• Organisation
  • SERVICE PROVIDER

Barnet, Enfield and Haringey Mental Health NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

15 May 2023 to 25 May 2023

During an inspection of Mental health crisis services and health-based places of safety

We carried out this unannounced comprehensive inspection as part of our programme of inspection activity and because at our last inspection we rated the service as requires improvement.

The trust has 3 Crisis resolution and home treatment teams (CRHTT) and 1 Health Based Place of Safety (HBPoS). At this inspection we decided to visit 2 CRHTT in Enfield and Barnet and the HBPoS which is located centrally in Enfield.

Our rating of services stayed the same. We rated them as requires improvement because:

  • The HBPoS and patient areas in the CRHTTs were visibly clean and well maintained. Staff managed infection risk well.
  • The service had enough staff, who received basic training to keep patients safe from avoidable harm.
  • The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff assessed risks to patients and acted on them. They provided effective care and treatment, and offered emotional support when patients needed it.
  • Staff worked well together for the benefit of patients, supported them to make decisions about their care and provided information to enable them to live healthier lives. They were focused on the needs of patients receiving care.
  • Staff treated patients with compassion and respected their privacy and dignity. Staff provided emotional support to patients, families, and carers.
  • The services provided effective evidence based treatments for adults based on national guidance and best practice.
  • Leaders ran teams well using reliable information systems. Staff felt respected, supported, and valued.
  • Staff worked well with patients, families, and carers. All staff were committed to continually improving the service provided.

However:

  • Although the trust had systems and processes in place to safely administer and record medicines use these were not embedded across all teams and we were not assured of the overall safety of medicines management.
  • The completion of mandatory training was low and below the levels required in some teams visited. Staff in the health-based place of safety had low rates of compliance with adult basic life support, adult immediate life support and prevention and management of violence and aggression. The failure to meet the target for this training was potentially a risk to patient safety.
  • Staff in Haringey crisis resolution and home treatment team had low rates of compliance with mandatory training in level 3 safeguarding adults and level 3 safeguarding children.
  • The Enfield crisis resolution and home treatment team had a team caseload of 52 on the day of the inspection. The team was working to reduce the size of the caseload, but it remained too high.
  • The Enfield crisis resolution and home treatment team was failing to meet the trust’s provisional target of 90% for a 4 hour turnaround for a face to face assessment of urgent patient referrals.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

To fully understand the experience of people who use services, we always ask the following five questions of every service and provider:

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive to people’s needs?
  • Is it well led.

Before the inspection visit, we reviewed information that we held about this service.

The team that inspected the service consisted of a lead inspector, 2 additional inspectors, 1 specialist advisor, with experience working in mental health crisis services and an expert by experience, someone who has experience of care and treatment in mental health crisis services.

During the inspection visit, the inspection team:

  • Visited 2 crisis resolution and home treatment teams (CRHTT) at Enfield and Barnet as well as the health-based place of safety (HBPoS) suite at Chalk Farm
  • Attended handover meetings
  • Spoke with the managers of all 3 services we visited
  • Spoke with 21 staff members including consultant psychiatrists, junior doctors, clinical psychologists, occupational therapists, registered nurses, associate mental health workers and health care assistants
  • Spoke with 5 patients and 4 carers or relatives
  • Looked at the quality of the environment in patient areas at the crisis resolution and home treatment teams and the health-based place of safety.
  • Reviewed 16 patients care and treatment records
  • Reviewed documents related to the running of the service

What people who use the service say

We spoke to 5 patients. The feedback we received was overwhelmingly positive. All patients said they received good care and treatment from staff. They described staff as brilliant, wonderful and said they really did care.

Patients told us that staff were supportive and caring and involved them in decisions about their care and treatment.

We spoke to 4 carers, and they were all positive about the support provided. They told us their relative was listened to, that staff were kind and caring and that they had been involved in all decisions about their relative’s care and treatment plan.

28, 29 April, 4, 5, 6, 7, 10 May 2021

During an inspection of Child and adolescent mental health wards

This was an unannounced focussed inspection of the Beacon Centre. At this inspection we followed up on some areas of concern identified during a focussed inspection of the service in October 2020.

