Barnet, Enfield and Haringey Mental Health NHS Trust

We rated community-based services for adults of working age as requires improvement because:

During this inspection, we found that services had addressed some of the issues that caused us to rate it as requires improvement following the December 2015 inspection. However, at this inspection we found areas where further improvement was required particularly in the Haringey adult community teams.

• Since the last inspection, in December 2015, we found that some improvements in risk assessment and risk management had taken place. However, in some teams we had ongoing concerns about the way that risk was assessed, managed and documented and the impact this had on patients. Some patients did not have up to date risk assessments and management plans in place. Also some risk management plans were not being following consistently. This included ensuring that patients met with their care co-ordinator at agreed intervals.

• We found that some teams had not ensured that patients’ care plans were up to date and person-centred, reflecting holistic assessments and care planning and that patients’ and their carers’ views were represented.

• At the last inspection in December 2015, we found that some teams were not supporting patients to have physical health checks and that the teams were not always aware of or able to respond appropriately to significant physical healthcare issues. Staff did not always document in care records how patients’ physical health needs were being addressed. During this inspection, we found that whilst there had been improvements some teams were not following up patients who had physical healthcare needs by ensuring that information on their records was up to date. When information was requested from GPs, this was not followed up in a systematic manner. If there was no response, from GPs, it was not clear that the service had tried to ensure that all attempts were made so that physical health information was up to date and that staff in the team, particularly staff prescribing medication, were informed about current levels of risk related to physical health needs.

• At the last inspection in December 2015, we found that some team managers were not using their leadership skills to ensure that issues raised within the teams were escalated and addressed in a timely manner. During this inspection, we found that whilst the governance processes had improved there were significant gaps in the governance within Haringey community services and in particular in Haringey West community support and recovery team (CSRT). Some staff had not received regular supervision, team meetings had not been recorded and therefore there was no evidence that incidents, complaints and performance data were regularly discussed. The governance meetings within the borough did not reflect the need for the team’s performance to improve.

• Staff across Haringey community services, in all the teams we visited, raised concerns about a culture of bullying and feeling the culture was not open in a way that enabled them to safely raise concerns.

• At the last inspection in December 2015, we found that there were some teams, particularly in Haringey, which had high levels of locum staff. During this inspection, we found that while the trust had put efforts into staff recruitment and in particular, nurse recruitment, there were some teams in Haringey which continued to have a high proportion of locum staff and that this could have an impact on the continuity of care for patients in this team.

However:

• The trust had made a number of improvements since our last inspection in December 2015.

• In December 2015, we found that staff were not using the trust lone working policies and all staff did not have access to mobile phones when in the community. During this inspection, we saw that the trust had updated lone working policies and staff were aware of their local lone working policies and followed them.

• In December 2015, we found that patients who were prescribed high dose anti-psychotic medication were not being systematically identified by the teams to ensure that they were receiving appropriate checks on their physical health. During this inspection, we found the teams had developed systems to identify patients who were prescribed high dose anti-psychotic medication.

• In December 2015, we found that Haringey CSRTs did not have access to appropriate clinic rooms. This was no longer the case.

• In December 2015, we found that all staff had not had access to mandatory training and team managers did not have accurate training records for staff. During this inspection, we found that most staff had access to mandatory training. Mandatory training information was available for team managers and senior managers, although there were no systems in place to monitor or collate information about non-mandatory training completed by staff.

• In December, 2015, we found that staff were not taking medicines administration records when visiting patients at home. This was no longer the case. We found that medicines were managed, dispensed and transported safely.

• Most patients we spoke with were positive about the support which they received from the service.

• Barnet teams had developed much closer working links with primary care and had developed a link working team, which meant that communication had improved with GPs.

• Teams were aware of local risk registers and most teams told us that they felt the working environment was positive and that they were able to raise concerns.

• Most teams had ensured that staff received regular clinical and managerial supervision.

• At the last inspection in December 2015, we found that patients were not consistently being monitored while on waiting lists for support, which meant that there was a risk that they could deteriorate and staff would not be aware. We found this had improved.

