  • The trust had made significant progress in addressing its financial challenges. At the end of the financial year 2016/17 there was a deficit of £12.3m. For the current financial year, the trust had agreed a control total deficit of £5.5m. They recognised there were some risks in achieving this total but were monitoring these closely. They were working closely with commissioners and were developing a shared understanding of the costs of meeting the needs of the local population.

  • The trust recognised the importance of working collaboratively to meet the needs of the population across north central London and had formed an alliance with the adjoining trust, Camden and Islington NHS Foundation Trust. This was at an early stage but will offer opportunities to develop care pathways for patients across the two geographical areas. For example, last year a female psychiatric intensive care unit was opened at St Pancras Hospital providing a service for both the trusts.

  • The trust was continuing to promote the equalities of staff and patients with protected characteristics. An equality and diversity forum was chaired by the chief executive. It was also positive that the trust had appointed a BME chief executive and chair. There was progress with the workforce race equality standards although there was more to do. The proportion of BME staff being promoted to senior roles had improved although the proportion of BME staff entering formal disciplinary procedures had deteriorated. The trust had four staff networks which were supported by the trust but might need more resources to grow and embed.

  • The trust was strengthening its leadership structures and governance arrangements. The trust had moved from having four to five divisions to enable the community services in Enfield to have more focused attention. A triumvirate leadership team was being put into place in each division. The governance structures and accountability frameworks were being reviewed across the trust to provide improved clarity and consistency. The quality governance processes were being refreshed to provide improved assurance. However, at the time of the inspection this was being put into place and so the improvements could not yet be seen operating in practice. During the interim period, the current systems were being maintained to provide ongoing assurance.

  • The trust valued the importance of multi-disciplinary working and was strengthening leadership and involvement across the organisation. A lead for allied health professionals was coming into post shortly.

  • The trust had made progress in the co-production work with people who use services and carers. The trust had produced a patient engagement strategy. Since late 2017 the provision of enablement services in the trust was awarded to a local charity. They had worked to embed peer roles within the trust and increase staff working in partnership with people using services. The trust had increased the number of peer workers from eight to 24 people. Peer service workers were part of the psychiatric liaison team at the North Middlesex Hospital. There were lots of examples of co-production work. However, further progress was needed to ensure this was embedded across all the divisions.

  • The trust was working to re-invigorate their programme of quality assurance and saw this as integral to the empowerment of staff and patients to make improvements and therefore the culture of the trust. A quality improvement strategy had been approved and an investment this year of £0.5m to employ some key staff and extend training. However, it was not clear if this would be an adequate investment to promote the necessary changes.

However:

  • The trust still needed to implement a system to automate the production of live business information. The trust had arrangements in place in the interim to generate accurate data and had made improvements in how this was presented, but the overall process was cumbersome. The trust intended to select a system later in the year. The trust was also in the process of tendering for a system to monitor the completion of supervision and appraisals and at the time of the inspection this data was collected manually.

  • The trust still needed to improve the timeliness of its completion of complaint responses and incident investigations although these were ultimately completed to an acceptable standard. Measures were in place to promote improvements and it was anticipated that the strengthened divisional structures would ensure closer monitoring of progress.

Checks on specific services

Community health services for children, young people and families

Good

Updated 12 January 2018

Overall rating for this core service GOOD

We rated the community children, young people and families service (CCYPFS) as good overall because:

  • Staff recognised incidents and knew how to report them. Incidents were shared at monthly team meetings and lessons were learned.

  • Staff kept patients safe from harm and abuse. They understood and followed procedures to protect vulnerable children and adults.

  • Staff provided care and treatment based on national guidance and evidence and programmes such as the Healthy Child Programme, Family Nurse Partnership (FNP) programme and the national child measurement program monitored against national guidelines.

  • Managers monitored the effectiveness of care and treatment through local and national audits.

  • Staff had regular supervision and an annual appraisal. Staff were supported and encouraged to undertake specialist training and had opportunities to further their clinical personal development and training.

  • We saw good multidisciplinary and joint working arrangements between the CCYPFS staff and other health professionals for the benefit of patients. The electronic patient record (EPR) was shared between CCYPFS staff to improve communication between each profession within the service.

  • Staff sought consent before undertaking care interventions. School nurses received training in consent which included the Fraser guidelines and Gillick competencies.

  • Staff were seen to be very considerate and empathetic towards children, young people and their families. People told us they had confidence in the staff they saw and the advice they received. We found the approach staff used when interacting with children, young people and families was appropriate and demonstrated consideration for the child or young person.

