Barnet, Enfield and Haringey Mental Health NHS Trust

Updated 11 October 2023

We inspected Barnet, Enfield and Haringey Mental Health Trust as part of our continual checks on the safety and quality of healthcare services. We also inspected the well-led key question for the trust overall.

We inspected three of the mental health services provided by the trust. We completed full inspections of the trust’s acute wards for adults of working age and psychiatric intensive care units (PICUs) and mental health crisis and health-based places of safety. We completed a focused inspection, which looked at the safe and well-led key questions, for community-based mental health services for adults of working age. We also inspected the community health services for children, young people and families that the trust provided in Enfield. We chose these core services as we knew there had been some challenges including serious incidents or there were requirement notices from the previous inspection and we wanted to see how the trust had responded and if high quality care and treatment was being delivered.

The trust provides the following mental health services, which we did not inspect this time:

• Child and adolescent mental health wards
• Forensic inpatient/secure wards (low secure)
• Long stay/rehabilitation mental health wards for working age adults
• Wards for older people with mental health problems
• Community-based mental health services for older adults
• Specialist community mental health services for children and young people
• Specialist eating disorder services

The trust also provides the following community health services, which we did not inspect this time:

• Adults
• End of life care

Our overall rating of the trust stayed the same. We rated them as good because:

• We rated effective, caring, responsive and well-led as good, and safe as requires improvement.
• We rated three of the trust’s services that we inspected as good and one as requires improvement.
• In rating the trust, we took into account the current ratings of the mental health and community health services we did not inspect this time.
• Overall, we found that whilst there had been progress since the previous inspection there was more to do. However, the trust leadership was aware of this and had plans to continue this work. They were focusing on improving the experience of patients accessing and using their services.
• The inspection took place at a time of complexity for the trust board. The trust had entered a partnership with Camden and Islington NHS Foundation Trust. The trusts now had the same skilled and experienced chair and chief executive and planned to have one shared executive director team by the end of June 2022. However, the board and other senior leaders needed the time to think through the implications including areas for opportunities and risks including potential conflict associated with the partnership with Camden and Islington NHS Foundation Trust. Also, executive directors whilst positive about the partnership were feeling understandably anxious about the impact of the changes on the trust and their individual roles and the support to them individually during the change needed to be kept under review.

