Ellern Mede Barnet

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Our overall rating of safe at Ellern Mede Barnet has improved and is now good. We assessed 8 quality statements. There was a positive learning safety culture where events were investigated and learning was embedded to promote good practice. Staff were open and honest when things went wrong or could be a risk. The service worked well with system partners to ensure that patients received continuity of care when discharged from the service. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. Patients reported that they felt safe on the wards. Staff assessed and managed risks to patients and themselves well. They achieved the right balance between maintaining safety and providing the least restrictive environment possible to support patients’ recovery. Patients were involved in formulating their least restrictive intervention management plan. Patients mostly lived in a clean and safe environment. However, we found two blind spots and three ligature points that had not been identified by the provider. Action was taken to address these in the assessment period. Staffing had improved. The hospital had recruited into nursing, care staff and occupational therapy and psychologist vacancies. Agency staff were no longer used and any locum staff that the service used to fill shifts had been trained in the provider’s bespoke restraint training. Medicines management and the post monitoring of rapid tranquilisation had improved. Medicine incidents were reviewed by the pharmacist and multidisciplinary team.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with 3 patients and 6 parents/ carers. Patients, parents/carers told us they could raise concerns with the hospital director and staff directly.

Staff understood how to raise concerns and report incidents. They demonstrated knowledge of accessing the incident reporting systems, knowing what to report and how to report it. Staff said they were encouraged to report incidents and raise concerns. All staff described a positive, safe working environment with the freedom to speak up, emphasising an open and transparent culture. The service had a strong culture of safety and learning. Staff told us incidents and never events were discussed in handover, multidisciplinary team meetings, in reflective practice, supervision and staff meetings. Team meeting minutes showed that staff discussed learning from incidents and actions required to improve patient care.

There were processes for dealing with complaints, accidents, incidents, and other adverse events. These were effectively implemented. There were systems to learn from things that went wrong. The staff were encouraged to report all incidents. For the month prior to our onsite visit there had been a total of 481 incidents reported. Of these incidents, 356 were planned nasogastric feeding incidents. A further 93 incidents were reported as self-harm incidents. Leaders and staff told us that learning from incidents was shared via the providers online learning system. Incidents were reviewed at each multidisciplinary team meeting. The clinical operations director also shared learning from incidents directly with staff through email bulletins and lessons learned meetings. Managers reviewed and analysed incidents at clinical governance meetings to understand themes and trends, how to reduce these and implementing action plans to put things right.

Patients and parent/carers told us they were involved in care planning and where appropriate plans for discharge.

The hospital received referrals for patients from a range of geographical locations through NHS England and commissioners outside of England. The service received referrals for the most complex patients. This meant discharging patients was challenging. Discharges followed a gradual approach made with the patient, their carers and the community teams. Barriers to discharge were discussed at the care programme approach meetings (CPA). Staff told us all patients had provisional discharge dates in their records. The service would not discharge a patient until there was sufficient community support in place. In the 6 months prior to our assessment 4 patients had been discharged. There were 4 patients waiting for discharge at the time of assessment. These were delayed due to finding appropriate community mental health teams to support them. The hospital had an annex with 3 beds which were used as a step-down unit to support patients who were approaching discharge. The annex had its own kitchen where patients were able to prepare their own meals. Staff worked effectively together and with other health and social care professionals to deliver effective care and treatment. Staff reported that they had good relationships with the local hospital and could refer patients to the emergency department and other specialists with any physical health concerns that could not be managed within the service.

Prior to our onsite inspection, we received feedback from NHS England commissioners regarding the delays in discharge at the service. We reviewed feedback from other commissioners that the service had received, comments included “It has been a pleasure to work closely with you and have always appreciated your transparency and openness” and “I just wanted to express my thanks to you and the rest of the EMB team for the support you have given patient and their family over the past 18months”

