North London NHS Foundation Trust

We rated substance misuse services as requires improvement because:

• Staff did not complete and update paperwork appropriately. Assessment, mental health, physical health and safeguarding documents contained blank pages. Staff did not routinely update risk assessments when a person’s situation changed. Recovery plans did not outline goals that were holistic and addressed a variety of needs alongside drug and alcohol misuse.

• Managers had not addressed issues with the electronic record system in a timely way. Information about risk had not transferred from the previous system in full and this made information about a client difficult to navigate. The new system was implemented in September 2015 and the issues had not been resolved in full and there was no long term plan to address this.

• Staff did not see clients for appointments as outlined in recovery plans and did not review clients’ medication regularly. Staff did not fully complete medication records and information was missing about client allergies

• Managers did not record specialised training completed by staff that supported them to work with this client group. Supervision records were poor quality. Managers did not record that staff were given the opportunity to discuss their individual development needs. Managers did not record training that staff had attended.

However:

• Medical professionals assessed physical health at the start of treatment and referred people for appropriate tests prior to starting medication. Medication was stored and managed well across all services and prescriptions were stored securely.

• Staff worked with clients in a positive and supportive way. They spoke to clients with respect and people told us that they felt safe using the service. People said they staff treated them as individuals.

• Staff dealt well with complaints and resolved them at a local level. Managers apologised to clients when things went wrong. Staff escalated complaints to the trust complaints team if clients were unhappy with the local outcome.

Overall we rated community mental health services for people with learning disabilities and autism as ‘good’ because:

• Staff undertook comprehensive assessments and developed high quality care plans. The assessment and resulting care plans were personalised and holistic and included the physical health of the patient. Staff made individualised risk assessments at the point of referral to the service, updated these regularly and developed good crisis and contingency plans for each patient. The care plans included the views of the patient.
• Staff followed best clinical practice. They took account of guidelines from the National Institute for Health and Care Excellence (NICE) and used a range of nationally recognised outcome tools.
• Staff worked well as a team and were well supported by their managers. Multi-disciplinary team meetings took place on a regular basis. Staff received regular supervision and 94% of staff had attended their mandatory training; with 96% having attended safeguarding training.
• The service managed referrals and allocations well. There was a single point of referral, all teams met the target for maximum waiting times and a senior nurse monitored the caseloads for each member of staff. Caseloads ranged from eight to 24 patients.
• Patients and carers had a positive experience of care. Staff treated patients with care, compassion and communicated well. The service ensured that patients and their carers know how to make a complaint. Information leaflets were available in both easy to read and standard formats.
• Staff described the electronic system to report incidents and their role in the reporting process.

However:

• Staff reported that they did not have access to lone worker devices.
• There were two electronic recording systems in operation in each team that did not link to each other at all, meaning that information may be entered twice on some occasions or being recorded on one system but not the other. Protocols were in place to address this issue.

When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence.

• It is our view that the trust needs to take steps to improve the quality of their services and we find that they were in breach of three regulations. We issued three requirement notices which outline the breaches and require the trust to take action to address. We will be working with them to agree an action plan to assist them in improving the standards of care and treatment.

We found that the trust was performing at a level which led to a rating of requires improvement because:

