Barnet Lane Clinic

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

We found a breach of the legal regulation 12, Safe Care and Treatment. Staff had made an error in recording how rapid tranquilisation for a patient had been given. Despite staff recording that they had checked equipment and medicine storage, staff had incorrectly stored adrenaline in the fridge when best practice suggest this should be stored at room temperature. Staff had not correctly recorded the stock level of a controlled drug and we found expired medicines in the emergency bag in the clinical room. Carers and patient feedback demonstrated further learning and improvements were required to continue to embed good practice at the service. Patients did not have access to a recovery college, educational or vocational opportunities to support and prepare them with their transition to discharge. Managers had not ensured the gender mix of staff consistently enabled female patients to have their immediate needs met. Some patients and carers said there had been occasions when staff were observed to have fallen asleep whilst observing patients on enhanced observations and some patients told us that staff were speaking in their own language in front of them, which they did not understand. Several patients we spoke with said there were not enough activities in the evenings or at weekends. Continued refurbishment of the hospital was required to make further improvements to the visiting space and accessibility for patients and carers. However, staff managed risks well and reported and investigated incidents and complaints. Managers used lessons learned information to improve the care at the service. Patients said they were supported to understand safeguarding and raise any safety concerns they had. There were effective systems, processes, and practices to make sure people were protected from abuse and neglect. Staff maintained facilities and equipment to be able to deliver safe care.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider conducted a survey in 2023 which 11 patients using the service and 4 carers responded to. Results showed that 50% of carers strongly disagreed that they received information on consent and confidentiality, 75% disagreed that they were offered time with staff to discuss their needs, 50% of carers disagreed that the visiting space had access to refreshments and a toilet and 50% did not feel involved in service development. However, 81% of patients knew how to make a complaint and 63% felt confident that their feedback would be used to improve the service. From the 8 patients and 9 carers we spoke with, they described improvements being made as a result of feedback, including more regular communication with doctors, new activities being introduced and changes in care plans being made for individuals using the service. Carer’s forum minutes demonstrated managers sought their feedback. However, areas discussed included improving communication, limitations of the environment, positive feedback about staff’s dedication and the quality of the kitchen facilitates and catering services. Managers had developed an action plan to address the concerns they had raised. Managers sent carers a monthly newsletter to update them with news about the service.

We spoke with 25 staff. All staff we spoke with were aware of lessons learned following incidents and complaints within the service and from the wider organisation. Staff said they were asked for feedback to improve the safety at the service and were able to raise any concerns if they had them. Managers shared information about lessons learnt after incidents with staff in various ways including holding an immediate de-brief and reviewing the incident at the daily operations meeting for further analysis and action in relation to learning. This was then cascaded to staff via emails and bulletins, in staff meetings, reflective practice, staff supervision and in lessons learned folders. These included many examples of learning from incidents and action taken as a result of these. Staff and managers shared examples of lessons learned. Clinical governance meeting minutes demonstrated lesson learned were part of the agenda and we saw evidence in staff meeting minutes that lessons learned were fed back to staff.

Managers held a site improvement plan demonstrating a culture of improvement and actions taken to address safety issues. Managers completed a closed culture audit in January 2024 to review the culture at the service. This found areas for improvement and development to the safety and quality of care as well as the environment. For example, feedback from people’s experience of care found that reasonable adjustments for disabled people were not always met. Renovations of the environment were underway at Barnet Lane Clinic to enable the service to meet all people’s needs. Carers and patient feedback demonstrated further learning and improvements were required to continue to embed good practice at the service. Managers had processes in place to manage safety but needed to ensure learning and improvements were fully embedded. Managers held daily operations meetings where safety and risk issues were discussed. All safety incidents were reviewed, and decisions were made on how these would be managed and investigated. Managers investigated incidents. Incident records included a section to record any learning. Managers reported that the majority of incidents between April 2023 to March 2024 (54%) related to self-harm and 22% related to aggression and violence. Managers reviewed and analysed these at clinical governance meetings and reducing restrictive practice meetings to understand themes and trends and how to reduce these. Clinical Governance and staff meeting minutes included lessons learned as a rolling agenda item. Learning was also shared between other services within the provider group. Managers debriefed and supported staff after any serious incident.