The provider had a process in place to ensure people had a safe journey when moving between services. Discharges followed a gradual approach made with the patient, their carers and the community teams. Patients would initially have escorted and unescorted leave. If this went well this would be extended to having time at home, followed by overnight leave. We reviewed 3 patient care records. All records had discussions of discharge recorded, however they were not specific. Staff told us discharge was always discussed when planning the patients care and at pre-admission. Staff communicated closely with care coordinators to plan discharges back to the community. Care coordinators were encouraged to attend discharge Care Programme Approach (CPA) meetings and were sent multidisciplinary team reports on patients when appropriate. The provider collaborated with other professionals through regular meetings to proactively identify which areas were causing delays. These concerns were shared with the commissioners of the service and local community mental health teams. Patients moved between ward areas, for example, when they turned 18, or were approaching discharge. These transitions ran smoothly as patients and staff knew each other across all ward areas. The hospital had an annex with 3 beds which were used as a step-down unit to support patients who were approaching discharge. The annex had their own kitchen where patients were able to prepare their own meals.

Parents and carers told us they did not have safety concerns when their loved ones were at the service. Patients told us they could raise any concerns about safeguarding.

Staff understood how to protect people from abuse and the service worked well with other agencies to do so. Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff were aware of safeguarding policies and procedures and could describe the process used to escalate any concerns. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Information was displayed to guide staff how to raise safeguarding concerns and seek advice when required. All staff said they had training appropriate for their role on how to recognise and report abuse, and they knew how to apply it. Staff said they felt confident that if they did raise concerns they would be listened to, and action taken. All the staff we spoke with showed a commitment to taking immediate action to keep people safe from abuse and neglect and felt comfortable and safe to do so. At the time of the assessment, 100% of staff had completed mandatory safeguarding training.

We observed patients being supported by staff who understood how to protect people from harm. The wards had a calm environment. There was no seclusion of patients. Patients could receive visits from other young people such as siblings or friends. All visits were risk assessed by the multidisciplinary team before taking place.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect. The management team regularly reviewed safeguarding concerns, these were discussed in monthly safeguarding lead team meetings, and at quarterly quality standards and safety group meetings. The provider had good oversight of safeguarding concerns. When staff raised a safeguarding referral, this flagged within the electronic patient record system so that the provider safeguarding team were aware. Staff received safeguarding supervision in a group. The provider was planning to develop individual safeguarding sessions for staff.

Patients told us that they were involved in discussing how they would be restrained if they required nasogastric feeding. Staff recorded the risks for people and how to manage these to keep themselves safe. Staff regularly reviewed care plans and risk management plans with people and updated these with new information when required. However, 1 patient told us they did not understand why they had different levels of restraint and different types of feeding in their care plan. Another patient told us they did not feel their care plan was co-produced.

Staff knew about any risks to each patient and acted to prevent or reduce risks. All staff we spoke with had a good understanding of each patient and the risks they posed. Staff were able to provide examples of risks posed by patients using the service and could describe how they acted to prevent or reduce risks for the individual. For example, staff told us about how they ensured that they had a good understanding of people’s sensory needs before they carried out any care or treatment. Staff had open conversations with patients concerning their risks and produced a collaborative care plan and risk management plan. This was updated if there was a change in current risks. Staff assessed and managed risks to patients and themselves well. They achieved the right balance between maintaining safety and providing the least restrictive environment possible to support patients’ recovery. Staff told us that restraint was only ever used as a last resort. Patients care and risk management plans were person-centred, proportionate and staff reviewed these regularly, including after any incidents. Patients that needed to be restrained for naso-gastric feeding had this discussed and explained to them and their parents or carers. Staff demonstrated a good understanding of the management of risk and reducing restrictive interventions. Staff followed procedures to minimise risks where they could not easily observe patients. Staff followed organisational policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm.

Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident or safeguarding concerns. All referrals to the service were screened by the multidisciplinary team before admission to ensure that the patient’s level of risk was suitable for the service. The clinical psychologist had developed the assessment and formulation pathway for the clinical team to use. Patients care and risk management plans were person-centred, proportionate and staff reviewed these regularly, including after any incidents. Patients that needed to be restrained for nasogastric feeding had this discussed and explained to them. Parents and carers were also involved in these discussions. We reviewed 3 patient records. The records showed that a comprehensive risk assessment was completed for each patient on admission, which was regularly reviewed, including after incidents. When patients were restrained for nasogastric feeding, this was discussed and reviewed at multidisciplinary team meetings, and with the patients and carers. The records showed that that restraint was only ever used as a last resort and only after other de-escalation techniques had been exhausted. Care records showed that patients were involved in formulating their least restrictive intervention management plan. Patient risk and management were discussed in the daily morning meeting, safety huddles, at handovers, ward rounds and in the weekly multidisciplinary meetings. This enabled staff to focus on the current risks and review how effective management and mitigation plans were working. Since our last inspection the service had made improvements to the recording of therapeutic observations. Observation forms no longer contained fixed times and staff were recording observations at random and varied times.

