The Care Quality Commission
  • Mental Health
  • Independent mental health service

Ellern Mede Ridgeway

Overall: Good read more about inspection ratings

Holcombe Hill, The Ridgeway, London, NW7 4HX (020) 3209 7900

Provided and run by:
Oak Tree Forest Limited

All Inspections

23 February 2022 to 24 February 2022

During a routine inspection

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

  • Staff assessed and managed risks to children, young people and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.
  • Staff understood how to protect children and young people from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The service had named safeguarding committee for safeguarding concerns.
  • Staff assessed the physical and mental health of all children and young people on admission. They developed individual care plans which were reviewed regularly through multidisciplinary discussion and updated as needed. Care plans reflected children and young people's assessed needs, and were personalised, holistic and recovery-oriented.
  • Managers supported staff with appraisals, supervision and opportunities to update and further develop their skills. Managers provided an induction programme for new staff.
  • Leaders had the skills, knowledge and experience to perform their roles. They had a good understanding of the service they managed and were visible in the service and approachable for children, young people, families and staff.
  • Staff felt respected, supported and valued. They could raise any concerns without fear.
  • The service managed safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave children and young people honest information and suitable support.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Staff explained children and young people's rights to them.
  • The majority of staff treated children and young people with compassion and kindness. They respected children and young people's privacy and dignity. They understood the individual needs of children and young people and supported them to understand and manage their care, treatment or condition.

However:

  • The provider did not have a comprehensive documented risk assessment of night time staffing levels across the two wards and the cottages outlining how risks were managed and mitigated to ensure that young people remained safe at all times.
  • Although some recent appointments had been made, there were vacancies in some key multidisciplinary roles, such as an occupational therapist and a senior social worker. This limited the professional expertise available to the service and the young people. Turnover of staff was high within this hospital, especially for non-registered nurses
  • Young people did not always feel they were involved in decisions about the service. Young people did not always get regular updates and timely information on the progression of the issues they had raised, such as information on timescales for the completion of repairs, from senior managers.
  • Reflective practice groups were not regularly taking place on all wards. When they did occur no more than two or three staff were able to attend the group because the wards were unable to release staff.
  • Staff were not recording clearly on the medicine administration records which route the medicine has been administered by, for example orally or by nasogastric tube. Staff did not always label opened liquid medicines with the date opened and new expiry date. The service did not always report incidents of omitted doses of medication. Incidents involving medicines were not always thoroughly investigated, there was therefore a risk that learning was not identified and shared with staff.
  • Whilst wards were safe, clean, well equipped and fit for purpose, furnishings were not always well maintained.
  • There was nothing on display in the wards that indicated the wards were inclusive environments looking to meet the needs of those young people with protected characteristics.
  • Young people were not told routinely about the closed circuit television (CCTV) cameras throughout the hospital on admission.

13 and 14 January 2020

During a routine inspection

We rated Ellern Mede Ridgeway as good because:

  • The service was safe, clean, well equipped and fit for purpose. Ligature risks had been assessed and fire safety arrangements were in place.
  • Staff assessed and managed risks to patients and themselves. Staff followed best practice in anticipating, de-escalating and managing behaviour which challenged. As a result, they used physical restraint only after attempts at de-escalation had failed. Staff participated in the provider’s restrictive interventions reduction programme.
  • Staff understood how to protect patients from abuse and/or exploitation and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and/or exploitation and they knew how to apply it.
  • The service had a good track record on safety. The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff provided care and treatment interventions suitable for the patient group. Staff ensured that patients had good access to physical healthcare.
  • Staff from different disciplines worked together as a team to benefit patients. They supported each other to make sure patients had no gaps in their care.
  • Staff understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • Patients were involved in developing their care plans. Patients attended ward rounds and were supported to arrive at decisions. Most patients’ views were incorporated, even when they differed from the clinical teams. All patients had access to a copy of their care plan and care programme approach documents.
  • There was a strong, visible person-centred culture. Staff across the multi-disciplinary team were highly motivated and inspired to offer care that was conducive to their recovery.
  • Staff empowered patients to have a voice and realise their potential. Patients were involved in decisions about the service. When rooms were redecorated, patients decided on the colour. Patients also decided parts of the activity programme and the menu. The quality of food served, and range of activities available at weekends had improved since the previous inspection in March 2017.
  • Staff encouraged patients to be independent and responsible for planning their meals as they progressed towards discharge.
  • Staff actively encouraged families and carers to be involved. The therapy team took the lead on this and was in regular contact with families and carers, providing them with training and support. Patients were supported to maintain positive relationships with them during their time at the service.
  • Discharge planning arrangements were well defined within patient care plans and started soon after a patient’s admission. Patients had clearly defined recovery goals.
  • The service treated concerns and complaints seriously, investigated them and invited patients and/or their carers to discuss their concerns with management.
  • Governance systems were in place which supported the delivery of high-quality care. Regular meetings took place within the service to discuss overall performance and learning from recent safeguarding and other incidents. A range of regular audits were undertaken, and improvements were made as a result.
  • The team had access to the information they needed to provide safe and effective care and used that information to good effect.

However,

  • Staff had not followed the organisation’s policy for ensuring relevant physical health checks were performed following rapid tranquilisation. Compliance audits had not been undertaken for rapid tranquilisation.
  • Staff had not consistently followed best practice when dispensing medicines or reporting medicines incidents. Medications for some patients were out of stock on several occasions and the correct legal documentation had not consistently been completed. Staff had not reported these as incidents.
  • Reflective practice sessions were not well attended. Staff told us they had not attended any sessions. Management informed us sessions were run but staff did not attend and they were looking into this.
  • Patients reported that a small number of staff could be rude and that they often used their mobile phone whilst providing enhanced observations.
  • Whilst staff had a good understanding about how to support the needs of patients with protected characteristics, for example sexual orientation, there was little information available to these patients to make them feel included and welcomed into the service.
  • The service did not have plans in place to ensure it complied with best practice guidance by eliminating shared sleeping arrangements by 2021.

7 - 8 March 2017

During a routine inspection

We rated the service as good because:

  • The service had addressed several areas of concern since the last inspection in March 2016. This included having sufficient emergency resuscitation equipment that staff checked regularly, ensuring staff accessed monthly individual supervision, and ensuring compliance with mandatory training in safeguarding, breakaway and physical intervention. The service had also reviewed and improved their processes for responding to complaints. Patient bedrooms now had wall alarms so patients could more easily alert staff if needed.

  • Patients gave positive feedback about most staff and said they felt their individual needs were met. Parents gave very positive feedback about the service and felt very involved in their child’s care.

  • Staff carried out timely and comprehensive assessments of physical and mental health needs and risks for each patient and developed care plans to meet these needs. Staff updated risks assessments and care plans regularly.

  • Some patients care involved physical restraint during naso gastric feeding. The service had developed a written tool to be able to include the patient in the planning of this. This was to ensure the patient had as much involvement in their care as possible. The service was also involved in the re-design of a chair for naso gastric feeding that could be used nationally.

  • There were effective governance processes in place. Staff knew how to report incidents and learning was disseminated and discussed at ward level. The service carried out regular audits and senior staff met regularly to review the running of the service.

  • The service were committed to and involved in several pieces of work in quality improvement and innovation.

However:

  • Although patients were involved in giving feedback about their care, several said they would like to see or keep copies of care plans and would like to be involved in developing them from the start.

  • Patients said some staff were impatient with them and inconsistent in how they enforced rules.

  • Patients said food was not as well prepared on the weekends compared to weekdays.

  • Space on the wards and in the cottages was limited. As patients shared bedrooms and bathrooms, there was a lack of private space.

  • There were limited activities available on the weekend. Male patients said they would like more sports activities to engage in.