  • Staff took time to ensure parents understood their child’s care and treatment. Staff demonstrated good communication skills during interactions with children young people and their families.
  • Parents were positive about the care children and young people received and told us they felt involved in their children’s care. We saw patients were treated with respect and their dignity maintained. Staff demonstrated they were caring and compassionate.

  • Clinics and services were located in places where people could access them including GP surgeries, baby clinics, schools and special schools within the London Borough of Enfield.

  • Children and young people had their needs assessed. Care plans and risk assessments had been completed which identified the children’s and young people’s care needs.

  • CCYPS services were meeting their targets for time to first assessment and referral to treatment. The did not attend (DNA) rate was below the 7% target for the period of April to August 2017 in all but one of the services.

  • Telephone interpreting services were available to staff when they needed them for children, young people and families where English was not their first language.

  • Staff were aware of the trust’s complaints policy and of their responsibilities within the complaints process. Formal complaints were directed to the trust’s complaints department.

  • Staff were aware of how they contributed to the trusts broader vision and strategy.

  • CCYPFS had a governance framework and a clear reporting structure from local team meetings to monthly management meetings which fed into the trusts clinical governance meetings.

  • Managers monitored performance and the trusts quality and safety committee monitored risk across the organisation. The CCYPFS risk register was reviewed regularly.

  •    Staff felt supported and respected by colleagues at all levels. Staff described an open culture and described an ‘open door’ management style.

However:

  • Health visiting staff were not clear about frequency of visits for targeted children; records showed that some children had not been followed up for 12 months.

  • Staff did not record patient care consistently. Records did not always show whether children and young people received nursing care because staff did not always complete the patient records.

  • Children young people and their families had not been consulted about the increase in in adult outpatient clinics at Cedar House which was the main hub for CCYPFS.

  • Most staff we spoke with felt there was little visibility from the chief executive team, and some staff felt there was a ‘disconnect’ between the community services and the wider mental health trust.

At the last inspection we made a requirement notice that the trust must ensure there are sufficient health visitors to deliver the healthy child programme. At this inspection the service was delivered in line with commissioning requirements. Two of the five elements of the programme were targeted to those families where there had been identified safeguarding or parental concerns. We recognised that the trust was prioritising the safety of children and families in delivering this work.

Community-based mental health services for adults of working age

Good

Updated 25 September 2019

Our rating of this service improved. We rated it as good because:

  • Since the last inspection in September 2017, Haringey and Enfield community-based mental health teams had made good improvements to the services they provided. In particular, Haringey had made good progress in regards to our previous concerns. At the last inspection, staff across Haringey community services reported a culture of bullying and felt unable to raise concerns. During this inspection, this was no longer the case. Staff told us there was an open culture. They felt able to raise concerns and bullying was no longer an issue. At the last inspection, in Haringey, leaders had not identified key challenges and governance systems were not robust. During this inspection, leaders had a good understanding of the services they managed, had good oversight of key challenges and robust governance systems were in place to monitor risk and performance. However, in Barnet, we found the Early Intervention Service (EIS) and the West and South Locality Teams were not of the same standard compared to the other eight teams we visited, and required some improvement.
  • Since the last inspection in September 2017, staff in the locality teams told us that communication with local GPs had improved since the reconfiguration to locality-based teams as they were now aligned with local GPs in their geographical patch. The GPs had direct communication links with the consultant psychiatrists in the locality teams.
  • All clinical premises where patients received care were safe, clean, well equipped, well-furnished and well maintained.
  • The teams were actively working to recruit staff, via public advertisements and recruitment open days. The trust had developed a care coordinator training programme, which developed existing band five workers into band six care coordinator posts. Managers told us this was still in its infancy, but it was a positive strategy to recruit into these posts. Despite this work, there were still teams where there were significant vacancies such as the Barnet West and Haringey East locality teams. Here they used long term locums to try and maintain the consistency of care. There were also teams where they were struggling to recruit staff from a particular professional background. For example, the Barnet West Locality Team had been without a permanent consultant psychiatrist for two months and at the time of the inspection, the team had a locum consultant psychiatrist in place, however, the specialist registrar post remained vacant. Care co-ordinators in Haringey and Barnet EIS had high caseloads on average of 22, which was not in line with the nationally recommended maximum of 15.
  • In nine of the eleven teams we visited, staff demonstrated good assessment and management of risk to patients and staff. Teams participated in regular multi-disciplinary meetings where risk was robustly discussed. Staff followed good lone working practice, which enhanced their safety when meeting patients. However, the Barnet West and South Locality Teams did not always assess and plan how to manage risk robustly. Staff did not always update risk assessments following changes in circumstances or incidents.
  • Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. Patients knew how to complain or raise concerns. Information about how to complain was on display in the patient waiting room in the service we visited.
  • Teams in Haringey and Enfield demonstrated a commitment to learning, continuous improvement and innovation. In Haringey, the South Locality Team and Early Intervention Service had participated in a research trial with a local university. This trialled a model of mental health care that involved a consistent family and social network approach and always involved the patient. Staff spoke very highly of this approach and its benefits for patient experience.
  • Since our last inspection, the trust had made improvements to reporting of incidents and learning from when things go wrong, most staff had access to specialist training, most staff received regular supervision, and patients received the required aftercare when in relation to the Mental Health Act.