Most patients told us they felt safe on the wards and did not raise any concerns regarding the environment. One patient commented that they felt unsettled with a particular staff member.

Staff and leaders spoke about how they maintained facilities and equipment to be able to deliver safe care to patients. Staff told us that they regularly completed daily security and environmental checks to ensure the environment was safe for patients. Staff had a good understanding of ligature management on each of the wards. They understood the ligature response protocols and knew the location of the ward’s ligature cutters. Staff reported that they mitigated ligature risks by using observation, engagement and individual risk management plans.

During the assessment we undertook a tour of each ward. We observed that all wards were clean and maintained and furnished. Each patient had their own bedroom and could keep their personal belongings safe. There were quiet areas for privacy. All ward areas had several blind spots, meaning staff could not see patients at all times. Staff mitigated this risk with regular staff observations, engagement with patients and understanding the needs of each individual patient. Observations were increased when a high level of risk was identified. At our previous inspection blind spot risks had not been appropriately mitigated by the use of convex mirrors to improve the visibility of the ward environment and individual patients. At this assessment, the service had convex mirrors in place and had closed-circuit television to monitor blind spots. During our tour we identified two additional blind spots. One on Rowan Ward and another on Ash Ward. We raised this with the hospital manager and additional convex mirrors were fitted within the assessment period.

The hospital carried out a ligature risk assessment of all ward areas. The assessment we reviewed was dated 31 November 2023. However, not all ligature risks were recorded on this assessment. This included a non-collapsible towel rail in an ensuite bathroom, and two bedroom door handles. We notified the hospital manager of this during the inspection. The service took immediate action to remove the ligature points. Anti-ligature door handles were ordered and fitted during our assessment. Fire safety arrangements were in place. 99% of eligible staff were up to date with inpatient fire safety training. A fire risk assessment was undertaken in August 2023. The service had developed an action plan to address the recommendations following the assessment. Where required, staff completed a personal emergency evacuation plan (PEEP) for patients who had mobility difficulties. The service conducted fire drills twice a year. The most recent fire drills took place in February 2024 and July 2023. This included a day and night drill. Staff followed organisational policies and procedures when they needed to search patients or their bedrooms to keep them safe from harm. Staff conducted room searches at random for all patients. Staff searched all patients when they returned from home leave and risk assessed those patients that needed regular searches due to the risk presented. The service had closed-circuit television (CCTV) in all communal areas and corridor areas. CCTV was recorded and was used to review incidents on the wards.

Patients told us there were enough staff available on each shift. They reported 1:1 sessions with their key workers were taking place.

There was appropriate staffing levels and skill mix to make sure that patients received consistently safe, good quality care that met their needs. At our previous inspection the service had a high number of vacancies and a high use of agency staff. Vacancies had reduced from the last inspection. Staff confirmed that they were able to use locum nurses contracted by the provider to fill shifts. The service no longer used agency staff. All staff reported improvements in staffing and this meant that patients received better continuity of care. Patients rarely had their escorted leave or activities cancelled. The service had enough staff on each shift to carry out any physical interventions safely. At our last inspection we required the provider to consider the skill mix of their staff to ensure restraints were being carried out in line with the hospital’s restraint training (Timian). At this assessment we found improvements. Shift leaders ensured that there was appropriate skill mix on each shift. Regular locum staff were offered bespoke restraint training. Timian champions were in place to support the frontline staff with restraint techniques. Staff told us they felt supported in their role. Staff said they liked working at the service and their views were listened to and valued. Staff told us the training programme was extensive and equipped them to do a good job. Staff had team meetings and could raise concerns or seek support when they needed it. Overall staff were very positive about working for the service.