• We rated mental health crisis services and health based places of safety as inadequate. We rated acute wards for adults of working age and psychiatric intensive care units, long stay/rehabilitation mental health wards for working age adults, community-based mental health services for adults of working age, and substance misuse services as requires improvement. We rated wards for older people with mental health problems, community-based mental health services for older people, and community mental health services for people with a learning disability or autism as good overall.
• There were a number of concerns about environments. In the health based places of safety the environment was not suitable. Patients in the health based place of safety at the accident and emergency department in the Royal Free hospital had to walk past other cubicles to use the toilet. The premises did not meet the guidance in the Mental Health Act code of practice or from the Royal College of Psychiatrist’s. The toilet also had ligature points in which could be used by a patient to self harm. The places of safety were housed in the acute hospital and were cleaned by their staff but the trust had not ensured the environment was clean and well maintained. Facilities at two of the three health based places of safety did not promote dignity, recovery, comfort or confidentiality for people using this service
• We received limited assurance about safety. For example we identified ligature points in wards which had not been removed or measures put in place to mitigate risks. In some wards staff could not see all parts of the ward, there were blind spots and no mirrors to mitigate risk. Three staff on Garnet ward did not know where the ligature cutters (equipment to cut safely through materials used to self harm) were kept, other wards did not have any ligature cutters. There were multiple ligature points at St Pancras Hospital. The trust had completed ligature risk assessments; however, these did not always contain plans for how staff could manage these risks. At the Highgate Mental Health Unit, we found one ward had identified a new fitting as a ligature risk in an assessment, but other wards had not identified the same problem. Therefore, other wards had no plan in place to manage this risk and staff were unaware of it. The service had breached the eliminating mixed sex accommodation guidance at Highview, there were five bedrooms on the second floor, four used by females and one by a male, there was evidence that this male had used the female facilities on that floor. The trust had not completed urgent repairs on three wards, at St Pancras, in a timely manner.
• Safeguarding was not always given sufficient priority. Safeguarding referrals for other services within the trust was being processed through community based adult mental health teams. The safeguarding referrals were being sent to email addresses within the community based mental health teams where the service was operating nine to five office hours. This meant referrals made out of hours were not being seen until the next working day. Staff were unclear how to make a safeguarding referral out of hours or at weekends. Staff did not always record safeguarding information appropriately and clearly.
• Record keeping was disorganised in paper files which meant information was difficult to find and could lead to key information being missed. Confidentiality was breached in some teams where patient names on files in the office could be seen by others. Staff had not stored hard copy care plans and legal documents effectively. Some care plans were not person centred or holistic. Patients had not signed their care plans because care plans were completed electronically separately from the patient appointment. Staff did not always clearly document the level of involvement of patients in their care plan or reasons why patients had not been involved. Some patients had not signed their care plan to indicate agreement with it. There were gaps in records. In the learning disabilities service there were two electronic recording systems in operation in each team that did not link to each other at all, meaning that information may be entered twice on some occasions or being recorded on one system but not the other. In order to address this, the teams had a protocol that identified their social care system as their primary record where all information should routinely be stored, with defined information being up loaded to the trust system when the patient was in hospital or at risk of going into hospital.
• In some services compliance with mandatory training for the service was below the trust target of 80%. In community adult services staff mandatory training rate was low, especially for safeguarding children training, safeguarding adults training and Mental Capacity Act and Deprivation of Liberty Safeguards training. This meant there was a risk staff were not trained sufficiently.
• Compliance for Mental Health Act (MHA) and Mental Capacity Act (MCA) training were low with some staff not receiving any training at all in MHA or MCA. Some staff were not aware of their responsibilities under the MHA and MCA. The trust set a target of 80% for mandatory training.
• Waiting times in some services were long. The waiting time for psychological support with the complex depression, anxiety and trauma service (CDAT) was one year. The assessment and advice team had a waiting list for routine referrals to be seen for an initial assessment of five weeks. North Camden recovery team had a patient waiting list for therapy of nine months, the personality disorder service had a waiting list to be allocated to a care coordinator of 16 weeks and a 12 month wait for therapy.
• The arrangements for governance and performance management did not always operate effectively. The leadership, governance and culture did not always support the delivery of high quality person-centred care.

However:

• We observed staff interactions with service users and their families in a variety of settings, found that they were responsive, respectful, and provided appropriate practical and emotional support. Staff were committed to working in partnership with people to ensure that the service users felt supported and safe. Staff supported families and carers to be involved in the service users’ care. Staff offered families and carers access to psychological therapies.
• Some wards were safe, visibly clean and well maintained. Clinical areas and ward environments were bright, airy and hygienic. Furnishings were of good quality and homely. Up to date cleaning records showed that the wards were cleaned regularly.Handrails helped patients to maintain their balance while walking around the wards. There were wheelchairs and bathing facilities specific to the needs of older frail people. The clinic rooms were fully equipped. Resuscitation equipment was accessible and regularly checked. Nurse call bells were in every bedroom, bathroom and communal area. Staff carried alarms to summon help.
• Some services managed risks to patients well. There were clear lines of sight from the nursing offices. Where there were blind spots, a convex mirror was used to help staff observe the ward. There was a robust policy on the use of patient observations in place. Environmental ligature points (fittings to which patients intent on self-injury might tie something to harm themselves) were mostly addressed and the trust was taking steps to mitigate the risks from these by using the guidance of the trust observation policy.
• Care plans in some services were personalised including patients’ views and staff wrote them in a way which met the patients’ needs. Patients had individualised risk assessments which had been commenced at the point of referral to the service and regularly updated thereafter. There were some good examples of crisis and contingency plans for each patient. Physical healthcare needs were identified and monitored during treatment. Staff used the ‘Modified early warning signs’ tool to monitor and assess physical health. Falls prevention plans were in place, all inpatient wards used the ‘Fallstop’ guidance. Pressure ulcer care was led by a tissue viability nurse.
• There was rapid access to a psychiatrist when needed, and teams included staff from different disciplines with varied skill bases. Guidelines from the National Institute for Health and Care Excellence (NICE) for prescribing were being followed in all teams. There was an audit programme to monitor adherence to NICE guidance. A range of nationally recognised outcome tools were used.
• Across the trust some teams used a balanced scorecard to monitor performance and quality of care. Some teams had a local risk register to identify and mitigate risks. Patients generally knew how to complain and complaints were logged. Learning from complaints was shared in team meetings in some teams.
• Staff said that they felt supported by senior managers. Ward managers said they had authority to make changes to the ward staffing levels when needed. Ward Managers engaged well with their staff. Staff said they felt supported to raise concerns without fear of victimisation and told us that morale and job satisfaction was good.

We rated mental health crisis services and health-based places of safety as inadequate because:

• Staff working in and emergency departments had repeatedly raised concerns regarding the provision of this service, but no action had been taken to address the concerns. Facilities at two of the three health based places of safety did not promote dignity, recovery, comfort or confidentiality for people using this service. There were significant safety issues at all of the health based places of safety and they did not meet the Royal College of Psychiatrist’s guidance.

• The health based places of safety were not clean or well maintained.

• Emergency equipment checks were not available in all areas for us to look at what staff checked and how often. We found essential emergency equipment was not present or had perished. Staff told us they checked the defibrillator was present, but did not check that it was functional.

• Staff did not copy crisis plans on to the electronic system. There was no clear record to show whether the person using the service had been involved in developing the plan or whether they had a copy of the plan.

• Staff did not show a clear understanding of the Mental Capacity Act and consent to treatment was not clearly documented in people’s records.

• Frontline staff told us they did not receive feedback from incidents.

• Governance arrangements were not in place locally to support the quality, performance and risk management of the services.

• Staff reported feeling under pressure because services were short staffed.

However:

• There was rapid access to a psychiatrist.

• Teams included staff from different disciplines with varied skill bases.

• Interventions included support for housing, employment and benefits. Patients had access to a range of psychological therapies.

• Some patients told us they felt understood and listened to by staff and never had to repeat information to them.

• Patients knew how to complain.

• We saw evidence of staff proactively trying to engage people who were avoiding contact with the service.

• Senior staff used balance score cards to monitor service performance and outcomes.

• Staff felt able to raise concerns without fear of victimisation.

• Staff told us they worked well together within their teams.

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

• Staff mandatory training rate was low, especially for safeguarding children training, safeguarding adults training and Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) training.

• Staff did not adhere to the trust’s lone working policy. Some staff did not have work mobile phones to use whilst on home visits and some staff did not call the office to check in with a duty worker.

• We saw medication and sharps disposal boxes transported in handbags, which is not in line with the trust’s policy.

• Some teams were not following trust processes to ensure that staff received feedback about learning from incidents.

• There were no systems in place to monitor patient’s physical healthcare needs when they were prescribed high dose antipsychotics and lithium.

• There was no standardised approach to supervision. We saw electronic and paper records which used different note taking templates.

• There was no emergency equipment available at any of the sites visited.

• Some care plans were not holistic, personalised or person centred.

However:

• All services reported rapid access to a consultant psychiatrist when required.

• Risk assessments were thorough and comprehensive and were updated following an incident.

• Staff were supported and de-briefed following an incident.

• Comprehensive assessments were completed in a timely manner.

• Staff worked closely with external agencies such as crisis teams, inpatient wards, the police and adult social care.

• Staff were caring, professional and treated patients with dignity and respect.