Patients told us there was no access to a recovery college, educational or vocational opportunities to support their transition to discharge. Seven of the patients we spoke with said they felt safe at the service whereas, 1 patient said they did not feel safe as they were due to leave and felt it could be chaotic at the service. In the past year, 3 patients stepped down to supported living settings. Staff were aware of support needed to help patients prepare for discharge. One patient said they had a smooth transition to the service, received an orientation and had time to get to know patients and staff. Most carers said they believed their relatives felt safe at the service, that staff knew the needs of their relative well and spoke positively about staff behaviour and approach to their relative. However, some carers felt that there were no discharge plans for their relative.

Managers told us that they were aware of the needs of the service group and were changing the remit of the hospital to an all female acute and rehabilitation service. Managers wanted to ensure patients with higher levels of acuity could access the appropriate service without having to transfer to another service. Although staff were aware of the support needed to help patients with their recovery and prepare them for discharge, staff spoke about patients not having access to a recovery college, educational or vocational opportunities to support their transition to discharge. Doctors and managers were clear that they would not take on any referral unless the team felt confident, they could meet their needs safely. Staff knew the needs and risks of patients and were able to provide examples of how they had supported patients with their needs and risks.

The advocate shared some concerns about transitioning processes and the gender mix of staffing at the service which we shared with managers. However, feedback was generally positive about the care and treatment delivered to patients at the service. They felt staff and managers were approachable, transparent, and responded to concerns. We sought feedback from commissioners who spoke positively about the service and said they were invited to attend the service regularly; they received feedback and updates about patients' progress and believed the staff knew the needs and risks presented by patients and how to care and support patients with these.

Although managers had identified areas of improvements with their rehabilitation model and training and vocational opportunities, these were not fully embedded and were not consistently provided to patients . Managers had also identified areas where the physical environment could improve and were in the process of a refurbishment project to be able to meet the diverse needs of people accessing the service. Multidisciplinary team meetings, where people’s care and treatment were reviewed demonstrated that staff focused on safety and continuity of care, there was an awareness and review of risks with a plan on how to support people with these. People were asked to give their views about their care and treatment. We reviewed six care records which evidenced multidisciplinary collaborative working and patient views. Risk assessments and treatment plans were updated and reflected current risks and needs. Staff we spoke with were aware of the complexities of some of the patients and were able to demonstrate how they would support and manage this with individuals. We found detailed discharge plans with patients being supported towards discharge and input from carers and commissioners at care and treatment review meetings.

Seven of the 8 patients we spoke with said they felt safe at the service although one patient said they did not feel safe at the service as they felt it could be chaotic. Most carers said they believed their relatives felt safe at the service, that staff knew the needs of their relative well and spoke positively about staff behaviour and approach with their relative. We reviewed weekly community meeting minutes throughout February 2024 where safeguarding was a standard agenda item. Although there were no safeguarding issues raised during the meeting, patients were encouraged and reminded to raise any safeguarding concerns and that they would be supported with this.

During the onsite assessment visits, we spoke with staff including managers, doctors, nurses, support workers, members of the multidisciplinary team, administrative and kitchen staff. All the staff we spoke with showed a commitment to taking immediate action to keeping people safe from abuse and neglect and felt comfortable and safe to do so. Staff knew how to make a safeguarding referral and who to inform if they had concerns.

During the site visit we observed that the ward felt safe, and staff were visible and engaging with patients. We saw information posters displayed on the ward giving details of the safeguarding lead for the hospital. We carried out an observation of the service using the Short Observational Framework for Inspection (SOFI) tool. The observations showed generally positive staff interactions with patients of a relaxed, inclusive, facilitative, and warm nature. Patients who were identified as being observed continuously by staff had staff present with them. We observed positive engagement and activity between staff and patients. Observation of multidisciplinary team review meetings and a review of care records showed that safeguarding concerns were discussed with a plan to safeguard individuals where necessary.

The provider’s processes promoted people living in safety, free from abuse, neglect, and avoidable harm. We saw evidence that there were effective systems, processes, and practices to make sure people were protected from abuse and neglect. Managers ensured the service had a comprehensive local safeguarding procedure which included good working relationships with other agencies, including the local authority. Managers held morning meetings where any safeguarding incidents were shared, discussed, and managed with onward referrals to the local authority and protection plans put in place. Staff received training on how to recognise and report abuse, appropriate for their role and kept up to date with their safeguarding training. Overall, the providers compliance with safeguarding training was 100%. As part of the assessment, we reviewed the hospital safeguarding log which was up to date and included details of the safeguarding incident, the incident date, and if concerns were reported to the local authority or being investigated by them with a record of the outcome.