However:

  • Patients identified as in need of a Mental Health Act (MHA) assessment were not always assessed promptly and there were significant delays to MHA assessments. Staff request that a patient is assessed under the MHA when they think that the patient is posing a risk to themselves or others. Delays in completing assessments mean that people may be at risk of harm. Staff across all teams told us that MHA assessment delays was a significant issue for their team, and told us of incidents where patients’ safety had been compromised whilst waiting for a MHA assessment. Despite the delays in MHA assessments being completed, the trust was working closely with other agencies, including the police and social services, to address these delays.
  • Although the teams had made improvements in supporting patients with their physical health needs since our last inspection, teams still needed to develop and embed the necessary skills to effectively support patients. Staff did not always promptly review patients’ medical test results for abnormalities and physical health well-being clinics were not always of a good quality.
  • In all three Early Intervention Services, care plans were generic and were not always personalised to demonstrate they met the needs of the patients. It was not always clear what interventions staff were offering to patients to support them with their first episode of psychosis, and did not always reflect the National Institute of Health and Care Excellence recommendations.
  • Although there was good sharing of information within teams in each borough, there were no formal systems in place to share information across the three boroughs. This meant that teams in different boroughs would not always be made aware of good practice occurring in other teams, or incidents and learnings.
  • Whilst we saw good examples of mental capacity being appropriately considered and assessed in most teams, Barnet Early Intervention Service did not evidence that capacity assessments were completed for all patients who may have had impaired capacity.
  • Although the trust had worked hard since our last inspection to reduce waiting times for psychological therapies, some patients continued to wait a long time for psychological interventions. Barnet had the highest waiting times, with some patients waiting up to 18-months for individual and specialist group psychological therapies. The trust was aware of this and working to reduce this further.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 25 September 2019

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

  • Whilst we found that the service had addressed most of the issues that caused us to rate it as requires improvement following the September 2017 inspection, we found new areas that the trust needed to improve on.
  • Patients often stayed in the health-based place of safety for longer than 24 hours which was contrary to the Mental Health Act Code of Practice. Between January 2019 and June 2019, 20 patients out of a total of 150 (13%) patients stayed for two days. A further three per cent of patients stayed for three days and one patient stayed for four days and one patient five days.
  • The trust had not ensured that teams embedded required changes after incidents. Managers, particularly in Barnet crisis resolution home treatment team (CRHTT), did not always share lessons learned from incidents with the whole team which could impact on the safety of care provided to other patients.
  • Staff in the Barnet CRHTT needed to further improve their patient records. They did not consistently update risk management plans for all patients when a change in risk had occurred. This meant the staff might not adequately manage these risks. Staff did not always develop holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers.
  • Whilst the service used systems and processes to manage medicines, staff in Barnet CRHTT did not always follow trust policy to check patients had the correct medicines.

However:

  • Staff worked hard to manage patients’ and staff risk within the community. They met daily to continuously review patients’ risk to themselves and others, and they managed most patients safely in their homes. Staff had created crisis plans with most patients.
  • The services had enough staff, who received basic training to keep patients safe from avoidable harm. The number of patients on the caseload of the mental health crisis teams was not too high to prevent staff from giving each patient the time they needed. The service was staffed 24 hours a day, with night staff provided by the bed management team to ensure patients are responded to in an emergency. Staff followed good personal safety protocols whilst out in the community.
  • The service was available 24-hours a day and was easy to access – including through a dedicated crisis telephone line. Staff accepted referrals rapidly from those patients that otherwise would be admitted to an inpatient bed.
  • Staff working for the mental health crisis teams provided a range of care and treatment interventions that were informed by best practice guidance and suitable for the patient group. They ensured that patients had good access to physical healthcare.
  • Staff from different disciplines worked together as a team to benefit patients. The teams had effective working relationships with other relevant teams within the organisation and with relevant services outside the organisation. The crisis teams came together each quarter and formed the ‘crisis collaboration’. This was a partnership with each crisis team to share best practice and offer informal training to support staff in areas their team performed well in.
  • Staff treated patients with dignity and respect. Staff enabled patients to give feedback on the service they received. Staff in Haringey CRHTT particularly involved patients in the running of the service through a co-production event held in February.
  • Staff involved patients’ families and carers in their care where appropriate. In Enfield CRHTT staff facilitated a monthly carers support group for patients they supported going through a crisis.
  • Leaders had the skills, knowledge and experience to perform their roles, were visible in the service and approachable for patients and staff. Consultant psychiatrists in Enfield and Haringey CRHTT provided strong clinical leadership to staff.
  • Staff felt respected, supported and valued. They reported that the provider promoted equality and diversity in its day-to-day work and in providing opportunities for career progression. They felt able to raise concerns without fear of retribution. In Barnet CRHTT the culture had improved, and staff were beginning to embrace the changes to the service.
  • Staff across the teams had taken up several quality improvement projects to improve the running of the crisis teams. These projects included, new co-produced welcome packs for patients, improving the referral process and a previous street triage pilot.

Wards for older people with mental health problems

Good

Updated 25 September 2019

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

  • We found a number of improvements across the service since the previous CQC inspections in September 2017 and March 2018.
  • As required following the inspection in September 2017, improvements had been made in the recording of risk assessments and risk management plans for patients, and these were reviewed regularly. There were also improvements in the calibration of blood glucose machines. Since the inspection in March 2018, as required, we found improvements in the recording of prescribed doses on medicine administration charts, staff handwashing prior to medicine administration, and storage and labelling of medicines to avoid errors.
  • The ward environments were safe and clean. The ward environment on Silver Birches had been upgraded to a high standard, providing a dementia friendly environment. Staff assessed and managed risk well. They minimised the use of restrictive practices, and followed good practice with respect to safeguarding.
  • As required following our inspection of this service in September 2017, staff had received training to support patients with diabetes and this was reflected in care plans. Systems had also been improved for staff to access patients’ individual blood results without delay, and patient’s individual needs (including pain management and continence, nutrition and hydration forms) were appropriately recorded, and reviewed regularly.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • Since our inspection in March 2018 the provider had recruited a permanent consultant for Silver Birches providing effective medical leadership. The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multi-disciplinary team and with those outside the ward who would have a role in providing aftercare. Managers ensured that staff received training, supervision and appraisal, although there was still work needed to improve the frequency of staff supervision.
  • 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.
  • The service managed beds well so that a bed was always available locally to a person who would benefit from admission and patients were discharged promptly once their condition warranted this.
  • Patients had access to a range of activities, and had opportunities to go out within the local community. Food provision on The Oaks and Silver Birches had been improved to meet the preferences of patients.
  • The wards were well-led and the governance processes ensured that ward procedures ran smoothly. Since our September 2017 inspection the trust had ensured that the electronic record system functioned at a speed that did not impact negatively on staff responsibilities.

However:

  • Staff did not always ensure that physical health monitoring of patients’ vital signs was undertaken after every use of rapid tranquilisation, record physical health observations accurately for patients, and seek medical advice when indicated.
  • Staff did not record formal medicines reconciliation records for patients and had not yet upgraded the medicines storage cabinets on The Oaks and Silver Birches to the correct specification in line with trust policy.
  • The frequency of fire drills did not ensure that all staff, including those working at night, had regular practice in procedures for protecting patients in the event of a fire.
  • A small number of patients on The Oaks and Silver Birches had to share bedrooms with another patient, which impacted on their privacy and dignity, although curtains were in place to try and mitigate this. None of the bedrooms on Silver Birches had en-suite toilet or shower facilities.
  • The medical provision on The Oaks and Ken Porter Ward needed review to ensure that there was sufficient access to doctors at all times.
  • Reviews were needed of separate governance arrangements for the Enfield wards, and Ken Porter Ward, to ensure that learning was shared, and arrangements for the admission of sub-acute patients on Ken Porter Ward due to trust bed pressures. The trust needed to continue to work to improve the frequency of staff supervision across the wards.

Specialist eating disorders service

Good

Updated 25 September 2019

Our rating of this service improved. We rated it as good because:

  • The management team had improved the quality of the service since our previous inspection by improving the ward environment.
  • The service provided safe care. The ward environment was safe and clean. The ward 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 and the management of incidents.
  • The ward teams included the full range of specialists required to meet the needs of patients with an eating disorder. Managers ensured that these staff received training, supervision and appraisal. The multidisciplinary team was effective and worked well with other services to ensure positive outcomes for patients.
  • 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 decision-making.
  • The service managed the use of beds well in partnership with community services and patients were discharged promptly once their condition warranted this.
  • The service was well-led, and the governance processes ensured that ward procedures ran smoothly.
  • The service had a positive and open culture and staff were committed to continuously improve the service and the care pathway for patients with an eating disorder.

