We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

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1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Chase Farm Hospital The Ridgeway, Enfield, EN2 8JL Tel: Date of Inspection: 10 January 2013 Date of Publication: March 2013 We inspected the following standards in response to concerns that standards weren't being met. This is what we found: Care and welfare of people who use services Safety and suitability of premises Staffing Assessing and monitoring the quality of service provision Records Inspection Report Chase Farm Hospital March

2 Details about this location Registered Provider Overview of the service Type of services Regulated activities Barnet, Enfield and Haringey Mental Health NHS Trust Barnet, Enfield and Haringey Mental Health NHS Trust provides a range of mental health services at Chase Farm hospital. These include inpatient services; acute assessment wards for adults, continuing care wards for people with dementia and cognitive impairment, forensic wards, a specialist forensic ward for people with a learning disability, rehabilitation and a forensic intensive care for service people who live in the boroughs of Barnet, Enfield, Haringey, Camden and Islington. Community healthcare service Community based services for people with a learning disability Community based services for people with mental health needs Hospital services for people with mental health needs, learning disabilities and problems with substance misuse Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Nursing care Treatment of disease, disorder or injury Inspection Report Chase Farm Hospital March

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Care and welfare of people who use services 6 Safety and suitability of premises 8 Staffing 9 Assessing and monitoring the quality of service provision 10 Records 11 About CQC Inspections 12 How we define our judgements 13 Glossary of terms we use in this report 15 Contact us 17 Inspection Report Chase Farm Hospital March

4 Summary of this inspection Why we carried out this inspection We carried out this inspection in response to concerns that one or more of the essential standards of quality and safety were not being met. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 10 January 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with staff. We were accompanied by a Mental Health Act commissioner who met with patients who are detained or receiving supervised community treatment under the Mental Health Act What people told us and what we found This was a themed inspection looking at seclusion, the practice of nursing somebody on their own in a locked seclusion room. We inspected four wards at this inspection; Suffolk ward for women, Sussex ward for men and Sage and Saffron wards, two forensic wards. We checked that practice on seclusion at these wards at Chase Farm hospital was in line with national guidelines and the provider's own policy and procedures. We inspected the seclusion rooms and a sample of seclusion records on each ward. We were not able to talk to all the patients whose records we inspected. We did talk privately to one patient. We also talked to staff; two service managers, three ward managers, a deputy ward manager and the Director of Nursing, Quality and Governance. We found people in seclusion were continuously monitored by ward staff and regular reports made on their condition. We found some good examples of patients' health being looked after while they were in seclusion and afterwards. There was one example where a patient alleged that they hurt themselves in seclusion and there was a lack of written evidence to find out if this was the case. The provider had made recent improvements to the auditing and recording of seclusion. We found in most cases, people had an opportunity to comment on their experience after being secluded. There were safety issues with some seclusion rooms where there was a lack of written risk assessment on the ward to address the known risks. You can see our judgements on the front page of this report. Inspection Report Chase Farm Hospital March

5 More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Chase Farm Hospital March

6 Our judgements for each standard inspected Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People generally experienced care, treatment and support that met their needs and protected their rights. Records generally showed continuous one to one monitoring of secluded patients was carried out to ensure their safety whilst in seclusion. A failure to provide an immediate medical examination to any patient who attempted to harm themselves in the seclusion room could leave them at risk of harm. Reasons for our judgement We looked at seclusion records to see if patients in seclusion had been cared for appropriately in accordance with the Mental Health Act Code of Practice. We also looked at the provider's policy on seclusion and checked whether staff were following it. We looked at the most recent episodes of seclusion on each ward. Each ward had a seclusion register where staff recorded basic details about the seclusion. Further information was recorded on the provider's electronic record system and in the patient records. We noted on Sussex ward that the seclusion register did not record the reason or the seclusion nor who had authorised it. The electronic records did record this information appropriately. People's care and treatment reflected relevant research and guidance. We found some good practice in checking the health and welfare of patients during and after seclusion. We saw one example of very good practice where staff had intervened twice during the patient's seclusion to prevent them from harming themselves and had taken the patient to the Accident and Emergency department for assessment and treatment. We also saw examples where patients' vital signs had been monitored, where they would allow staff to do this. We found one example where seclusion records showed that the patient had been self harming whilst in seclusion and there was no record of any intervention. The patient said that staff did not intervene to talk to them or offer support and they did not see a doctor for a physical examination once the seclusion was terminated. There was no record that a doctor checked the patient for injury on the same day after the seclusion, despite the records showing that they had been attempting to harm themselves. The patient told us that they sustained a self inflicted injury during this period of seclusion. There was no record of a post seclusion medical check which could confirm or deny this. The provider Inspection Report Chase Farm Hospital March

