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

Reports


Inspection carried out on 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 This included the redevelopment of St Ann’s hospital, which would replace outdated and inappropriate provision.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.


CQC inspections of services

Service reports published 25 September 2019
Inspection carried out on 18 June to 30 July 2019 During an inspection of Community-based mental health services for adults of working age Download report PDF | 537.16 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 18 June to 30 July 2019 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 537.16 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 18 June to 30 July 2019 During an inspection of Wards for older people with mental health problems Download report PDF | 537.16 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 18 June to 30 July 2019 During an inspection of Specialist eating disorders service Download report PDF | 537.16 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 18 June to 30 July 2019 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 537.16 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
Inspection carried out on 18 June to 30 July 2019 During an inspection of Community health inpatient services Download report PDF | 537.16 KB (opens in a new tab)Download report PDF | 1.83 MB (opens in a new tab)
See more service reports published 25 September 2019
Service reports published 25 May 2018
Inspection carried out on 27 March 2018 During an inspection of Wards for older people with mental health problems Download report PDF | 238.69 KB (opens in a new tab)
Inspection carried out on 26 March 2018 During an inspection of Community health services for adults Download report PDF | 227.42 KB (opens in a new tab)
Service reports published 12 January 2018
Inspection carried out on 25 -28 September 2017 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 583.26 KB (opens in a new tab)
Inspection carried out on 25 -28 September 2017 During an inspection of Child and adolescent mental health wards Download report PDF | 387.72 KB (opens in a new tab)
Inspection carried out on 25th – 28th September 2017 During an inspection of Community health services for children, young people and families Download report PDF | 327.57 KB (opens in a new tab)
Inspection carried out on 25 -28 September 2017 During an inspection of Wards for older people with mental health problems Download report PDF | 313.29 KB (opens in a new tab)
Inspection carried out on 25 -28 September 2017 During an inspection of Forensic inpatient or secure wards Download report PDF | 438.94 KB (opens in a new tab)
Inspection carried out on 25 -28 September 2017 During an inspection of Community-based mental health services for older people Download report PDF | 364.92 KB (opens in a new tab)
Inspection carried out on 25 – 28 September 2017 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 400.47 KB (opens in a new tab)
Inspection carried out on 25 to 28 September 2017 During an inspection of Specialist community mental health services for children and young people Download report PDF | 350.36 KB (opens in a new tab)
Inspection carried out on 25 -28 September 2017 During an inspection of Community-based mental health services for adults of working age Download report PDF | 424.41 KB (opens in a new tab)
See more service reports published 12 January 2018
Service reports published 22 December 2016
Inspection carried out on 22 September 2016 During an inspection of Mental health liaison service Download report PDF | 328.83 KB (opens in a new tab)
Service reports published 24 March 2016
Inspection carried out on 30 November 2015 – 04 December 2015 During an inspection of Mental health crisis services and health-based places of safety Download report PDF | 362.52 KB (opens in a new tab)
Inspection carried out on 30 November – 4 December 2015 During an inspection of Acute wards for adults of working age and psychiatric intensive care units Download report PDF | 570.95 KB (opens in a new tab)
Inspection carried out on 30 November – 4 December 2015 During an inspection of Community health services for adults Download report PDF | 334.42 KB (opens in a new tab)
Inspection carried out on 1 December 2015 During an inspection of Community health inpatient services Download report PDF | 312.3 KB (opens in a new tab)
Inspection carried out on 23 November, 1-3 December 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 277.33 KB (opens in a new tab)
Inspection carried out on 30 November – 4 December 2015 During an inspection of Community-based mental health services for older people Download report PDF | 300.78 KB (opens in a new tab)
Inspection carried out on 30 November, 1-4 December 2015 During an inspection of Forensic inpatient or secure wards Download report PDF | 338.79 KB (opens in a new tab)
Inspection carried out on 1 December 2015 During an inspection of Child and adolescent mental health wards Download report PDF | 289.47 KB (opens in a new tab)
Inspection carried out on 30 November – 4 December 2015 During an inspection of Community-based mental health services for adults of working age Download report PDF | 346.54 KB (opens in a new tab)
Inspection carried out on 2-3 December 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF | 320.42 KB (opens in a new tab)
Inspection carried out on 30 November – 4 December 2015 During an inspection of Community health services for children, young people and families Download report PDF | 297.65 KB (opens in a new tab)
See more service reports published 24 March 2016
Inspection carried out on 25 - 28 September 2017

