North London NHS Foundation Trust

Updated 27 January 2023

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

• We rated two of the core services we inspected comprehensively as good overall and one as requires improvement overall. Following the inspection, seven of the trust’s core and specialist services in the trust were rated good overall and one was rated as requires improvement overall.
• We rated well-led for the trust overall as good.
• There was good, effective leadership at all levels of the organisation. The trust senior leadership team was visible across the trust and modelled openness and transparency. The board and senior leadership team had set a clear strategy and staff were aware of what it was. Since the last inspection, the trust had refreshed their strategic priorities.
• The trust worked effectively in partnership with other stakeholders across north London. It had entered a formal alliance with Barnet, Enfield and Haringey NHS Mental Health Trust, which was progressing well. It had continued to work with people using its services to develop innovative models of care. It had an excellent clinical strategy that guided its work and service developments.
• Clinical premises where patients received care were mostly safe, clean, well equipped, well furnished, well maintained and fit for purpose. The wards at St Pancras hospital did not provide a good environment for patient care, but the trust had undertaken remedial work to address risks and had plans to build new wards.
• The service had enough staff, who knew the patients and received statutory and mandatory training to keep patients safe from avoidable harm. The trust had worked hard to reduce its vacancies and develop new roles. Since the last inspection published in March 2018, the trust had reduced the size of the team caseloads in its mental health crisis services. Nevertheless, some teams and wards continued to have challenges with staff vacancies although temporary staff were used where needed.
• Staff across the trust worked hard to reduce the use of restrictive interventions. Most acute wards for adults of working age and psychiatric intensive care units had taken part in the Safewards initiative and initial data showed reductions in restrictive interventions.
• Staff provided care that was personalised, holistic and recovery-oriented. Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. Staff were proactive in involving families and carers in patient care, when appropriate.
• The trust had systems in place for escalating and gaining assurance on risk. This included the corporate risk register and board assurance framework. It had appropriate arrangements in place to oversee the management of medicines, the Mental Health Act and safeguarding.
• Services treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with the whole team and wider services.
• The trust engaged positively with service users and staff. This included a wide range of co-production work. The trust was also extending the number of peer support workers. Plans were in place to develop a trust strategy for user involvement and to ensure this was embedded throughout the organisation. The trust was working to improve staff health and well-being, for which it had produced a strategy.
• Staff had been engaged in various ways to learn, improve and innovate and were given time to do this in their day to day roles. The trust was committed to delivering a Quality Improvement (QI) programme and had invested in this across the organisation. The QI programme had flourished since the last inspection and was well embedded across the trust

However:

• The trust was experiencing high demand for its acute wards for adults of working age and psychiatric intensive care units. When beds were not available, some patients had to be placed in beds in external hospitals in the private sector, which may be out of the local area, and on temporary beds that compromised their privacy and dignity.
• Patients identified as in need of a Mental Health Act (MHA) assessment were not always assessed promptly. Staff did not complete some assessments for more than four weeks due to delays in obtaining a warrant and accessing support from the police, who only provided limited time-slots to support assessments. Staff continued to monitor patients waiting for assessments and would offer more intensive support to patients where this was possible.
• Some community-based mental health services for adults of working age teams, and individual members of staff in these teams, had caseloads that were too high to allow the staff to give each patient the time they needed.
• The trust was completing serious incident investigations appropriately, but it was continuing to miss the timescales. Whilst the senior leaders were aware of this and plans were being considered to establish a central team to undertake this work as part of the alliance, these improvements were not yet taking place
• The trust had started work to meet the needs of staff and patients with protected characteristics, but more work was needed. For example, staff networks required strengthening. This work needed further promotion so that the trust could become a beacon of good practice.

Updated 22 August 2014

Camden and Islington NHS Foundation Trust adult community-based services provide assessments and support services for adults coming into contact with mental health services for the first time. They also provide services for people who have complex depression, anxiety, trauma and personality disorder needs and require longer term support.

The adult community-based services provided a good service. There was visible leadership in all the services we visited and the staff had a clear sense of the vision of the service and how this was going to be achieved. There were also good systems in place for supporting staff, for example through individual and group supervision sessions, team meetings and daily briefings.