7 may find it useful to note that a failure to carry out a medical examination of a patient who has attempted to harm themselves in the seclusion room could leave them at risk of harm. We spoke with one patient who had experience of seclusion on the ward. This person told us that they had negative experiences and said that they saw staff using their mobile phones when they were supervising the patient in the seclusion room. We passed this allegation to the ward manager who said they would immediately look into it and tell us the outcome. We looked at the 15 minute observation records that staff completed when a patient was in seclusion to record their welfare. We noted that in two cases these had not been uploaded to the provider's electronic record keeping system as the provider's policy required. The paper records were available for inspection, so we were able to see that these did meet the recommendations of the Mental Health Act Code of Practice. The records showed evidence that staff were monitoring the patients' behaviour in seclusion. We saw one patient in a seclusion room at the time of our inspection. This patient had been in seclusion for a few days following a serious incident. We found that the records showed evidence of good nursing care for this patient. The patient was transferred to the seclusion room on Sage ward which had improved facilities such as outside space, facility for listening to music and adjustments to heating and lighting in the room. The patient was receiving one to one nursing and was settled at the time of our inspection. Records showed that patients had regular nursing and doctor reviews in accordance with the recommendations of the Mental Health Act Code of Practice. We saw one instance of a late medical review during the night when the doctor on call was at another site. We saw that staff had requested the doctor's attendance as required and the late review did not impact on the patient's care as they were sleeping at the time. The other reviews that we checked had taken place at the recommended intervals. There were arrangements in place to deal with foreseeable emergencies. At night a senior nurse assessor was available to ward staff at all times to authorise a seclusion and provide advice and support. Inspection Report Chase Farm Hospital March

8 Safety and suitability of premises People should be cared for in safe and accessible surroundings that support their health and welfare Our judgement The provider was meeting this standard. People were generally protected against the risks of unsuitable seclusion facilities though there were some areas where safety could be improved. Reasons for our judgement The provider has taken steps to provide care in an environment that is suitably designed and adequately maintained. We checked the seclusion rooms on four wards. One ward in the forensic service had an outside area attached to the seclusion room so that secluded patients could have some fresh air and exercise. We found that one person who had been in seclusion for a few days was transferred to this ward seclusion room so that he could benefit from this facility. We saw that all seclusion rooms were kept clean. We saw that one seclusion room did not have a viewing panel in the door. The viewing panel was in the office and staff used CCTV to observe the room as it was not always easy to see though the panel. The patient was able to see staff clearly. There was a corner of the room which staff were unable to see on the camera which meant the patient could not be observed at all times. Staff entering the seclusion room had to rely on staff in the office to tell them when it was safe to enter. The provider may find it useful to note that an inability to be within sight and sound of the patient at all times could be a safety risk. We saw that seclusion rooms had intercoms. Staff on each ward assured us that patient could be heard at all times through the intercom. On the two acute wards the bathrooms used for secluded patients were designed for people with a disability and had grab rails which were potential ligature points. On one ward we saw that a curtain had been fitted to give privacy to the patient using the toilet, while staff stood outside the curtain to protect the patient's safety and dignity. In the other bathroom staff would have to enter the bathroom for safety reasons and there was no privacy for the patient. The ward manager said that the room was on the provider's risk register and the provider was aware that action was needed to improve the safety of this facility. Both seclusion rooms on the acute wards were near to patient bedrooms. One ward manager had purchased a mobile screen so that the seclusion room and supervising nurse could be screened off. This was to provide some privacy. On the other ward, the ward manager said this would not be safe as the patients may use the screen as a weapon. There was no documented risk assessment about this. The provider may find it useful to note that a lack of risk assessment for each seclusion facility to minimise risk to patients may lead to some risks not being identified and addressed. We saw that all rooms had sight of a clock which is a recommendation of the Mental Health Act Code of Practice. Inspection Report Chase Farm Hospital March