Overall we rated wards for older people with mental health problems as ‘good’ because:

• The wards were safe, visibly clean and well maintained. Clinical areas and ward environments were bright, airy and hygienic. Furnishings were of good quality and homely. Up to date cleaning records showed that the wards were cleaned regularly. Handrails helped patients to maintain their balance while walking around the wards. There were wheelchairs and bathing facilities specific to the needs of older frail people. The clinic rooms were fully equipped. Resuscitation equipment was accessible and regularly checked. Nurse call bells were in every bedroom, bathroom and communal area. Staff carried alarms to summon help.

• The provider managed risks to patients well on both wards. There were clear lines of sight from the nursing offices. Where there were blind spots, a convex mirror was used to help staff observe the ward. There was a robust policy on the use of patient observations in place. Environmental ligature points (fittings to which patients intent on self-injury might tie something to harm themselves) were mostly addressed and the provider was taking steps to mitigate the risks from these by using the guidance of the trust observation policy.

• Both wards met the Department of Health guidance and Mental Health Act 1983 Code of Practice in relation to the arrangements for mixed sex accommodation.There was a female only lounge on each ward. Every bedroom had its own basin, shower and toilet. Continence equipment was available.

• The wards supported patient recovery. There were easy read signs at eye level height that used both words and symbols. The dining rooms were spacious and welcoming and encouraged people to talk to each other. There were menu options that included the needs of a culturally diverse group of patients. Food was available in pureed, finger and other forms to meet patient need. Mealtimes were protected from distracting ward activities such as medicine rounds and meetings.

• Care records included comprehensive assessments and care plans. Falls prevention plans were in place, both wards used the ‘Fallstop’ guidance. Pressure ulcer care was led by a tissue viability nurse. Staff used the ‘Modified Early Warning Signs’ tool to monitor and assess physical health. There was secure and easily accessible patient information stored on electronic systems. Learning from incidents was shared at handovers and team meetings.

• Managers and clinical staff engaged well with patients and carers. Staff spoke kindly with patients and responded to patient needs with discretion and respect. Carers told us they were supported and welcomed onto the wards. Staff knew what potential abuse was and what to do if they had any safeguarding concerns.

• Ward Managers engaged well with their staff. Staff felt supported to raise concerns without fear of victimisation and told us that morale and job satisfaction was good. Staff had regular supervision and an annual appraisal. The ward managers had sufficient authority to run the ward and administrative support to help them. Staff were provided with opportunities for leadership training at ward management level and staff sickness and absence rates were low.

However:

• Staff told us that more staff were needed. There was an unfilled psychology post.

• Staff said they did not know much about the most senior trust managers.

• Some staff did not know where the ligature cutters (equipment to cut safely through materials used to self harm) were kept.

• Some patients said that the behaviours of other patients at times made them feel unsafe.

On Garnet ward;

• Tablet crushers were found with residue from previous medications. Four more sets of tablet crushers were immediately ordered.

• Patient names could be identified on the spines of files from outside the nursing station.

On Pearl ward;

• Some patients said staff occasionally responded to them in ways that were not helpful or kind.

• The clinic room and fridge temperature records showed gaps in recording, the worst being a week of no monitoring between 15 February 2016 and 22 February 2016.

• Compression stockings prescribed from 21 January 2016 were marked as unavailable. No alternative had been provided.

We rated Camden and Islington NHS Foundation Trust Community-based mental health services for older people as good because:

• Most staff completed a risk assessment of every patient at the beginning of treatment and updated them regularly. Care records reviewed all contained up to date, personalised, holistic, recovery-oriented care plans.
• All care records reviewed all contained up to date, personalised, holistic, recovery-oriented care plans.
• Staff followed National Institute for Health and Care Excellence (NICE) guidance when prescribing medication. Service users within the Camden team had a least two NICE informed interventions on their care plans which included psychological interventions.
• We observed staff interactions with service users and their families in a variety of settings, found that they were responsive, respectful, and provided appropriate practical and emotional support. Staff were committed to working in partnership with people to ensure that the service users felt supported and safe.
• Staff supported families and carers to be involved in the service users’ care. Staff offered families and carers' access to psychological therapies.
• Staff were committed to improving the service by participating in research. They had been innovative in implementing a ‘brain food’ group that was making a positive difference to service users.
• Staff assessed and recorded a person’s capacity to consent following every appointment.
• Team managers assessed and managed caseloads to ensure that all service users were allocated care co-ordinators.
• Team managers had recruited to all qualified nursing posts.They were actively recruiting to fill other vacancies within the multidisciplinary team.
• A duty team was in place across the service to monitor the waiting list. Staff monitored the waiting list to detect service users’ increase in risk or to respond promptly to a sudden deterioration in their health.
• The provider used balance score cards to gauge the performance of the team. The scorecards were available in an accessible format.
• Team managers had a risk register for the service, which they completed and monitored in monthly senior management meetings.
• Across the service, there was 100% compliance for staff attending monthly clinical and managerial supervision.
• Staff reported that they enjoyed their roles and that morale within the team was good.