During a routine inspection

Our rating for the trust stayed the same. We rated it as requires improvement because:

  • Of the 12 separate mental health and community health services managed by the trust that we have rated, four are now rated as requires improvement: acute wards for adults of working age and psychiatric intensive care units, mental health crisis services and health-based places of safety, community based services for adults of working age, and specialist eating disorder services.

  • Ratings for two of the five overall ratings for key questions (safe and effective) remain as requires improvement.

  • Following the inspection in December 2015, the trust implemented a comprehensive improvement plan. At this inspection in September 2017, it had made many improvements, but in a few areas this had not been fully implemented or embedded. We also found some new areas for improvement.

  • Staff found it hard to keep patients safe and protect their privacy and dignity because some of the trust’s buildings were old and did not provide a good environment for patient care. Some patients at St Ann’s hospital were required to sleep in dormitory rooms. Patients who needed access to seclusion rooms sometimes had to be moved through public areas and had to use bathrooms that contained potential ligature anchor points. The trust had improved many ward environments since the last inspection and had proposals to rebuild St Ann’s hospital, but it needed to continue work to improve all environments.

  • Staff in three of the core services did not always complete and update risk assessments in sufficient detail to ensure they managed risks to patients and themselves. Staff in the acute wards for adults of working age and psychiatric intensive care units did not complete physical health checks for patients following rapid tranquilisation.

  • The trust still needed to embed improvements in physical health monitoring and planning especially in community services for adults with mental health needs. Staff did not always ensure, in partnership with GPs, that patients had received physical health monitoring. Staff in wards for older people with mental health problems did not complete diabetes plan care for patients that required them.

  • Staff did not always receive regular formal supervision. In some teams managers did not record when staff completed formal supervision or what had been discussed.

  • Patients could not always access advice and support from teams. Ten percent of calls made to the trust’s hub telephone service did not get answered.

  • The trust needed to ensure its management systems identified and addressed all areas of risks. The trust had not identified some areas of concern so they could be addressed in a timely manner. In addition, managers on some acute wards were recently appointed. They needed to ensure improvements were made and embedded in all wards.

However,

  • Of the 12 separate mental health and community health services managed by the trust, two are now rated as outstanding: forensic inpatient/secure wards and community based mental health services for older people. This is a significant achievement.

  • Six of the services are now rated as good: child and adolescent mental health wards, wards for older people with mental health problems, specialist community mental health services for children and young people, community health inpatient services, community health services for adults, and community health service for children, young people and families.
  •  The trust is rated as good for three of the five overall ratings for key questions  (caring, responsive and well led).

  • Whilst the trust is still rated as requires improvement it is now close to achieving a rating of good in the future.

  • We carried out a full review of the trusts leadership and governance processes and found the trust was well-led and had made many improvements since our last comprehensive inspection. It had embedded its divisional management structure and improved its assurance processes, which had helped it deliver many of the required improvements to services.

  • Despite the significant financial challenges faced by the trust and the ongoing cost improvement plans, leaders in the trust planned resources to ensure this had as little impact as possible on the care patients received.

  • Most staff felt proud to work for the trust and were committed to ensuring they delivered good care for patients. Most staff supported patients with kindness, respect and support.

  • Staff in the outstanding community based mental health services for older people and forensic/secure inpatient wards worked in partnership with patients and carers to plan care and develop services that were responsive to their needs. Staff had supported patients in the forensic/secure inpatient wards to deliver self-catering food.