• The inspection also took place at a time where there were concerns about a new COVID-19 variant and the potential impact on plans for the winter. The trust had worked hard to ensure patients continued to receive safe care during the COVID-19 pandemic. The trust had implemented infection, prevention and control procedures. They had changed models of working, such as offering some services remotely, to support people to continue to access services. The trust had also worked closely with other stakeholders and providers in the North Central London health and care system to meet the needs of patients, such as setting up crisis hubs so children and young people could access support without having to go to an emergency department. The trust had progressed with vaccinating staff and were commended for setting up a service to vaccinate people with a learning disability in a calm and supportive environment.
• The trust’s estate had seen a major improvement with the opening of the new wards at St Ann’s Hospital, the opening of Oak Partnership Ward in Southgate and the removal of all shared bedrooms, but many of the trust’s other buildings were old. They often contained risks that made it harder for staff to manage them safely and did not offer therapeutic environments. The seclusion room on Trent Ward at Edgware Community Hospital did not, offer patients full privacy and one of the rooms used in the health-based place of safety contains environmental features which could potentially harm patients. Senior leaders acknowledged the need for further improvements to the trust’s estate, and a strategic outline case for the rest of the trust estate to be modernised had been submitted with the support of the integrated care system and NHS London.
• The trust had a clear strategic plan to meet the needs of its local population, but further work was needed to ensure this was delivered. Since the last inspection, the trust had developed a new clinical strategy aligned to Camden and Islington NHS Foundation Trust. The divisional structures had been embedded since the last inspection, with local services being managed by geography. Divisional leaders were very enthusiastic and committed to improving services. Divisional objectives were also in place although these needed to be further developed and embedded to ensure transformation of community services took place as planned and were aligned to the care pathways being developed across North Central London in line with objectives of the Long Term Plan.
• The trust was working in partnership with third sector providers to meet the needs of people. It had, as part of the transformation of community mental health services for example, awarded contracts to third sector providers so people could be supported with housing, employment and finances. The trust needs to progress with its plans to extend this further to ensure it meets the needs of communities and reduces inequalities.
• Organisational culture was improving. We heard about staff feeling more able to speak up when needed and improved connections between front line and senior leadership staff. The staff survey engagement rate had just improved from 44% last year to 54% this year. The external and independent Freedom to Speak Up Guardian arrangements were working effectively and staff awareness of this had improved. The four staff inclusion networks had been sustained and there had been developments especially for the Better Together network for Black and Asian minority ethnic staff. We also heard about the work to improve WRES, the in-depth listening exercises and the development with staff of a behavioural framework to focus on staff living the values of the trust. Many staff we spoke with also spoke positively about how Black History Month had been celebrated at the trust. However, more work was needed to embed this work, to ensure it was adequately resourced and that the progress with key actions was monitored. For example, the network leads needed enough time to carry out their roles. Also, whilst sixty-three percent of interview panels for posts at band seven or above now included a panel member from an ethnic minority background this needed to increase.
• The trust continued to focus on improving the quality of care it provided. Its ‘Brilliant Basics’ approach had progressed well since the last inspection. It was talked about by staff and improving services for patients. There had been a sustained reduction in restrictive practices in the trust’s acute wards, particularly across the new wards, with improvement methodologies being rolled out. We also heard about the safety huddles taking place at every level.
• Quality improvement work had developed and started to embed since the last inspection. A team was in place to support the development of this approach, over 1000 staff had been trained and the trust was developing a quality improvement academy. We heard staff talking about how they had started to use the methodology and it was being used in a wider range of areas including patient access and flow. This work needed to be further extended and embedded.
• The trust had progressed work to support more people to participate in the development and running of its services. It now employed 45 peer support workers and planned to employ a further 30 people. There were also around 100 Experts by Experience on an involvement register and this grew by 5-10 people each month. They helped in a wide range of roles across the trust including work on the development of strategy and policy, recruitment, supporting service users and training staff. It was positive to hear that there were patient forums in three of the divisions and plans for the other two. Trust leaders told us that they hoped to develop this work more and embed it more in the work of the divisions. There was also scope to further extend the people participation to ensure people who use services are central to all the trust developments, for example, through ensuring people are trained in quality improvement methodologies so they can be part of teams progressing this work.
• The trust was in the process of improving its IT infrastructure and the information available to staff. Over the last two years, it had spent £5.8m on improving IT systems and hardware, and it was in the final stages of delivering a data warehouse. The digital strategy was going to the next board for approval. The trust recognised the need to ensure staff had access to live data to enable them to manage services effectively and hoped that the first versions of new dashboards would be available imminently.
• The trust had started work to improve its research and development and had become a member of University College London Partners. The development of research was not just to increase the number of research projects, but also to widen the scope of who completed research to other professionals including nursing, and ensure research involves service users and makes a contribution to improving the services they receive.
• The trust had arrangements in place for staff to implement the Accessible Information Standard, which applies to people using services (and where appropriate carers and parents) who have information or communication needs relating to a disability, impairment or sensory loss, and its website had been recognised nationally as an example of good practice in accessibility. Staff working in services did not, however, always know what the standard was or how they would apply it in their work.

However:

• The trust continued to have pressures on its acute adult services. Although staff had worked hard to reduce inpatient lengths of stay and fewer adult patients had to be placed in services outside the local area, further work was still required. Many patients remained in the health-based place of safety for more than 24 hours, often waiting for a bed, and patients identified as requiring assessments in the community under the Mental Health Act were not always assessed promptly. Trust staff continued to work with stakeholders, such as the police and local authorities, and on quality improvement initiatives, but further improvements were still required.
• The Barnet crisis resolution and home treatment team had a team caseload of 60. The team was working to reduce the size of the caseload, but it remained too high.
• The recruitment and retention of staff remained a significant challenge for the trust. The trust had continued with work to review its staffing model, with a new nursing strategy and a focus of developing new career paths. However, vacancies remained. Some acute and PICU wards had high rates of unfilled staff shifts.
• The completion of mandatory training had improved overall and at the time of the inspection was 87%. However, Immediate Life Support (65%) training was still below the levels required, with particularly low completion in some services, having fallen behind due to the pandemic presenting challenges for face-to-face training. The failure to meet the target for this training was a risk to patient safety. There were plans for this to be addressed with additional capacity for face to face training arranged but this needed to be fully implemented.
• The trust did not always respond to complaints quickly. Whilst it was acknowledged that during the height of the pandemic responding to complaints was a lower priority, at the time of this inspection the completion of complaint responses within the agreed timescales was only 25%. A quality improvement project was in place to identify the reasons for this and make changes, but this needed to be implemented and target response times met.
• The trust continued to work to improve the timeliness and quality of its serious incident investigation, but further work was required to embed improvements. There was now a trust-wide group to support shared learning, improve the consistency of reports and to review the quality and effectiveness of recommendations and there was improved confidence in incident reporting and in the identification of when an investigation was needed. The trust had also introduced a new template for the completion of reports and hoped to involve service users and carers more in the process. Nevertheless, the five serious incident reports we reviewed still needed some improvements, such as by ensuring the most important findings are clear, and the timeliness of responses needed to improve. Although the average completion period for serious incident reports had reduced from 118 days, it was still 80 days. Whilst we heard how the trust shared learning from incidents, further work was needed to ensure a reduction in incidents with recurring themes across the trust.