However

• The recovery team did not update risk assessments when service users were admitted to the service.
• No compliance rates were available for Mental Health Act training.
• Only 34% of staff had completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards.

We rated acute wards for adults of working age and psychiatric intensive care units as requires improvement because:

• The trust delivered acute inpatient services over two sites, Highgate Mental Health Unit and St Pancras Hospital. We found extensive differences between the two environments. Wards at Highgate Mental Health Unit had recently been refurbished. The trust had not completed similar work at St Pancras Hospital, where wards remained in need of refurbishment and updating. Some patient care areas were unhygienic, for example on Laffan ward, we saw dust on surface areas and a ball of human hair on the nurses’ office floor. We found items at St Pancras Hospital that posed a risk to patient safety. For example, plastic leaflet holders with sharp edges and a brick attached to a bench in an outside courtyard, which could be used as a weapon. We found damage to patient areas at both sites, which the trust had not repaired.

• There were multiple ligature points at St Pancras Hospital. A ligature is a fixed item to which a person could tie something for the purpose of self-strangulation. The trust had completed ligature risk assessments. However, these did not always contain plans for how staff could manage these risks. Wards on this site had multiple blind spots from where staff could not easily observe patients.

• At the Highgate Mental Health Unit, we found improvements to all patient care areas.

• The staff duty rotas showed high reliance upon the use of bank and agency staff. When bank or agency staff could not be booked, the wards were short of staff. Staff and patients told us this had a negative impact on patient care and access to outside space.

• Staff had not completed regular checks of emergency equipment on two wards. Staff could not be sure that the equipment was fit for use in an emergency. One ward had not replaced defibrillator pads following an incident.

• The trust operated a non-smoking policy. However, at the Highgate Mental Health Centre we found extensive evidence of patients smoking in the courtyard. We found a can of lighter fuel hidden in bushes and a strong smell of cigarette smoke in one of the bedroom corridors.

• The trust required staff to complete mandatory training and average compliance was low at 66%. A total of 26% of staff had completed safeguarding children training and 39% were compliant with training on the Mental Capacity Act (2005) (MCA). The Care Quality Commission had highlighted poor staff awareness and low compliance with training in the MCA in previous inspections, which the trust was required to address.

• The trust had a process for reporting safeguarding concerns but staff did not routinely raise concerns directly to the local authority and were unclear how this process would be actioned out of hours or at weekends.

• On the psychiatric intensive care unit, records showed that medical staff were not completing medical reviews for patients in seclusion in line with the revised Mental Health Act Code of Practice. We noted that the trust seclusion policy was dated December 2014, which pre-dated the revised code. The trust had not ensured that patients were provided with required safeguards in accordance with the MHA Code of Practice.

• The trust did not offer mandatory Mental Health Act or Code of Practice training for staff. Staff did not always inform patients of their rights under section 132 in a timely manner did not routinely refer or encourage patients to access independent mental health advocacy services. Staff did not always document patients’ capacity to consent to treatment prior to first administration of medication and some capacity assessments contained contradictory information. Medical staff did not always fully complete patient leave forms to indicate terms of leave or to whom they had given copies.

• The quality of care plans was variable. We found little evidence of patient involvement and many care plans did not include the full range of patients’ problems and needs, or considered discharge planning.

• The trust provided data, which showed 53% of non-clinical staff had received an appraisal over the past 12 months. This was below the trust’s overall achievement at 72%.

• The trust had no female psychiatric intensive care (PICU) beds. Female patients who required a PICU bed were admitted to beds outside of their local area. The trust also placed patients out of area when no local beds were available on the acute wards. This meant patients could potentially be placed far away from their local area, making contact with friends and family more difficult.