Due to the immediate concerns we had, after the inspection, we asked the trust to take immediate action in Haringey West CSRT. This was because we were concerned that the team were not effectively identifying, assessing, managing and recording risk. The trust provided us with a comprehensive action plan, which addressed the immediate concerns and we are continuing to monitor this.

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.

Overall rating for this core service GOOD

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

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

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

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

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

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

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

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

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

• Staff took time to ensure parents understood their child’s care and treatment. Staff demonstrated good communication skills during interactions with children young people and their families.

• Parents were positive about the care children and young people received and told us they felt involved in their children’s care. We saw patients were treated with respect and their dignity maintained. Staff demonstrated they were caring and compassionate.

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

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

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

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

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

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

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

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

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

However:

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

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

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

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

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

We rated mental health crisis services and health-based places of safety as requires improvement overall because:

• Staff in the home treatment teams did not always complete and update a full multidisciplinary risk assessment for all patients. They did not always update records during planning meetings. The teams did not ensure that staff knew patient risks prior to supporting them.

• Managers in the Haringey and Enfield teams did not ensure that all staff received regular supervision that was recorded and monitored.

• Patients could not always contact the trust easily. Calls to the trust hub did not always get answered.

• The trust did not have effective systems or processes to effectively assess, monitor and improve the quality and safety of the services provided. Although the trust had made many improvements since the last inspection, staff in the Enfield team did always receive regular supervision, communicate clearly with patients and assess patient risks. The trust needed to embed the sharing of learning between teams.

However:

• Since the last inspection, the trust had made improvements. The trust had opened a new health-based place of safety, implemented a new lone working policy and reduced caseloads across the home treatment teams.

• Patients received care from staff from a range of professional backgrounds. Staff received specialist training.

• The home treatment teams supported patients 24 hours a day, seven days a week. Staff responded to referrals quickly and assessed most patients promptly. They approved almost all admissions to inpatient wards. The teams had access to crisis houses in which they could support patients in the community. They worked proactively with community teams to discharge patients.

• The trust had redesigned patient pathways in Barnet. This had improved continuity of care for patients, as consultants could support patients throughout the care pathway.

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

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

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

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

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

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

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

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

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

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

However:

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

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

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

• Responding to formal complaints was taking too long.

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

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

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

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

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

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

However:

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

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

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

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

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

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

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

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

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

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

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

We rated Barnet, Enfield and Haringey Mental Health NHS Trust’s acute wards for adults of working age and psychiatric intensive care wards as requires improvement because we found the following:

• Although significant improvements had been made in these services since the previous inspection, these improvements had not always been completed consistently across all the wards. This was particularly so at the Chase Farm hospital site.

• At our previous inspection in December 2015, the seclusion rooms on the Chase Farm and St Ann’s hospital site did not protect the patients’ privacy and dignity. Whilst the trust had taken steps to make these facilities safer, the location, access through public areas and lack of ligature free en-suite bathroom facilities compromised patient’s privacy and dignity. At St Ann’s. this will be addressed by the proposed hospital rebuild, but at Chase Farm further work was needed.

• There were other areas where improvements had taken place since the previous inspection, but further work was needed to ensure this was completed thoroughly and the changes were embedded. This included ensuring medicines were always stored at the correct temperature, updating risk assessments after significant incidents, keeping blanket restrictions under review, completing the correct checks after the administration of rapid tranquilisation, ensuring patients have their rights read to them and that this is recorded after their detention, supporting staff to have regular supervision and that this is recorded, completion of essential mandatory training, supporting staff to learn from incidents from other parts of the trust and continuing to review the quality of patient food.

• At our previous inspection, we found that the number of beds on Avon ward exceeded the number recommended in the national guidelines for PICUs. The trust planned to move the ward to another location and reduce the number of PICU beds. This meant that the number of PICU beds that would then be provided would be in line with the recommendations contained in the national guidelines for PICUs.

• Staff did not always updated ligature risk assessments or identified ligature anchor points.

• The trust had not maintained all areas well. There were a number of maintenance issues, which posed a risk to patient and staff safety, which needed to be addressed on Fairlands ward, Sussex ward, Avon ward and Haringey assessment unit.

• Staff working on the wards at Chase Farm hospital did not always support patients with their physical health needs in a timely manner. There were delays in updating food and fluid charts for patients who needed this monitoring.