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

Requires improvement

Updated 25 September 2019

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

  • The service did not have enough permanent nursing staff who knew the patients. This impacted on their ability to form the professional relationships needed to understand and support each patient consistently with their individual needs. This was leading to instances of violence and aggression which might have been managed better by permanent staff. Some nurses had not completed mandatory training to keep patients safe from avoidable harm although plans were in place to deliver this training.
  • The physical environment of some wards was not fit for purpose. Staff did not record all potential hazards during environmental checks. Some low-risk ligature anchor points were not recorded. Seclusion rooms did not ensure patients’ privacy and dignity.
  • A bed was not always available locally to a person who would benefit from admission. The service worked hard to manage access to beds, but local patients were frequently referred to other hospitals because the trust could not accommodate them. Although patients were discharged promptly once their condition and circumstances warranted this, most admissions lasted longer than the target of 28 days. This was because many patients had complex needs and, for some, there were difficulties in finding appropriate accommodation.

However:

  • Staff assessed and managed patient risk well. They worked towards minimising 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 and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • 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.
  • The ward teams included or had access to the full range of 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.
  • The service was well-led and the governance processes ensured that ward procedures ran smoothly.

Community health inpatient services

Good

Updated 25 September 2019

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

  • Service leads had acted to improve the service and address concerns identified during the last inspection. The service had processes in place to ensure meal times were managed effectively and patient’s received personalised care and treatment. Although staff vacancy rates remained high, the service had a recruitment plan in place to ensure there were enough staff to care for patients and keep them safe.
  • Staff assessed risks to patients, understood how to protect patients from abuse, and managed safety well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and supported them to make decisions about their care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their care and treatment. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people and took account of patients’ individual needs. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. They understood and managed the priorities and issues the service faced. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Leaders encouraged innovation and supported staff to identify opportunities for learning and improvement.

However:

  • Although the service provided mandatory training in key skills to all staff, not all staff had completed it. The overall completion rate for nursing and care staff was 78%, although there were variations between individual courses. The managers were aware of where individual staff needed to complete this training and had plans in place for this to be completed.
  • Procedures were in place to maintain standards of infection control. However, two staff were observed not to be following these correctly.
  • Patient records were not always clear, up-to-date, stored securely and easily available to all staff providing care. The ward was still using a combination of electronic and paper records.
  • Although management of patient meal-times had improved and arrangements were in place to ensure patients had access to food and drink, staff did not always clearly document decisions around nutrition monitoring. A few recorded nutritional risks assessments were not fully completed.
  • Some of the risks we identified during the inspection, for example around patient records and medicines reconciliation, had not been identified by the service.
  • The service had not collected any patient survey feedback since February 2019 and it was not clear when this would start again.

Community health services for adults

Updated 25 May 2018

We carried out a focused inspection of this service in response to a complaint the CQC received reporting that the service was not providing good quality care to patients. The complaint raised concerns regarding the monitoring and recording of patients’ nutrition and hydration intake, patients not receiving their medicines on time and some staff not being caring. At the time of the inspection, the complaint was still under investigation by the trust. We did not rate the service following the inspection.

During the inspection, we followed up on each area of concern raised and found the following;

  • The ward had a high nursing staff vacancy rate, which had impacted on the quality of patient care. Some patients reported that they had to wait long periods of time for the bedside call bells to be answered. We found occasions when agency and bank staff worked 50 hours or more in one week, which increased the risk of errors in patient care.

  • Patients did not always have care plans in place that reflected their needs. Care plans did not consistently demonstrate that families and carers were involved and some care plans did not reflect individual risks.

  • Whilst medicines were mostly managed well on the ward, some medicines were not correctly labelled once opened. Medicines storage systems did not comply with the trust medicines management policy and British standards institution guidance.

  • The ward did not have an effective system in place to ensure that those patients identified as needing extra support with eating and drinking received help during mealtimes. During the inspection, we observed that there were not sufficient staff available to support patients. Food and fluid charts were not always completed.

  • A complaint that had raised concerns about the service had been managed effectively. The ward manager had ensured that all staff were aware of the complaint and the areas for improvement.

At the time of the inspection, we told the ward management team the negative feedback we had received from patients on the day of the inspection. Following the inspection, the ward manager put an immediate action plan in place that addressed most of the concerns identified in this report.