22 to 24 March 2016

During a routine inspection

We rated Oak Tree Forest Ltd. t/a Ellern Mede Ridgeway as requires improvement because:

  • Medical and emergency equipment was not checked regularly and the systems in place were not robust enough to ensure that equipment was maintained, clean and fit for purpose. Some emergency equipment, such as defibrillator pads and oxygen masks, had passed the date by which they were safe to use and had not been replaced. Not all actions identified through audit had been completed.
  • Naso-gastric feeds were sometimes carried out in the main corridor of Bryan Lask ward as patients could not be safely treated in their bedroom or conveyed to the treatment room. At the time of our inspection this had happened on multiple occasions with one patient. Whilst the provider took steps to maintain the patient’s privacy and dignity when this happened, these steps were not always effective and the patient’s privacy and dignity were compromised. Patient details and records were visible through the nursing office door on Nunn ward. Patient bedrooms did not provide privacy for patients who were sharing bedrooms.
  • At the time of the inspection only female patients were admitted to Bryan Lask ward, however on occasion male patients were also admitted to this ward, the provider was not able to provide a female only lounge which would place them in breach of best practice guidance. Some ward areas were small and felt uncomfortable, for example the dining room and the room used for relatives on Bryan Lask ward. Patients did not have a secure space to store their personal belongings.
  • Mandatory training compliance for permanent staff was low at 58%. For bank staff, 79% had not completed mandatory training. After the inspection, the provider confirmed that its mandatory training records were not accurate at the time of the inspection and that by March 2016 permanent staff compliance with mandatory training was 71%, no update was provided for bank staff. Some specialist training, for example the searching of patients and the observation of patients had low compliance rates.
  • Whilst all staff were receiving regular group supervision, not all staff were receiving regular one to one supervision.
  • The provider did not have effective governance systems in place that effectively monitored the delivery and quality of the service provided. Complaints were not dealt with effectively as the providers system did not acknowledge, investigate and respond to all complainants. The provider had systems and processes in place to monitor staffing levels, individual staff supervision, handling and managing complaints, infection control and clinical equipment. However; the systems in place were not operating effectively. The supervision completion records were not accurate and did not reflect the actual supervision compliance rates. Mandatory and specialist training information was not accurate and did not readily identify staff who required update training.

However:

  • The provider was open and transparent in regularly reporting the high number of restraints to the service commissioner and communicating with the local safeguarding team. The use of physical interventions was regularly reviewed and several work streams were in progress to continuously monitor and review the use of restraint to ensure that was used only when absolutely necessary.
  • Patient records were clear and included comprehensive admission assessments, risk assessments, behavioural plans, routine capacity assessments and physical health examinations.
  • The majority of staff demonstrated a caring and positive attitude and were dedicated to ensuring patients improved and recovered. Patients commented that some staff were caring and that they were able to be involved in planning and reviewing their care. Patients, families and carers were able to give feedback about the service through an annual friends and family test and the results of this survey fed into the development of the service.
  • The provider had completed a joint quality review of the service with Quality Network for Inpatient for Child (QNIC) and Adolescent Mental Health Services CAMHS (CAMHS).
  • The service had a large multi-disciplinary team (MDT). On a weekly basis, an MDT discussion took place where patients’ care and treatment was discussed. The provider used teleconferencing in order to involve teams that were unable to attend the MDT meetings.

24 April 2014

During an inspection looking at part of the service

We carried out this inspection to check whether improvements had been made since our last inspection of the service. At our inspection in January 2014 we found that the provider did not have suitable arrangements in place for obtaining and acting in accordance with the consent of patients or those persons able lawfully to consent on their behalf. In addition, systems designed to regularly assess and monitor the quality of service were not always effective. In view of our concerns we served two warning notices informing the provider that they needed to take action to address the areas of non-compliance identified by 31 March 2014.

At our inspection of the service on 24 April 2014 we found that significant improvements had been made and the provider had complied with both warning notices.

A young person using the service described staff as 'really nice and supportive' and said the service was flexible in meeting their individual needs. They said they found the lack of privacy in service 'difficult' but had been made aware they would be sharing a room with another young person before they were admitted.