The Beacon Centre is provided by Barnet, Enfield and Haringey Mental Health NHS Trust. The service is a 16-bed mixed gender inpatient child and adolescent mental health unit for young people aged between 13 -18 years old. It is the only child and adolescent mental health ward provided by the trust. At the time of this inspection, 12 young people were using the service. The Beacon Centre aims to provide care for young people at risk when their mental health needs cannot be safely met in the community. The service provides a range of treatments including psychological therapies and treatment with medicines. Young people admitted to the service are diagnosed with a range of mental disorders, including depression, psychoses, severe anxiety disorders and emerging personality disorder.

As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent on the ward to prevent cross infection. Two CQC inspectors and a CQC medicines inspector visited the service on Wednesday 28 and Thursday 29 April 2021. The remaining inspection activities were completed off-site and were completed on Monday 10 May 2021.

During the inspection the team:

  • visited the ward, looked at the quality of the environment and observed how staff were caring for young people
  • spoke with five patients and one relative
  • spoke with the ward manager, modern matron, service manager and three directorate leaders
  • spoke with 12 other staff across the multidisciplinary team
  • reviewed five patient care and treatment records
  • looked at a range of policies, procedures and other documents relating to the running of the service.

At the last inspection in October 2020 we rated the service as requires improvement overall, with ratings of requires improvement for the effective and well led domains and a rating of inadequate for the safe domain. The caring and responsive domains were not rated. At this inspection the ratings for the safe, effective, caring and well led domains all increased to good, and the overall rating for the service increased to good.

We rated it as good because:

  • Significant improvements had been made to the service since it was last inspected and most actions had been met.
  • Progress had been made with recruitment of registered nurses despite ongoing nurse recruitment challenges across the sector. This involved the launch of a new band five recruitment package. Long-term agency staff were now used to cover vacant posts and all healthcare assistant vacancies had been filled. This meant that patients were now starting to receive consistent care from staff they were familiar with.
  • Staff were better aware of how to manage individual patient risk and we observed thorough discussions about patient risk on the ward where all staff contributed. Patient risk records were sufficiently detailed and kept up to date and the risk audit system had improved. Staff were still considering how embed risk assessment and management by considering how a 'safety huddle' approach could be used in handover meetings.
  • The administration and appropriate monitoring of patients who had received medication by IM rapid tranquilisation had improved. Staff were focussed on taking the least restrictive intervention when managing incidents of violence and aggression. They considered each patients sensory needs and used a tailored approach to verbal de-escalation.
  • Restraint incidents were better recorded. Patients and staff now received a debrief and staff were actively considering how to minimise the need for restraint by using de-escalation practices in line with each patient’s positive behavioural support plan.
  • Staff had a good awareness of safeguarding and maintained clear documentation in relation to safeguarding. Leaders used a safeguarding tracking system to ensure they had oversight of all cases.
  • Staff could now access regular supervision. However, the trust needed to closely monitor completion figures because, whist these had improved, they had fluctuated in the first few months of 2021.
  • Specialist training was available to staff and helped provide them with the skills they needed to support the patient group.
  • Improvements had been made to the way records were kept when patients refused their medication. This meant that all staff were now aware of when patients had refused medication.
  • The new local leadership team were passionate about their work and committed to the improvement of the service. Leaders had a very clear vision of how to continue to improve the service and ensure recent improvements were sustained.
  • Leaders were aware that the staff group remained anxious and that there was tension around feeling heavily scrutinised. They recognised that a key priority going forward was on transitioning from the focus on immediate improvement and continued scrutiny to embedding a supportive, business as usual atmosphere where staff felt more supported. Leaders also had a strong vision for embedding an improved cohesive team culture that focusses on wellbeing and achieving consistency amongst the staff group.

However

  • Staff still needed to ensure liquid medicines were dated when opened. Although an auditing system was in place at the time of the inspection, this had not successfully identified that some liquid medicines were not labelled when opened.
  • A continued focus on how the staff team could systematically learn from incidents was also needed. Although improvements had been made to the way staff learnt from serious incidents, the current governance system did not allow for ward staff to systematically discuss and learn from more routine ward incidents.
  • Discussions that took place at the new staff business meeting were not documented and we received mixed feedback about whether staff had been able to attend these. This presented a risk that key information may not be systematically shared with all staff, other than on an ad-hoc basis.