How we carried out the inspection

Our inspection teams comprised of nine CQC inspectors, two CQC inspection managers, four specialist advisors and three experts by experience who contacted patients and carers on the telephone.

The well-led review team comprised an executive reviewer who was Chair of an NHS mental health trust, two specialist advisors, a financial governance assessor from NHSE/I, two CQC inspectors, an inspection manager and a head of hospital inspection.

The core service inspections, gave short-notice to the services they were visiting to ensure the staff were available to be interviewed.

During our inspection of the four core services and the Well-led review, the inspection teams:

• reviewed records held by the CQC relating to each service
• visited five inpatient wards: Daisy and Tulip Wards at St Ann’s Hospital, Devon and Suffolk Wards at Chase Farm Hospital, and Trent Ward at Edgware Community Hospital. We looked at the environment, medicines and observed interactions between staff and patients
• visited six community teams supporting people with mental health needs, including three crisis resolution and home treatment teams, one early intervention team and two locality teams supporting adults of a working age
• visited teams providing community health services for children and young people in Enfield, including team bases and two specialist schools
• visited the health-based place of safety
• spoke with 25 members of staff and conducted three focus groups during the well-led review
• spoke with 15 senior leaders during our inspections of services, including matrons, divisional directors, team managers and ward managers
• spoke with 107 other members of staff, including registered and non-registered nurses, doctors, occupational therapists, speech and language therapists, clinical psychologists, physiotherapists, dieticians, activities coordinators, peer support workers, pharmacists, graduate mental health workers, nursing associates, support worker and social workers.
• completed two focus groups with staff from across Enfield community health services
• interviewed 53 patients and 21 relatives of patients
• reviewed 82 patient care and treatment records
• observed six patient appointments and two home visits, with the patients’ consent
• attended the morning daily planning meetings at all crisis resolution and home treatment team and four meetings at adult community teams, including a risk management meeting and caseload review
• attended meetings on all five wards, including two staff handover meetings, a quality safety meeting, a ward round, three ‘Pride and Joy’ multi-disciplinary meetings, and one bed management video call
• carried out a specific check of the medication management on the wards, including looking at 22 medicines administration records for patients
• looked at nine records of patients who had been administered rapid tranquilisation
• looked at a range of policies, procedures and other documents relating to the running of each service.

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

What people who use the service say

During this inspection, we spoke with 53 patients and 21 relatives of patients

Patients that we spoke to supported by the community mental health teams were very positive about the service they were receiving. They said that the staff were caring and treated them with dignity and respect. Patients said that staff were easy to contact and that they received regular communications with their care co-ordinator over the phone or face to face. Several patients that we spoke to told us that they felt the service had saved their lives. Most patients we spoke to said they felt involved in their care and that they had a copy of their care plan. Patients knew who to contact out of hours and told us that they knew what their crisis plan was.

All parents of children supported by the Enfield community health teams we spoke with told us that staff treated them with compassion, kindness and dignity. Parents said staff were approachable, non-judgmental and were responsive to their needs in addition to their child’s needs.

Most patients we spoke with on the wards said staff treated them well and behaved kindly and they felt safe, although sometimes they thought there were not enough staff to meet everyone’s needs. Patients generally described the staff to us as nice, friendly and helpful. However, some patients said that some bank and agency staff could be less helpful with them, and some could be rude.

Patients spoke of a huge improvement in the accommodation provided in the new Haringey Wards at St Ann’s Hospital.

Patients across all wards told us it often took some time for nursing staff to respond to their requests at the nurses’ station. Some patients also described staff not getting their names right, and not coming when they called them.

Patients told us that staff supported them to understand and manage their own care condition. Most patients told us they knew their diagnosis, medications and what their rights were whilst in hospital. Patients confirmed that staff supported them with their physical health needs.