  • The trust leadership was open. The trust engaged well with staff and encouraged them to raise concerns when they had them. Many staff told us they found the trust a good place to work.

  • The trust systems enabled staff to escalate risks. In most areas, senior leaders knew where areas of concern were and had plans to address these.

Inspection carried out on 30 November – 4 December 2015

During a routine inspection

We have given an overall rating to Barnet, Enfield and Haringey Mental Health NHS Trust of requires improvement.

We have rated five of the eleven core services that we inspected as requires improvement, five as good and the forensic services as outstanding. The services that require improvement are the acute mental health admission wards for adults, the community based mental health services (mainly the community recovery teams), the child and adolescent mental health ward the Beacon Centre, the specialist community mental health services for children and young people and crisis mental health services which include the home treatment teams. The Enfield community services had an overall rating of good.

At the start of the inspection, the chief executive of the trust gave a presentation about the areas they were proud of and the challenges faced by the trust. Our inspection findings reflected most of the priorities identified by the trust. This demonstrated that the senior trust managers had identified many of the problems that they needed to address. However, we believe that there is still a great deal to do for services to be a consistently high standard. We found that these challenges are greater in the borough of Haringey where more improvements are needed. We have also concluded that at St Ann’s the physical environment of the three inpatient mental health wards is not fit for purpose due to it’s age and layout. This impacts on the trusts ability to deliver safe services within this environment.

The main areas for improvement were as follows:

  • The trust had a substantial problem with staff recruitment and there was a high use of temporary staff that was impacting on the consistency of care. There were too few regular staff to consistently guarantee safety and quality in the acute mental health wards, the child and adolescent ward and in the Enfield health visiting services. There were staffing problems in some other areas but these are not as severe.
  • A significant number of new or interim managers provided important support roles or directly led teams providing care. Permanent managers with strong leadership skills were needed to improve and sustain standards of care.
  • The management of risk was very variable across the mental health services. In some cases this was because staff had not considered individual risk or updated records following specific incidents. Sometimes the record keeping needed to improve. This meant that there was a possibility of staff not safely supporting patients with their individual risks.
  • The trust did not operate lone working arrangements robustly in some of the community mental health services. Staff safety was potentially compromised.
  • Patients had absconded from mental health inpatient wards whilst detained under the Mental Health Act. These incidents and the learning from them were not being addressed.
  • Staff in acute mental health inpatient wards did not always recognise when a patient’s physical health was deteriorating and ensure they received timely input.
  • The trusts communication with primary care needed to improve, not only when patients were being discharged from inpatient services, but also throughout their ongoing care and treatment.
  • The telephones and IT systems did not support effective working by staff in the community. Whilst the trust was working on this there was more to be done.

Despite these problems there was much for the trust to be proud of. The senior executive team were committed to improving services and to providing a high standard of care for patients receiving treatment from the trust. Staff working for the trust valued the leadership provided by the senior team, especially the chief executive.

The main areas which were positive were as follows:

  • Most of the staff we met were very caring, professional and worked tirelessly to support the patients using the services provided by the trust.
  • The trust was continuously looking at how the patients using their services could be supported with their ‘enablement’ and new projects with other external providers were happening.
  • The trust had improved the arrangements for patients to access the Enfield community health services.
  • The trust was working to reduce the use of physical interventions. The use of restraint was low and on the forensic wards they made good use of relational security to minimise the use of restraint and seclusion.

  • Staff had access to a wide range of opportunities for learning and development, which was helping many staff to make progress with their career whilst also improving the care they delivered to people using the services.
  • Staff morale was good and most staff said how much they enjoyed working for the trust.
  • Staff felt able to raise concerns and most had done so where needed.
  • The trust had a robust governance process that identified areas of concern and monitored progress in addressing these matters.

The trust had recently introduced a new management structure for services based on borough lines and this was well received. There was ongoing work to improve patient, carer and staff engagement in the work of the trust. These and the many other positive developments need time to consolidate.

We will be working with the trust to agree an action plan to assist them in improving the standards of care and treatment.

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.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


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.