07 October to 19 October 2020

During an inspection of Child and adolescent mental health wards

  • We changed our rating as Safe to inadequate and Effective and Well-led to requires improvement due to the concerns that we identified during this inspection. We did not re-rate Caring as we did not collect enough evidence for us to be able to do this. We did not inspect any aspects of Responsive during this inspection.
  • Leaders had identified concerns with the service earlier in the year, and they had developed an implementation plan to address the concerns, but there had been limited progress in putting in place agreed actions to ensure young people were safe and received good care.
  • The service did not have enough registered and non-registered nursing staff working on each shift who knew the young people and had received appropriate training and supervision to keep the young people safe from avoidable harm.
  • Risk management arrangements were not adequate. Staff had not consistently assessed and managed risks to young people. Staff had not always undertaken risk assessments in advance of young people taking leave. This meant staff might permit a patient to leave the ward without fully considering the young persons assessed risks to themselves or others. Handovers were ineffective. They were not documented and staff described them as chaotic, which meant staff could be unaware of the risk status of patients on the ward.
  • Staff had not consistently followed trust policies on ensuring young people were kept safe after the administration of rapid tranquilisation medication.
  • Staff use of de-escalation to prevent incidents escalating on the ward was not consistent. Staff and young people told us that temporary staff were sometimes too quick to restrain, and other times they did not restrain them when needed. We shared our concerns with the trust, who responded promptly. The trust placed a member of staff on the ward who specialised in the prevention and management of violence and aggression, to provide additional support and training for staff. The trust also arranged meetings with the young people to speak about their concerns.
  • Lessons learned from incidents were not always shared with the whole staff team.
  • Safeguarding alerts were not always passed on to the local authority.
  • Staff had not received regular clinical supervision. There was limited training available specific to supporting young people with mental health needs. Staff completion of the additional training provided was low.
  • Some agency staff did not always treat young people with compassion and kindness.

However,

  • Young people spoke highly of permanent members of staff across the multi-disciplinary team. Permanent staff had completed most of their mandatory training.
  • A range of activities were provided for young people, including attending school, therapies as well as craft making and cooking activities.
  • Staff understood how to protect young people from abuse and in most instances the service worked well with other agencies to do so.

28 September 2020 to 28 September 2020

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

We did not rate acute wards for adults of working age and psychiatric intensive care units at this inspection as we only visited two of the trust’s wards. We visited Devon Ward, a 12 bedded male psychiatric intensive care unit (PICU), and Sussex Ward, an 18 bedded male treatment ward. We visited these wards due to concerns we had received from the trust and patients. These concerns related to staffing, risk and incident management, culture and leadership of the wards.

This was a focused inspection of safe, effective, responsive and well-led.

As this inspection took place during the Covid-19 pandemic, we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. This meant that we limited the amount of time we spent on the ward to prevent cross infection. Two CQC inspectors and one CQC inspection manager visited the ward unannounced on 28 September 2020 during the night shift to complete essential checks. Whilst on site we wore the appropriate personal protective equipment and followed local infection control procedures. The remainder of our inspection activity was conducted off the ward. We conducted staff interviews over the telephone on 1, 5, 7 and 12 October 2020. We reviewed patient care records on-site, but off the ward, on 5 October 2020.

We found:

  • The service had already made improvements in relation to the concerns. In May 2020, senior leaders completed a review of Devon PICU and identified the need to provide additional support to the ward. They had developed an improvement plan, which clearly identified what action needed to be taken to improve the safety of the ward. This plan was reviewed every two weeks by senior leaders and staff members from the ward. The action plan was still in progress and leaders needed to ensure recent changes made were embedded.
  • The staff members we spoke with on Devon PICU felt the ward had improved. Staff told us there had been many positive changes since the action plan had started, particularly around the safety and leadership of the ward. Staff told us that they now felt supported by management.
  • The trust had improved senior leadership on Devon PICU. In May 2020, an interim senior nurse was recruited as a PICU practice lead and provided excellent day-to-day clinical leadership to staff on the ward. In addition, a substantive and experienced ward manager was recruited to the ward. All staff we spoke with said the PICU practice lead and ward manager were very supportive and had made a positive impact on the ward. Prior to May 2020, the ward had experienced changes in ward management, which contributed to an instability in leadership on the ward.
  • The wards managed patient safety incidents well. Staff recognised incidents, such as restraints and patient assaults, and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • Staff had improved how they assessed and managed risks to patients and themselves. The service had introduced morning safety huddles, which helped staff better understand and manage patients. Each ward now had a security nurse present in communal areas 24/7 to check the safety of the environment. Staff participated in the trust’s reducing restrictive practice programme.