Most patients understood how to make a complaint about their care, including speaking with their named nurse, the ward manager, or asking for support from an advocate to make a formal complaint.

Family members/carers across the wards, gave mixed feedback about the service. Reporting some good support from staff, helping their relatives to recover, and some less helpful staff. Three family members thought they should have been given more information about their relative’s care.

Updated 24 March 2016

Overall rating for this core service Good

We rated the adult community health service as good because:

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

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

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

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

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

Updated 28 February 2022

Updated 25 September 2019

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

• Service leads had acted to improve the service and address concerns identified during the last inspection. The service had processes in place to ensure meal times were managed effectively and patient’s received personalised care and treatment. Although staff vacancy rates remained high, the service had a recruitment plan in place to ensure there were enough staff to care for patients and keep them safe.
• Staff assessed risks to patients, understood how to protect patients from abuse, and managed safety well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and supported them to make decisions about their care.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their care and treatment. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people and took account of patients’ individual needs. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. They understood and managed the priorities and issues the service faced. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Leaders encouraged innovation and supported staff to identify opportunities for learning and improvement.

However:

• Although the service provided mandatory training in key skills to all staff, not all staff had completed it. The overall completion rate for nursing and care staff was 78%, although there were variations between individual courses. The managers were aware of where individual staff needed to complete this training and had plans in place for this to be completed.
• Procedures were in place to maintain standards of infection control. However, two staff were observed not to be following these correctly.
• Patient records were not always clear, up-to-date, stored securely and easily available to all staff providing care. The ward was still using a combination of electronic and paper records.
• Although management of patient meal-times had improved and arrangements were in place to ensure patients had access to food and drink, staff did not always clearly document decisions around nutrition monitoring. A few recorded nutritional risks assessments were not fully completed.
• Some of the risks we identified during the inspection, for example around patient records and medicines reconciliation, had not been identified by the service.
• The service had not collected any patient survey feedback since February 2019 and it was not clear when this would start again.

Updated 25 September 2019

Our rating of this service improved. We rated it as good because:

• The management team had improved the quality of the service since our previous inspection by improving the ward environment.
• The service provided safe care. The ward environment was safe and clean. The ward had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding and the management of incidents.
• The ward teams included the full range of specialists required to meet the needs of patients with an eating disorder. Managers ensured that these staff received training, supervision and appraisal. The multidisciplinary team was effective and worked well with other services to ensure positive outcomes for patients.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in decision-making.
• The service managed the use of beds well in partnership with community services and patients were discharged promptly once their condition warranted this.
• The service was well-led, and the governance processes ensured that ward procedures ran smoothly.
• The service had a positive and open culture and staff were committed to continuously improve the service and the care pathway for patients with an eating disorder.

Updated 16 July 2021

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

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

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

During the inspection the team:

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

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

We rated it as good because:

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

However

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

Updated 12 January 2018

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.

Updated 12 January 2018

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.

Updated 11 October 2023

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

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

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

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

However:

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

How we carried out the inspection

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

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

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

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

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

During the inspection visit, the inspection team:

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

What people who use the service say

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

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

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

Updated 12 January 2018

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.  

Updated 11 October 2023

Overall Summary

Our rating of this service went down. We rated it as requires improvement because:

• Despite additional support from senior managers, governance processes on Silver Birches were not always sufficient to ensure the safety of patients. Managers did not follow-up actions agreed at governance meetings to check they had been completed. Records of some governance meetings were poorly written. No data on incidents was available to enable staff to monitor themes and trends.
• Learning from incidents was not always shared with staff. On Silver Birches, some staff were not aware of incidents that had happened on the ward. Six incidents relating to either safeguarding matters or falls that led to bone fractures had not been discussed with staff. Recommendations from investigations were basic and did not involve any significant changes. In some cases, learning from incident investigations had not been implemented.
• On Silver Birches, only two of the five staff required to complete mandatory training on immediate life support had done so.
• On Silver Birches, safety huddles were infrequent and poorly recorded. In some cases, records of risk incidents were poorly written, giving insufficient details of why a risk incident occurred and how it could be prevented.
• Staff did not always ensure that informal patients were fully aware of their rights and able to exercise these rights.
• Some wards did not have sufficient consultant psychiatrists to enable them to be actively involved in both patient care and leadership of the ward.

However,

• The ward environments were safe and clean. Ward environments were appropriate for people with dementia, with clear signage and symbols to indicate different areas of the ward.
• The wards had enough nurses and healthcare assistants. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Updated 28 February 2022

Updated 28 February 2022