• Patients on Dorset ward did not have access to facilities to secure their belongings.

However:

• At this inspection we found lots of improvements which had taken place. This included the medical emergency equipment on Fairlands ward being easily accessible in an emergency, addressing blind spots on wards, reviewing incidents where patients absconded and putting measures in place to keep these to a minimum. Also with the exception of one ward they were using the national early warning scores properly to identify patients who were physically deteriorating. Staff completed clear and comprehensive records of medicines reconciliation and reviewed ‘as and when’ medication.

• At this inspection, another improvement was that patients could close the observation windows on their bedroom doors to improve their privacy. There were also cleaner and better maintained ward environments. Patients could make a call in private on all wards except Suffolk and Sussex wards and had improved access to their personal mobile phones.

• Also patients almost always had a bed available when they returned from leave and patients were rarely transferred between wards for non-clinical reasons.

• Since the last inspection we found the trust had been proactive in recruiting permanent staff, which had improved the consistency of care for patients. They had also recruited more permanent managers and consultant psychiatrists for the wards. More staff had completed their refresher training in their prevention and management violence and aggression. At this inspection, the completion rate for this course was 87%.

• At this inspection, the information provided to informal patients had improved and was legally accurate. Also in most cases doctors provided clinical judgement details in the patients’ capacity to consent or treatment assessments.

• Other developments included staff knowing the correct procedure for dealing with illicit substances. At this inspection in, we found staff at St Ann’s and Edgware Community hospitals developed plans with patients that were recovery focused, although this was not always the case at Chase Farm hospital. In addition patients on the acute wards had improved access to psychology input. The service was meeting patients’ religious and spiritual needs.

• At our previous inspection in December 2015, we found that the trust had not ensured that wherever possible staff involvement with patients was caring and supported patient recovery and was not merely task-focussed. At this inspection, on the wards at St Ann’s and Edgware Community hospital staff interactions were positive and supported recovery. However, this was not the case on the wards at Chase Farm hospital.

• Staff encouraged patients to keep fit and healthy. There were gym and yoga sessions available. Patients who smoked were offered support to stop.

• The majority of interactions we observed between staff and patients were good. The majority of feedback we received from patients was positive.

• Staff encouraged patients to give feedback on services.

• The wards managed access to beds proactively. Ward managers made referrals to PICU beds in a timely manner. This ensured that patients received care and treatment appropriate to their needs.

• The ward managers had access to a range of dashboard and clinical governance meetings. The ward managers were knowledgeable about the wards they managed and used dashboards to identify areas for improvement.

• The trust invested in the development of their staff through training course. The trust recognised and celebrated staff success. The trust encouraged staff to be innovative.

Overall, we rated wards for older people with mental health problems provided by Barnet Enfield and Haringey Mental Health Trust as good because:

• The service had made improvements in areas we identified in the last inspection. For example, mandatory training rates had improved and there was now an occupational therapist on Ken Porter Ward who could support patients to engage with activities.

• Patients and relatives gave very positive feedback about the wards. Staff supported patients to maintain contact and relationships outside of the ward and to involve their relatives in decisions about their care. Staff had an understanding of the personal preferences of patients, such as how they like to dress.

• There was a sufficient number of staff from a range of disciplines to meet the needs of patients.

• Staff assessed patients’ physical and mental health needs and risks appropriately.

• Staff received regular training on mental health topics relevant to the patient group for example caring for patients with dementia.

• There was adequate medical input to the wards and medicines were stored and managed well. Prescribing was in line with best practice guidance.

• Staff made good use of the Mental Capacity Act and where appropriate ensured decisions were made in the best interests of the patients.

• The wards were working with other stakeholders to reduce delayed discharges, especially for patients needing more support than before their admission.

• Ward managers were supported by appropriate governance systems to enable the delivery of the service, identification of risk and monitoring of the quality and safety of services.

• Staff on the wards were positive about their roles and were involved in quality improvement initiatives for example on reducing the risk of falls.

However:

• Staff did not always develop care plans with sufficient detail to support patients who had diabetes.

• Staff on The Oaks did not complete hydration forms accurately to assure themselves that patients were drinking enough throughout the day.

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.  

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.

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.

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.

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.