We saw good use of best practice and clinical guidelines in both the personality disorder and complex depression, anxiety and trauma services. This meant that people received a service that was supported by evidence and research. People who use the service felt that the staff understood their needs and worked together with them. Staff and people valued having a service user representative employed by the trust, although this role was only present in the personality disorder services.

There were a number of areas where the service should make improvements. This included training staff in areas relevant to their work, such as the Mental Capacity Act 2005 or training to support people whose behaviour is challenging, or when to use physical interventions.

Updated 22 August 2014

Camden and Islington NHS Foundation Trust provides learning disabilities through its two community teams: Camden learning disabilities service (CLDS) and the Islington learning disabilities partnership (ILDP). There are also four nominal beds on Dunkley Ward at St Pancras Hospital. This is a 16-bed ward for people with a mental illness. However, if a bed is not available on Dunkley Ward, then the person will be admitted to another acute inpatient ward in the trust. This report specifically looks at the care of people with learning disabilities. Other issues relating to the acute ward are addressed in the report for acute admission wards.

We found that the services for people with a learning disability and autism were good.

Treatment and support was provided in the community by multidisciplinary teams that were integrated between health and social services. This meant that staff had effective working relationships, which benefited people using the service. There was a single point of referral to the community teams. After referral, staff completed an assessment and developed a care plan for each person.

People who needed hospital treatment were admitted to an acute mental health ward. In order to promote continuity of care, one ward (Dunkley Ward) was nominated to admit people with a learning disability. However, people were also sent to other wards in the hospital and were moved between wards. Although hospital staff had received little formal training, we saw that they understood about working with people with a learning disability. Staff from the community teams continued to provide treatment and support to people when they were in hospital.

Staff were person-centred, and discussed and reviewed people’s care and treatment with them. Information was discussed with, and provided to, people in an accessible way. This included the use of pictures and easy-to-read materials.          

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.

Updated 6 March 2018

A summary of this service appears in the Overall summary.

Updated 28 January 2020

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

• We rated effective, caring, responsive and well led as good. We rated safe as requires improvement.
• The service provided safe care. Clinical premises where patients were seen were safe and clean and the physical environment of crisis resolution and home treatment (CHRT) teams and Crisis House were fit for purpose. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• 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 and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The mental health crisis service was easy to access. Those who required urgent care were taken onto the caseload of the crisis teams. Staff completed most initial assessments within two days. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
• The service was well led, and the governance processes ensured that service procedures ran smoothly.

However:

• The Crisis resolution and home treatment teams did not have a robust system in place to keep an audit trail for medicines in stock. Staff did not always count and record the medicines the teams had received and dispensed, which meant they may not always have an accurate oversight of the medicines for which they were responsible.
• There were high levels of staff turnover and all the CRHT’s had vacancies. However, there was ongoing work on recruitment and retention of staff and where needed temporary staff covered vacant posts.
• Staff working for the mental health crisis teams did not always provide copies of care plans for patients.
• Arrangements for safe lone working needed to be strengthened further. Staff were being provided with new personal alarms to call for help if needed during a home visit. However, staff were still receiving training to use this new equipment and were not yet confident. Other arrangements to ensure safe lone working were in place such as carrying out visits in pairs where needed and maintaining a calendar of staff visits.

Updated 12 January 2018

We did not rate this service as this was a focussed inspection.

We found the following issues that the service provider needs to improve:

• Although Camden and Islington hadengaged with the three acute trusts, the Whittington the Royal Free and UCLH, to develop a joint action plan following a serious incident involving the death of a patient, there were some areas where the actions were not fully embedded. Camden and Islington had not effectively assured themselves that necessary actions were being carried out.At the Whittington Hospital ED, the assigned acute staff did not attend to their observation duties consistently. These are responsibilities to observe patients with mental health problems who have been assessed by the liaison team as having a risk of self-harm. At the Royal Free and UCLH, security staff, rather than clinical and adequately trained staff, observed patients whilst mental health nurses were requested.

• Camden and Islington needed to continue their work with the Whittington, to ensure the assessment rooms in the ED offered appropriate levels of privacy and provided an environment where patients could wait in comfort. There were plans to make improvements by December 2017.

• Camden and Islington was not making improvements in response to some feedback from inspections and peer review visits. For example the provision of information about services and legal rights under the Mental Health Act 1983 and Mental Capacity act 2005 and the completion of comprehensive patient records.