However:

  • Staff did not always ensure that physical health monitoring of patients’ vital signs was undertaken after every use of rapid tranquilisation, in line with trust policy. Staff were not always clear about the frequency required as outlined in the trust policy. It is important to monitor patients’ vital signs post rapid tranquilisation to detect and escalate possible deterioration in physical health.

During this focused inspection, the inspection team:

  • Spoke with eleven patients
  • Spoke with the ward manager and the PICU practice lead for Devon Ward, the modern matron for Sussex Ward, the night manager, Enfield Mental Health Divisions Managing Director, clinical director and head of nursing.
  • Interviewed 26 members of staff, including the consultant psychiatrists, deputy ward managers, registered nurses, healthcare assistants, and an associate mental health worker.
  • Looked at six patient care records, including risk assessments and care plans
  • Looked at a sample of records relating to patient restraints, seclusion and rapid tranquilisation.
  • Looked at other documents relating to the running of the wards, including Devon Ward’s improvement programme, incident records, minutes of team meetings and shift handovers.

18 June to 30 July 2019

During a routine inspection

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.

27 March 2018

During an inspection of Wards for older people with mental health problems

We carried out a focused inspection of this service in order to assess whether the service was implementing changes as a result of the unexpected death that occurred on the ward in late 2017. The Care Quality Commission (CQC) also received a complaint in January 2018 that related to the service delivering poor care and treatment. The concerns related to staff not being respectful towards patients and a lack of monitoring and recording of physical health results. At the time of the inspection, the complaint was under investigation by the trust. We did not rate the service following the inspection.

We found the following areas that the provider needs to improve:

  • The ward did not have a robust system in place to ensure ward staff had access to patients’ individual blood results in a timely manner.

  • The service did not always manage medicines safely. Prescribers did not always ensure that they completed medicine charts correctly, medicines that had been opened were not correctly labelled, and stored medicines were not organised. Medicine storage cabinets did not comply with the trust’s medication management policy.

  • Staff did not always assess patients’ individual needs and care plan for this appropriately. This included a lack of assessment and monitoring of continence care and patients’ individual pain levels.

  • The ward lacked effective medical leadership. The ward had not had a permanent doctor in post since November 2017. The issues we identified during the inspection were a reflection of the need for consistent medical oversight.

However, we found the following areas of good practice:

  • Ward staff discussed outcomes from incidents and lessons learned. We found that the ward had begun to implement improvements following the recent serious incident investigation.

  • Staff actively encouraged regular hydration and regularly monitored food and fluid intake.

  • Additional specialist training was offered to staff to improve their physical health monitoring skills. This included heart monitoring checks (ECG) and national early warning score (NEWS) training. NEWS is a systematic way of recording physical health results to identify improvement or deterioration.

  • Staff engaged in activities and conversations with patients. At the time of the inspection, we found that staff treated patients with dignity and respect.

25 -28 September 2017

During an inspection of Forensic inpatient or secure wards

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.  

4 and 5 September 2017

During an inspection of Specialist eating disorder services

We rated the service as requires improvement because:

  • Although the trust had made improvements to address the concerns we raised at our previous inspection in February 2017, we found new areas for improvement.

  • The trust did not ensure that patients were protected from potential ligature risks in all areas of the ward. Bathrooms and toilets had been identified as potential ligature risks on the ligature risk assessment and were to be kept locked. During our inspection, this was not the case and on four occasions these were found to be open. This meant that measures in place to manage and mitigate these risks were not being followed.

  • The ward environment did not promote comfort, dignity and privacy. The main communal lounge was located in the middle of the corridor. Patients had their post meal support group in this area and staff regularly walked through the group to access the clinic room and managers office. The dining rooms were not conducive to people’s eating experience and the therapy rooms were bare and being used to store equipment

  • Mandatory training compliance with basic life support and information governance was at 59%.