  However:

• The trust had completed extensive refurbishment work at Highgate Mental Health Unit, which had improved the patient care areas and reduced ligature risks. Lines of sight were good and the environments were clean and airy. There were ample rooms available for care and treatment.

• The trust had recruited qualified staff to vacancies. The wards had a range of staff to deliver care and treatment to patients. The trust tried to ensure they used regular bank and agency staff to promote continuity of care for patients. When bank or agency staff could not be booked, the wards were short of staff. Staff and patients told us this had a negative impact on patient care and access to outside space.

• Practices were in place to ensure infection control and staff had access to protective personal equipment such as gloves and aprons.

• We observed good interaction between the ward staff and medical teams on the wards. Medical cover was available day and night and a psychiatrist could attend wards in an emergency.

• Staff were skilled in verbal de-escalation to manage disturbed behaviour. The training delivered reflected the Department of Health principals of Positive and Proactive Care (2014).

• Medical staff prescribed rapid tranquilisation in accordance with National Institute for Health and Care Excellent (NICE) guidelines.

• There were good medicines management processes and clinic rooms were clean and tidy. Good systems were in place for reporting and recording incidents and complaints.

• Staff were professional and respectful. Most patients told us staff were caring. Staff showed a good understanding of the care and treatment needs of patients and we observed good interactions between patients and staff.

• Staff reported being well supported by their managers and managers were visible on the wards.

We rated rehabilitation mental health wards for working age adults as requires improvement overall because:

• There was breach of the guidance on single sex accommodation at Highview and154 Camden Road. 154 Camden Road did not have a dedicated female lounge. Staff managed this by offering the use of a therapy room for female patients. Staff could not observe all areas of the wards to maintain patient and staff safety. The provider had mitigated risk and promoted observation by installing mirrors on Malachite ward. However, 154 Camden Road, Sutherland ward and Montague ward did not have mirrors in place.

• Staff on Montague ward had not received an annual appraisal.
• There was poor ligature management at Aberdeen Park and no ligature cutters at Aberdeen Park or Highview.
• The managers at Aberdeen Park and Highview did not clearly understand their responsibilities under the Mental Health Act. Staff had not received adequate training on the Mental Health Act code of practice. Records did not show that residents had their rights regularly explained to them when subject to a community treatment order (CTO). Recording of assessment of capacity to consent to treatment was variable. There was no evidence of any section 117 aftercare planning. Eligible patients told us that they were unaware of their right to access independent mental health advocate (IMHA). We found minimal evidence that consent to treatment forms had been completed. There was no effective system in place for storing legal documents.
• Storing of other information was disorganised and not easily accessible and medicines management required improvement.
• There were several staff vacancies at Highview and Aberdeen Park and no effective measures in place to cover long-term staff absences.
• There were no alarms in the bathrooms or bedrooms at Highview or Aberdeen Park.

However:

• The wards at St Pancras, Highgate and 154 Camden Road were mostly clean and comfortable. There was a range of rooms and each patient had their own ensuite bedroom which they were able to personalise. The wards had access to outside space. Snacks and hot and cold drinks were available throughout the day. Clinic rooms were equipped with accessible resuscitation equipment and emergency drugs. We saw evidence that staff regularly checked equipment and kept a record of this.

• Patients received care and treatment from a range of professionals including nurses, doctors, psychologists, activity coordinators, occupational therapists and pharmacists. Staff regularly monitored the physical healthcare of patients and recorded this in the care record appropriately. Patients told us that they usually felt safe on the wards and that staff treated them with respect. Each ward had printed information to give to patients about what to expect during their stay. This included visiting times, policy for the use of mobile telephones, mealtimes and access to the internet.
• Staff said that they felt supported by senior managers. Ward managers said they had authority to make changes to the ward staffing levels when needed. Ward managers engaged well with their staff. Staff felt supported to raise concerns without fear of victimisation and told us that morale and job satisfaction was good.
• Staff at Highview and Aberdeen Park were aware of their responsibilities of identifying safeguarding concerns and there were effective processes in both for both reporting and learning from safeguards. Patients had individualised risk assessments, crisis and relapse plans. Patient reviews included both physical and mental health needs and staff said that multidisciplinary meeting were patient focused and effective.