Barnet, Enfield and Haringey Mental Health NHS Trust

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.

• 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.

Published 11 October 2023