  • Staff did not always update patient care plans promptly when there had been a change in risk.

  • Patient feedback was mixed, and we heard concerns about poor staff attitude and that they were not treated with dignity and respect.

However:

  • At this inspection, we found that the trust had taken appropriate action to improve the service and had addressed all previous breaches of regulation and all of the previous recommendations. The service had made improvements in staffing and ensuring that there were enough staff on duty to meet the needs of patients, including one-to-one time with staff and ensuring that staff had undertaken and completed training on how to care for patients with an eating disorder. Blanket restrictions in relation to bathing and shower times had been reviewed and used only in response to individual patient risk. The service had also made improvements to patient risk assessments so that they were comprehensive and updated following incidents. Care plans were person centred and developed in collaboration with patients so that their views were included. Patients’ individual meal plans and requests were mostly met. Where staff were unable to accommodate this, an alternative agreed with the patient was provided. Staff carried out robust monitoring of food provision with the support of the dietetics team.

  • The wards were clean and well maintained. Furnishings were in good condition. Staff had undertaken infection control training and followed infection control practices. Emergency equipment in the clinic room was checked regularly.

  • The trust had an on-going programme of staff recruitment and had carried out a staffing review so that they could bench mark themselves against other inpatient eating disorder services.

  • The service protected patients from the risk of abuse and avoidable harm. There were clear, open and transparent processes for reporting and learning from incidents. Records showed that staff apologised to patients and family members when things went wrong.

  • There were systems in place to ensure that patients consistently received their medicines safely and as prescribed.

  • Patients’ care and treatment was planned, delivered and reviewed regularly, in line with best practice guidance.

  • Patients were involved in their treatment and had been included in decisions about their care. The multidisciplinary team had specialist skills in eating disorders which supported the effective delivery of care and treatment.

  • The trust had acted on the findings of our inspection in February 2017 and had developed an action plan to address the shortfalls identified. The appointment of the ward manager and changes in the senior management team for the service had a positive impact on the service.

15 February 2017

During an inspection of Specialist eating disorder services

We have not rated this service because this was a focussed inspection.

We carried out this inspection to assess whether the provider had made improvements and met the requirement notices that were served following our inspection in February 2016.

We found the following areas where the service needs to improve:

  • Staff had not completed comprehensive risk assessments for some patients or updated them following some incidents. There had been very little progress since the previous inspection in February 2016.

  • The ward did not always plan staffing to ensure patient safety. Some patients did not receive planned one to one time with staff. On the day of our inspection, the staffing levels were not sufficient to meet the needs of the patient group.

  • Staff had not completed some care plans to address all of the individual needs for each patient. We found that one patient did not have any care plan in place and two other patients did not have a care plan in place to support their mental health needs.

  • Staff still imposed a restriction regarding the times patients could use the shower. This restriction prevented the freedoms of patients that applied to everyone rather than being based on individual risk assessments and the needs of individual patients. At our last inspection in February 2016, a blanket restriction was in place which only allowed patients an hour in the morning and in the evening to use the bath and shower facilities. However, the blanket restriction where patients were expected to remain in their rooms for seven days after admission had been removed, although some patients told us that staff asked them if they preferred to eat in their rooms or the dining room.

  • At our last inspection in February 2016, staff had not received specialist training to ensure they understood how to care for patients with an eating disorder. At this inspection, we found that the ward had provided a training programme. However, whilst most staff had started the training they still had further sessions to complete.

  • Patients did not always have access to snacks. During our last inspection, the food available did not always meet some patients’ individual meal plans. Some food choices that were included in individual meal plans were either unavailable or stock was limited. At this inspection, staff and patients told us that that this continued to be an issue and food still ran out.

  • The main entrance door to the ward did not protect patients’ privacy and dignity. It had a clear panel of glass which allowed people outside the ward to see into the main ward area.

However, we found the following areas of improvement since the last inspection:

  • At our last inspection in February 2016, staff had not received regular supervision to support them to carry out their roles. At this inspection, we found staff received regular supervision.  

  • At our last inspection in February 2016, medicines were not reviewed regularly and some medicines were prescribed above British National Formulary (BNF) recommended limits. At this inspection, we found that this had largely improved and staff reviewed medicines prescribed to each patient regularly.

