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Provider: Barnet, Enfield and Haringey Mental Health NHS Trust Requires improvement

Reports


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.


CQC inspections of services

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 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 Forensic inpatient/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 Wards for older people with mental health problems Download report PDF | 313.29 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 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 -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 Child and adolescent mental health wards Download report PDF | 387.72 KB (opens in a new tab)
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 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 November 2017
Inspection carried out on 4 and 5 September 2017 During an inspection of Specialist eating disorder services Download report PDF | 373.81 KB (opens in a new tab)
Service reports published 4 May 2017
Inspection carried out on 15 February 2017 During an inspection of Specialist eating disorder services Download report PDF | 234 KB (opens in a new tab)
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 6 May 2016
Inspection carried out on 18 February 2016 During an inspection of Specialist eating disorder services Download report PDF | 278.17 KB (opens in a new tab)
Service reports published 24 March 2016
Inspection carried out on 30 November, 1-4 December 2015 During an inspection of Forensic inpatient/secure wards Download report PDF | 338.79 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 1 December 2015 During an inspection of Child and adolescent mental health wards Download report PDF | 289.44 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 23 November, 1-3 December 2015 During an inspection of Wards for older people with mental health problems Download report PDF | 277.24 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)
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 | 568.24 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 | 346.48 KB (opens in a new tab)
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 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)
See more service reports published 24 March 2016
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.