Child and adolescent mental health wards

Good

Updated 12 January 2018

Our overall rating of the Beacon Centre improved. We rated it as good because:

  • The trust has made significant improvements to the staffing of the Beacon Centre. At our previous inspection of the service, in December 2015, we found that the trust was in breach of a Health and Social Care regulation in relation to staffing.At this inspection in September 2017, we found that the trust had rectified this. There were now no vacancies for nursing staff. Young people told us they were now supported by staff who knew them well. Previously, we found the service did not have a permanent ward manager. Now there was an experienced ward manager in post who was providing effective leadership for the service. Staff now received monthly clinical supervision.

  • Staff received training to carry out their work roles. Communication within the multidisciplinary team was effective. The team thoroughly assessed the needs of young people and identified any risks. Staff worked with young people and their parents to develop effective care and treatment plans. These plans focused on the young person’s goals and their recovery. Staff took action to minimise risk and reviewed risks each day. The multidisciplinary team delivered care and treatment in accordance with best practice guidance and legal requirements.

  • Young people received education whilst on the ward and participated in a therapeutic programme which was designed to meet their individual needs. Young people said staff were supportive and took the time to get to know them well. The ward had been recently redecorated and was well furnished.

  • The staff team listened to the views of young people and their parents and acted on their views. There were now fewer restrictions in place for younger people. The staff team delivered care and treatment in accordance with legal requirements.

  • Governance arrangements were robust. The staff team checked the quality of the ward environment, the delivery of care and treatment, the completeness of care records and the management of medicines.

However:

  • Records of monthly supervision sessions were very brief and in some instances were not on file. Clinical governance arrangements had not identified risks in relation to the quality and completeness of supervision notes.

  • Whilst learning from incidents was taking place in team meetings, the template to record team meetings did not allow for the recording of these discussions. This meant that staff who could not attend the team meeting could not readily access this information in one place.

  • In the case of one young person, there was no record that they had been informed of their rights after a second opinion doctor had authorised their treatment.

Forensic inpatient or secure wards

Outstanding

Updated 12 January 2018

We rated Barnet, Enfield and Haringey Mental Health Trust forensic inpatient wards as Outstanding because:

  • At the last inspection in December 2015 we rated the service as outstanding. At this inspection we found that the previous good practice had been sustained and additional developments had taken place to improve the quality of the service further.

  • The service undertook numerous initiatives to ensure that patients were engaged and involved in the care they received. This included a focus on collaborative risk assessments and holistic care plans, and a robust clinical governance process which included patients attending clinical governance meetings.

  • Each ward had a patient representative who attended the user forum for the service to raise issues relevant to their ward. The chairperson and vice-chair of the forum (patients on the wards) met with senior managers regularly to feedback on patients’ views. Changes that had been made as a result included the introduction of mobile phones and laptops on the wards and rolling out self-catering on all wards.

  • The service had recruited 20 experts by experience ensuring that patients who had left the service were able to input into the current service. Experts by experience were paid to co-design and co-deliver the recovery college workshops. They were also employed to assist with staff recruitment, staff training and mentoring patients.

  • Patients and staff had co-produced and co-delivered a recovery college programme starting in May 2017. This included workshops on a wide range of topics co-facilitated by experts by experience, such as hearing voices, basic life support, getting the best out of care programme approach meetings, creative writing, sleep hygiene, and returning to study. Experts by experience were recruited by a vocational manager, with a view to providing a user led rather than a professional led programme.

  • The Kingswood Centre, an activities resource centre for forensic patients, enabled patients to access a wide range of therapeutic, educational, vocational, and leisure activities. The centre was accessible over the weekend as well as during the week. Patients undertook vocational work experience which included paid and voluntary work and were able to learn a wide range of skills including shop and café roles, horticulture, bee keeping, bicycle maintenance, light industry servicing, and jewellery making. They also had access to a fully equipped gym, sports hall, outside tennis courts and a wide range of sports. Other activities included music and art therapies, pet therapy, pottery and social events.

  • To support patients on discharge into the community, the service paid for gym membership in their local area for their first year after discharge. They were also able to continue to participate in the community football team, and contribute to the recovery college.

  • The service had brought in total self-catering across all low secure wards, and was introducing this on the medium secure wards. Results were positive with staff recording patients losing weight, and reduced aggression as a result of the change.

  • The service had recently purchased equipment that screened for various drugs and medicines in a non-intrusive way. This machine detected a wide range of drugs and was also able to detect if patients had been in contact with drugs.