We found that the provider had reviewed and revised all consent forms used by the service to ensure that clear explanations were provided to patients and parents in respect of consent to care and treatment. Staff showed good understanding of the law and its application to children and young people in respect of obtaining lawful consent to treatment, including assessments of competence and capacity depending upon the age of the patient.

In addition, the service had reviewed and revised a number of key policies related to issues of consent to treatment, including the nasogastric feeding policy. The revised policies were easier for staff to understand and the content we reviewed was consistent with legal requirements.

Clinical governance arrangements for the service had been strengthened. The service had introduced regular meetings of senior managers to consider issues of quality, safety and standards. There was evidence of learning from incidents, feedback from parents and young people and clinical audits. Outcomes for young people were measured to ensure care and treatment was effective.

17 January 2014

During an inspection looking at part of the service

We carried out this inspection to check whether improvements had been made since our last inspection of the service in April 2013. At that inspection we found that several patient care plans had not been reviewed for long periods of time and no longer reflected patient's needs. Some risk assessments conducted by nurses and by the multidisciplinary team were contradictory. As a result there was a risk that patients' individual needs were not being met. Senior managers monitored the service to ensure appropriate standards of care and treatment were maintained but the system in place was not always effective. In addition, we found that there was a risk that not all patients had been treated in accordance with the provisions of the Mental Health Act 1983. Arrangements for obtaining and acting in accordance with the consent of patients were not always effective.

On the day of the inspection on 17 January 2014 there were 21 young people under the age of 19 admitted to the ward, eight of whom were detained under the Mental Health Act 1983. We were accompanied on the inspection by a Mental Health Act Commissioner and a specialist advisor.

We found that improvements had been made in the risk assessment and planning of care for the young people admitted to the unit. Care plans were much more detailed than on our last inspection and a single risk assessment was reviewed and updated weekly.

However, although we found some improvements had been made in relation to our concerns about consent and systems designed to monitor the quality of the service we identified a number of concerns in these areas. Arrangements for obtaining and acting in accordance with the consent of patients were still not always effective. Systems for reviewing the accuracy and clarity of key policies that underpinned the quality and lawfulness of care and treatment that patients received had not identified a number of inaccuracies and shortfalls. In view of our concerns in these areas we served warning notices on the registered provider on 4 February 2014.

24 April 2013

During a routine inspection

We spoke with four young people who were admitted to service, all of whom were detained under the Mental Health Act 1983. They told us they were mostly satisfied with the care and treatment provided to them. Patients had mixed views on the way staff interacted with them although we observed many positive interactions between patients and staff on the day of our visit.

Appropriate arrangements were in place to ensure that medicines were managed safely. Staff received appropriate training and support to enable them to deliver the care to patients that they needed.

However, we found that several patient nursing care plans had not been reviewed and no longer reflected patient’s needs. Some risk assessments conducted by nurses and by the multidisciplinary team were contradictory. As a result there was a risk that patients’ individual needs were not being met and they were not protected against the risks of unsafe or inappropriate care. Senior managers monitored the service to make sure that risks to patients were minimised and an appropriate standard of care and treatment was provided but the system in place was not always effective. We found that there was a risk that not all patients had been treated in accordance with the provisions of the Mental Health Act 1983.

12 April 2012

During a routine inspection

We spoke with a group of four of the six young people using the service. They told us that they were able to express their views and were involved in making decisions about their care and treatment. They were satisfied with the care they received and felt their needs were being met. The unit was described as 'comfortable' and 'homely'. One young person said the unit was 'cosy, in the evening everyone gets together and it is like normal life'. The young people attended a school on-site and took part in activities they were able to choose. They felt safe on the unit and one typical comment we received was, 'you feel safe, because it's secure'. There were suitable arrangements in place to protect the young people from the risk of harm.

Not all staff received regular individual clinical supervision but had the opportunity to attend externally facilitated group supervision. There were systems in place to assess and monitor the quality of service being delivered to young people and their families.