9 Staffing There should be enough members of staff to keep people safe and meet their health and welfare needs Our judgement The provider was meeting this standard. Patients in seclusion benefited from being continuously monitored by staff who were experienced. The provider was in the process of confirming that all ward managers were fully aware of the requirements for safe nursing of patients in seclusion. Reasons for our judgement There were enough qualified, skilled and experienced staff to meet people's needs. A ward manager told us that the provider gave staff a summary of the provider's seclusion policy as part of their induction training. Ward managers told us there was no specific training on seclusion but the provider trained staff in observation and risk management. They said they discussed seclusion in team meetings where they advised staff on how to carry out seclusion. In recent months the provider had issued a clinical alert advising staff on carrying out seclusion in accordance with the provider's policy. The Director of Nursing, Quality and Governance told us that all ward managers were in the process of being assessed for their competency in managing seclusion on the ward. We saw from records that staff had been allocated to patients to observe them continously while they were in seclusion. Inspection Report Chase Farm Hospital March

10 Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had introduced an improved system to identify, assess and manage risks to the health, safety and welfare of people who are nursed in seclusion. Reasons for our judgement We found that staff had used the previous auditing system as a report of the seclusion episode rather than an audit of whether it had been carried out and recorded correctly in accordance with the provider's policy and the recommendations in the Mental Health Act Code of Practice. We checked an audit form on Sussex ward to see if the seclusion episode had been audited properly. We found the form had not been completed accurately. For example, the form indicated that a doctor had attended when records showed this was not the case. We found that since November when we raised concerns about the recording of seclusion at another of the provider's hospitals, the provider had carried out audits of seclusion practice on each ward and had taken action to ensure that all staff were aware of the requirements of the seclusion policy. The Director of Nursing, Quality and Governance told us that they had recently introduced a new reporting system. Ward staff had to immediately notify the doctor, service manager and unit coordinator when a patient was placed in seclusion. We saw a new seclusion checklist form. Staff told us this form had been implemented the day before our inspection. The form detailed what staff were expected to record; from the time the seclusion started and reason for seclusion through to offering the patient opportunity to discuss their experience after the seclusion. The form was for audit purposes so that senior staff could check that the seclusion had been carried out appropriately and note any gaps in records. We looked at an audit of seclusion records on one ward which was written two days before our inspection. This showed that records of 15 minute observations had not always been saved electronically as the provider's policy requires. The paper records were available, so this met the recommendations of the Mental Health Act Code of Practice. There were other areas for improvement identified in the audit. This indicated that the provider was using audits effectively to identify areas which needed improvement. We saw from patient records that the provider had made improvements in asking patients for their experience after a period of seclusion and making a record of their views. This is a recommendation of the Mental Health Act Code of Practice. Inspection Report Chase Farm Hospital March

11 Records People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was meeting this standard. People were generally protected from the risks of unsafe care and treatment in seclusion because accurate and appropriate records were maintained. Improvements to the auditing of seclusion records in progress at the time of the inspection were aiming to further protect patients from risk of unsafe care. Reasons for our judgement We checked a selection of records relating to seclusion of patients. These were; the seclusion registers, electronic patient observation records, paper observation records, reports of the incident leading to the seclusion, nursing and medical reviews, audits of seclusion episodes and records of patients' experiences. We found that, with the exception of the audits, records were accurate and showed evidence of appropriate care which met the national guidance for care of patients in seclusion. There was evidence that staff understood what records they had to keep when nursing a patient in seclusion and evidence of improvements in the quality of records. Records were kept securely and could be located promptly when needed. Inspection Report Chase Farm Hospital March

12 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of dentists and other services at least once every two years. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times but we always inspect at least one standard from each of the five key areas every year. We may check fewer key areas in the case of dentists and some other services. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Chase Farm Hospital March

13 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Chase Farm Hospital March

14 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. We make a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation) from the breach. This could be a minor, moderate or major impact. Minor impact people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Chase Farm Hospital March

15 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Chase Farm Hospital March

16 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Chase Farm Hospital March

17 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Inspection Report Chase Farm Hospital March

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