  • At our last inspection in February 2016, staff did not always formally report incidents, including medicine administration errors. At this inspection, we found staff reported medicine related errors.

  • The trust had appointed a new ward manager who had been in post a few weeks. Staff on the ward told us they felt the new ward manager was having a positive impact on the ward. The manager was aware of the need to make improvements and was starting to make changes. Action plans were in place with clear timescales for the improvements to be completed within a short period of time.

22 September 2016

During an inspection of Mental health liaison service

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.

18 February 2016

During an inspection of Specialist eating disorder services

We have not rated this service because this was a focussed inspection.

We found the following areas where the service needs to improve:

The layout of the ward did not meet the needs of the patients. Rooms on the ward were used for outpatient appointments which did not protect the privacy of patients that were staying on the ward. Four bedrooms were located away from the main ward area which made it hard for staff to observe and support patients when they were in these rooms. During the inspection the safety and security of the ward for the patients was reduced as the front door had been left unlocked and rooms which we were told have been locked to maintain patient safety such as the laundry room had been left unlocked.

The ward had two blanket restrictions in place. The first was that patients were prevented from leaving their bedrooms for up to seven days after admission. This was not appropriate clinical practice and the blanket approach did not reflect the individual needs of the patients. Staff told us that patients could be physically unwell and would require close supervision and monitoring on admission. Patients told us that staff had shouted at them when they had attempted to leave their bedroom and that they did not understand the reason for the rule. The second blanket restriction was that the ward was only allowing patients an hour in the morning and in the evening to use the bath and shower facilities. The rule applied to all patients and was not based on individual need.

Patient records did not demonstrate that staff updated risk assessments regularly. Risk assessments were completed on admission and then reviewed at 6 month intervals, but not in relation to the changing needs of the patients.

Staff had attended specialist workshops and seminars. However, staff attendance rates were not available for the sessions provided. The trust provided specialist training to all qualified staff on the ward in nasogastric (NG) feeding.

The ward staff were not receiving regular supervision to support them to carry out their roles. When supervision did take place this was not always completed thoroughly to consider staff development needs.

As required medicines was not reviewed regularly and some medicines were prescribed above British National Formulary (BNF) recommended limits.

Incident records demonstrated that physical intervention had not been required for NG feeding.

The food available did not always meet some patients’ individual meal plans. Some food choices that were included in individual meal plans were either unavailable or stock was limited. This meant that some patients would not have a snack, and therefore not eat.

Patients were not happy on the ward and felt that some staff were approachable but others were not. Complaints reflected that patients were not happy with how staff had treated them. Patients did not feel listened to and were not fully informed of ward decisions.

Overall, there were areas of practice on the ward which required considerable improvement.

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

The ward environment was clean and free from clutter. The ward provided good access to advocacy services and supported patients to make contact with advocates when required.

The ward had good links with the local general hospital and was able to gain support and advice if concerned about a patient’s physical health.

A multidisciplinary meeting took place on the ward on a daily basis where staff discussed patients that may require an admission to the inpatient unit. The meeting was well attended by various professionals who provided specialist input.

30 November – 4 December 2015

During an inspection of Community health services for adults

Overall rating for this core service Good

We rated the adult community health service as good because:

We observed staff treating patients with dignity and respect. Patients told us they had received good and compassionate care. Teams respected the individual needs of each patient including their religion and culture. We saw examples of teams taking different approaches to respond to people in vulnerable circumstances.

Staff were aware of the trust values and told us these resonated with team values and approach. Staff consistently reported they felt well supported by team leaders and senior managers. Staff felt valued and respected by the organisation. Staff told us they felt safe in their work and had arrangements in place for lone working.

There were examples of innovation and close working with the local commissioners. The trust annual awards celebrated such developments.

There were arrangements in place that promoted the safety of patients and staff. Teams learned from mistakes made and had a culture of openness and transparency. Staff received training to help to keep people safe. Staff told us they felt well supported, had access to regular supervision and annual appraisals. They were able to undertake training to develop and maintain their clinical skills. There were good examples of multi-disciplinary working.

The teams were monitoring how services were delivered and whether they met the needs of patients. Local and national audits were undertaken. A range of measures were used to evaluate the outcomes of patient treatments.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.