  • We received very positive feedback from patients and carers that they were treated with respect, kindness and compassion and observed staff interactions which were caring and respectful. Staff across the service, including the senior management team, had a good understanding of individual needs of specific patients.

  • The forensic service had a strong focus on relational security and the staff were committed to minimising the use of restrictive practices such as restraint and seclusion.

  • Staffing was maintained at a level to ensure patient safety and without the use of agency staff. Staff undertook mandatory training and followed best practice in ensuring the safety of staff and patients.

  • Staff reported incidents which took place on the wards through the trust incident reporting system. Staff were aware of serious incidents across the trust and resulting learning was put in place, as recommended at the previous inspection.

  • Patients were supported by a multi-disciplinary team of staff on each ward. Staff had access to specialist training, and staff from forensic services shared best practice with other staff within the trust, as recommended at the previous inspection.

  • Wards were kept clean and well maintained, and had a good range of facilities including quiet rooms and outdoor garden space with gym equipment provided.

  • The service met the cultural, religious and spiritual needs of patients. There was access available to interpreters and information was available in community languages.

  • There was a complaints process. Patients were aware of how to make complaints and the service responded to all patients who had made formal complaints. There were processes in place to ensure that learning from complaints was embedded in clinical governance meetings. Ward staff encouraged formal and informal complaints which were used to improve the service delivery.

  • Patients and staff spoke positively about the senior management team within the service. Work which was undertaken reflected the trust values and we saw that recovery was a strong theme of the service from the initial admission.

  • The trust had access to significant information about the service in real time, and used the ward ‘heat maps’ which contained information about staffing to respond to the service. Senior managers had a very good understanding of the needs of particular wards. Each ward had a risk register, and staff across the service had an understanding of where the main risks lay.

  • There were a number of initiatives which pushed innovation such as the ‘dragon’s den’ within the trust which had provided financial assistance for the development of projects suggested by staff members. Staff were encouraged to drive improvement and pursue innovative ideas.

However:

  • The location of the de-escalation room on Cardamom Ward impacted on the safety, privacy and dignity of patients using this room.

  • Patients on Sage Ward had a blanket restriction of having all meetings with their visitors supervised.

  • Staff were recording seclusion records in four different formats, which was time consuming and made it difficult to assess whether a patient was supported appropriately.

  • On Devon Ward changes in risk were recorded in patients’ progress notes, but risk assessments were not always kept up to date, making it more difficult to access the most up to date risk information.  

Community-based mental health services for older people

Outstanding

Updated 12 January 2018

We rated community-based mental health services for older people as outstanding because:

  • There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Staff were responsive to individual patients’ needs and actively engaged in assessing and managing risk. Patients could access a comprehensive range of treatments and therapies.

  • Staff empowered patients and carers to be partners in their care and treatment. Staff developed positive relationships with patients and carers to ensure their needs and individual preferences were reflected in planning their care. Patients and carers reported that staff went the extra mile and exceeded their expectations.

  • The services were flexible, provided choice and patients could access them at times that suited them. Staff responded promptly and appropriately to heightened patient risk. Carers were provided with extensive support and opportunities to gain skills to help them with their caring responsibilities. For example, carers programmes featured guest speakers who shared tips and experiences, events were held with community organisations to give advice about how to care for loved ones safely in the community, and carers were trained to continue practicing cognitive behavioural therapy with their loved one at home.

  • Staff were fully engaged with developing services. They took individual responsibility for completing quality improvement projects and quality audits. Staff supported each other through regular clinical discussions in groups and as part of one to one supervision sessions. This ensured they were providing the most appropriate support possible to patients on their caseload.

  • Staff worked hard to keep waiting times as short as possible. They had collaborated with stakeholders such as GPs and other healthcare providers to help improve the flow of patients through services and the timeliness of diagnoses.

  • Staff met the individual and diverse needs of patients, and the facilities were appropriate for the patient group they served. Staff took time to make links with local organisations that could help promote the wellbeing of patients and carers. For example, staff had developed links with a Greek care home, which could be accessed to offer respite care to Greek patients, and with an LGBT support charity, which provided a community for older LGBT people.

  • Staff were well supported by their managers, and were given opportunities to have a say about how the services were run. Staff had access to career development opportunities, specialist training, and regularly discussed career progression plans with their supervisors.

Specialist community mental health services for children and young people

Good

Updated 12 January 2018

We rated specialist community mental health services for children and young people as good because:

  • The trust had made progress with addressing the areas for improvement identified at the last inspection. Since the last inspection there had been changes to the teams in terms of their size and some of the processes they used. This meant that the service delivered to children and young people had improved, although there were still areas for further development.