We saw staff on the wards engaging well with patients. If a patient needed anything there were always staff available to attend to patient’s needs. Patients who were being observed continuously by staff had staff present with them. We observed positive engagement and activity between staff and patients. We observed sufficient numbers of staff with the appropriate skill mix to meet people's needs.

The mandatory training programme was comprehensive and met the needs of patients and staff. The service also provided a mandatory specialist training on eating disorders, autism and specific restraint training for patients with a low body weight to ensure they had the appropriate knowledge and skills to carry out their roles safely. The overall training compliance across the service averaged at 99%. Staff had effective supervision and annual reviews of their work, and discussions about future learning and development opportunities. The service had day and night medical cover and a doctor was available to attend the ward in an emergency. The hospital had 2 part time consultant psychiatrists for adults and a specialist registrar. The doctors worked a rota to provide cover out of hours. All medical staff were permanent members of staff. The service was able to access a child and adolescent consultant psychiatrist as needed from its nearby sister service and the medical director who was also a CAMHS consultant.

The provider conducted a survey in 2023 which 11 patients using the service responded to. Results showed that 68% of patients reported that the premises were kept clean and well maintained. No concerns were raised by patients at the time of our site visit.

The hospital manager was able to demonstrate their understanding of infection prevention and control policies and procedures and how they ensured people were protected as much as possible from the risk of infection. Staff and leaders we spoke with said they made sure the service was regularly cleaned and cleaning records were up to date.

Ward areas were clean and well maintained. Walls were painted with murals and some famed pictures in communal areas such as stairs between the two wards. All ward areas shared a garden, which was well maintained. Adults, children and young people all used this space. Staff ensured all patients were supervised when in these areas. Staff made sure the premises were clean. We saw housekeeping staff cleaning ward areas throughout the day.

There were procedures for managing and preventing infections. Staff had access to personal protective equipment (PPE), handwashing facilities and training in infection control to keep themselves and patients safe. Training rates for infection control were 100%. Staff followed hand hygiene guidelines and regularly completed hand hygiene audits. The service had an Infection Prevention and Control lead that staff could contact for support and guidance.

Staff were very knowledgeable about each patient’s preferences regarding the administration of their medicines. When medicines were administered when required, the reason for use was clearly documented on the medicines administration record. Staff followed STOMP (Stopping over medication in patients with Learning Disabilities and Autism) principles. We did not see any evidence of recent use of rapid tranquilisation during this inspection. Staff reviewed patient’s medicines regularly as part of the multidisciplinary meeting (MDT) and provided specific advice to patients and carers about their medicines. Staff were knowledgeable about the patients and knew their medicines administration preferences.

Medicines were administered by registered nurses who were trained and assessed as competent at least annually. An external pharmacy contractor visited the hospital once every two weeks to provide a clinical pharmacy service and were involved in the provision of medicines training.

Medicines and equipment (including those used in an emergency) were checked regularly. All documents relating to the use of medicines were stored securely. When medicines were being crushed, records were not always available to prove that a clinician had advised it was safe to do so. We discussed this during the inspection, and staff said they would review this. We did not see any evidence of negative impact on patients as a result. Following the onsite visit the provider confirmed that most crushed medicines were now being administered in liquid form.

The clinical pharmacy reviewed all prescriptions through the electronic system. This meant that prescriptions could be checked for appropriateness before medicines were administered. We saw two examples of medicines being used that were slightly different to what had been prescribed. Fortunately, none of the patients came to any harm. We highlighted this to staff during the inspection. At our previous inspection we found that staff were not following the providers medicines policy when recording and administering medicines. At this assessment we found improvements. All recording and administration were now recorded on the electronic medicines administration records (eMARs). At our previous inspection we required the service to carry out monitoring of post rapid tranquilisation administration in line with national guidance. At this assessment we found improvements. Whilst there had been no rapid tranquilisation prior to our onsite visit, the hospital manager reported that the post rapid tranquilisation form had been updated so that required information was recorded. All rapid tranquilisation incidents and post monitoring physical health monitoring forms were reviewed at the morning meeting by the multidisciplinary team.