However, we also found the following areas of good practice:

• Liaison staff assessed most patients promptly within their target of one hour after they arrived at the ED.
• At all three acute trusts, liaison staff delivered regular training sessions to acute staff working in ED to develop their knowledge of mental health patients.

Updated 28 January 2020

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

• The service provided safe care. The ward environments were safe and clean. The wards 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.
• 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 cared for in a mental health rehabilitation ward 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 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 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 care decisions.
• Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
• The service worked to a recognised model of mental health rehabilitation. It was well led and the governance processes ensured that ward procedures ran smoothly.

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.

Updated 27 January 2023

We carried out this unannounced inspection because, at our last inspection, we rated acute wards for adults of working age as requires improvement.

Camden and Islington NHS Foundation Trust has 9 acute wards for adults of working age and 2 psychiatric intensive care units (PICUs). The wards are situated across two sites: Highgate Centre for Mental Health and St Pancras Hospital. During the inspection, we visited Rosewood and Sapphire Wards at St Pancras. We visited Coral (PICU), Opal and Topaz Wards at Highgate Centre for Mental Health. Rosewood and Sapphire Wards at St Pancras had 12 beds. The acute wards at Highgate had 16-17 beds. The PICU had 12 beds. Whilst our inspection activities focused on these wards, most of the data we reviewed covered all 11 wards within this core service.

The previous comprehensive inspection of this core service was in October and November 2019. At that inspection, we rated the service as requires improvement. We rated the service as ‘requires improvement’ for the domains of safe and responsive.

Camden and Islington NHS Foundation Trust is registered to provide the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury.

Our rating of acute wards for adults of working age and psychiatric intensive care units services improved. We rated them as good because:

• The ward environments were safe and clean. Staff managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding
• Staff developed 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 understood and discharged most of 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 care decisions
• The service managed beds well so that a bed was always available locally to a person who would benefit from admission 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

However,

• The wards did not have enough permanent nurses
• Less than 75% of staff had completed required training in basic and intermediate life support however there were plans in place for this training to be delivered.
• Staff did not always ensure that clinical equipment was sufficiently checked to ensure readings were accurate
• Staff did not receive specific training to meet the needs of some of their patients, specifically patients with autism and learning disabilities although training was planned.
• Staff did not always inform patients detained under the Mental Health Act of how the Act applied to them and their rights to appeal against detention in a timely manner
• The trust did not have clear policies and procedures on how to address abuse towards staff.

How we carried out the inspection

During this inspection, the inspection team:

• visited five wards, including one ward visited unannounced in the evening
• conducted a review of the environment on each ward and observed staff supporting patients
• spoke with four ward managers
• spoke with 24 staff including registered nurses, support workers and activity co-ordinators
• spoke with the director of hospital services and a Mental Health Act manager
• spoke with 3 doctors
• spoke with 7 patients
• reviewed the records for 14 patients
• reviewed the medication charts for 13 patients
• attended handover meetings, safety huddles, multidisciplinary team meetings and a community meeting
• reviewed other documents, performance data and policies relating to the running of the service

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.

What people who use the service say

Patients were generally positive about the service and felt safe on the wards. They said that it could be frustrating that they were unable to leave the ward whenever they wanted to but, overall, they said the service was good. Patients said that staff were caring and listened to what they said. They enjoyed activities such as reading, art, cooking and music.

Patients said that doctors were good. They were able to give their views on their care and they felt that their treatments were helping them to get better.

Updated 6 March 2018

A summary of our findings about this service appears in the Overall summary.

Updated 28 January 2020

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

• Our overall aggregated rating did not change in this inspection because we did not inspect Effective, Caring, Responsive and Well-led. In these key questions, our ratings for from our previous inspection published in March 2018 remain unchanged. At that inspection, we rated the trust’s community-based mental health services for adults of working age as good for caring, responsive and well-led. We rated it as outstanding for effective.

However, our rating of Safe went down. We rated Safe as requires improvement because:

• Patients identified as in need of a Mental Health Act (MHA) assessment were not always assessed promptly.

• The number of patients on the caseloads of some teams, and of individual members of staff in these teams, was too high to allow the staff to give each patient the time they needed.

• Nevertheless, the service provided safe care to most patients. Clinical premises where patients were seen were safe and clean. Staff managed most waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.