  • Staff were compassionate, demonstrated an in-depth knowledge of the young person’s circumstances and were respectful towards them. Young people felt listened to and said that their views were valued. The majority of carers were positive about the service they had received. They said that staff appeared to understand their child and their needs.

  • Staff completed comprehensive assessments of the children and young people referred to the service. They recognised patients’ physical health needs and communicated with their GP where needed. They delivered treatment and therapies in accordance with NICE guidance. Staff completed and updated risk assessments in line with trust policies.

  • The trust was almost meeting their target times for referral to assessment of 13 weeks. At the time of inspection, 93% of children and young people were being assessed within the 13 week trust target of 95%. Teams knew how they were performing against targets and were working hard to ensure patients were seen as quickly as possible. The trust was almost meeting their referral to treatment target time of 18 weeks but it had only recently begun to monitor compliance against this target.In September, almost 95% of children and young people were being seen within 18 weeks.

  • Arrangements were in place to see young people quickly who were assessed as needing urgent treatment. For other young people who were waiting for an assessment or treatment, they were monitored and were advised how to seek support if needed.

  • Safe staffing levels were maintained. Recruitment was ongoing and agency staff covered the majority of unfilled posts. Caseloads were within national guidance. They were manageable and were kept under regular review. Teams were made up of a wide range of professionals. Staff were highly skilled and experienced. Team managers were experienced and led staff teams effectively.

  • Young people engaged with the services. They were able to provide feedback and get involved in aspects of the service such as the recruitment of staff. In Haringey young people were offering peer support to other young people using the service.

  • Managers had governance systems in place to monitor service provision and performance. Waiting lists were managed on a weekly basis across the service.

  • Staff demonstrated a sound understanding of the Mental Capacity Act and Gillick competency.

However:

  • Alarm systems at Barnet to ensure the safety of staff and patients were not in place.

  • Whilst the majority of physical health tests were carried out by GPs, some checks were carried out by staff. Not all equipment used in in these checks was regularly calibrated. At some sites, children and young people’s privacy and dignity were compromised as height and weight measurements were taken in a corridor.

  • Staff did not clean toys at the Haringey and Barnet sites regularly. This could present an infection control risk.

  • Responding to formal complaints was taking too long.

Mental health liaison service

Updated 22 December 2016

We do not currently rate liaison psychiatry services.

We found the following areas of good practice:

  • The mental health liaison service at North Middlesex Hospital comprised experienced and well-trained staff from the appropriate professional disciplines and a consultant psychiatrist was always available for advice. Staff worked together to meet patient needs and were well supported in their work role.

  • The service had safe facilities provided by North Middlesex University Hospital in which to interview patients. Arrangements for out-of-hours cover were robust and effective.

  • The mental health liaison service had an operational procedure developed with North Middlesex University Hospital. The procedure ensured the effective operation of the service and clarified the roles and responsibilities of each organisation. This ensured that the risks to patients and others were well-managed. There was joint learning from adverse incidents across both organisations.

  • The mental health liaison service promoted the understanding of their role to North Middlesex University Hospital staff in ED and on the wards. Staff contributed to the development of good practice at the North Middlesex University Hospital in terms of meeting the needs of patients with mental health needs and their carer’s.

  • The mental health liaison service had a set of key performance indicators which were used to judge its performance. The service performed at slightly below the expected levels in terms of response times to referrals. The mental health liaison service managers worked with managers in North Middlesex University Hospital, Barnet, Enfield and Haringey Mental Health NHS Trust and other areas to analyse the challenges in meeting these KPIs.

  • The mental health liaison service included professionals who were trained to carry out brief psychological interventions and advise North Middlesex University Hospital staff on the treatment and care of patients. Staff gave patients support to access advice from other organisations or on-going mental health support. The mental health liaison service sent details of their intervention to the patient’s GP.

  • The mental health liaison service promoted an understanding of the mental health needs of patients amongst North Middlesex University Hospital through training activities. The service had set up a forum to obtain feedback from users and carers and acted on their views.

  • The service had been accredited by the mental health liaison accreditation network. The mental health liaison service had been awarded the Barnet, Enfield and Haringey Mental Health NHS Trust ‘team of the year’ in 2015 for its innovative multi-agency work.

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

  • The mental health liaison service should continue to work with North Middlesex University Hospital and all relevant agencies to analyse its performance with the aim of ensuring key performance indicators are consistently met.

  • The mental health liaison service should continue to work with North Middlesex University Hospital to ensure that there is an appropriate alarm system available in the mental health room.