Most patients said they were involved in producing their care plans and had a copy of these, whereas some patients said they had not been involved in producing or had a copy of their care plans. Patients told us that they understood why they had observations, and they were carried out properly and in a respectful way. Staff recorded the risks for people and how to manage these to keep themselves safe. Staff regularly reviewed care plans and risk plans with people and updated these with new information when required. Some people using the service had positive behaviour support plans that included people’s views of how they preferred to be cared for and how to manage risks they may have presented with. Restrictive practice was a regular item on the community meeting minutes and patients were able to raise any issues they had. Community meeting minutes throughout February 2024, included questions from patients about why they were not allowed to have blankets in the lounge areas. This was due to maintaining infection control standards and was explained to people using the service. Managers held a reducing restrictive practice audit meeting where a person using the service attended and gave their views on areas involving restrictive practice. The group discussed and reviewed these deciding whether to lift the restriction or not or to take away for further consideration at the Clinical Governance meeting. An action plan was created as a result of this meeting with some restrictions lifted.

Staff were able to provide examples of risks posed by some people using the service and could describe how they acted to prevent or reduce risks for that person. All the staff we spoke with told us that staff undertook a risk assessment for each patient on admission and updated these after incidents. Staff demonstrated a good understanding of the management of risk and reducing restrictive interventions. Staff told us that restraint was only ever used as a last resort and only when a patient was causing harm to themselves or others. Staff reviewed risks to patients, discussed and updated risk plans with patients as necessary and after incidents. Staff identified and responded to any changes in risks to, or posed by, patients.

Staff completed risk assessments for each patient on admission, using a recognised tool, and reviewed this regularly, including after any incident. Managers had a reducing restrictive interventions policy which included guidance and procedures for managing restrictive practice and blanket restrictions. This policy was comprehensive and last reviewed and updated in September 2022. Staff held reducing restrictive practice meetings to review, discuss and lift any blanket restrictions. This was attended by a patient who contributed and challenged the group on any restrictive practices. The provider held a reducing restrictive interventions regional group where all services would come together to review incidents and practice with the aim of reducing restrictive practice. Each service held a reduction plan and registers to demonstrate where they had reduced restrictions which they submitted to the regional group for provider oversight. The provider shared lessons learned on restrictive practice with all services within the group. As part of the assessment, we reviewed minutes from clinical governance meetings, multidisciplinary team meetings, and team meetings. Safety and risks were reviewed in detail at these meetings, including learning from incidents, reducing restrictive practice, and learning from concerns. During the assessment we reviewed 6 care plans. Care plans were person centred and provided guidance to staff on how best to support patients in the way they wished to be supported. Risk assessments were completed on admission, regularly thereafter and after any incidents.

Some carers fed back that the reception area, visiting space and facilities for visitors was limited and further improvements were required to ensure the environment met all patients accessibility needs. Similar feedback was also made by families at the family forum meeting held in March 2024. However, the majority of people we spoke with told us that the environment was clean, well maintained, with the facilities and equipment to meet their needs.

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 we spoke with were aware of a ligature map which highlighted ligature risk points within the service. This enabled staff to be aware of ligature risks so that they could keep people using the service safe. Staff were aware of blind spots within the service and knew how to mitigate against these. The hospital had fitted mirrors and closed-circuit television to monitor communal areas and staff used enhanced observations to support patients with additional risks. Staff were aware of potential psychological, physical, or sexual harm and used the environment to manage this such as by caring for people in different parts of the service. Managers spoke about the use of closed-circuit television to review any incidents of harm so that this could be learned from and prevented. However, the provider were in the process of refurbishment works to make improvements to the evironment that had impacted on peoples' experience of care.

Refurbishment works at the service impacted on people's experience of the service. The current visiting room did not provide all facilities for people. Visitors had raised these concerns and were keen for the improvements to the visiting room to be made. Accessibility had been impacted for some patients whilst the refurbishment works were in progress. However, The service was clean, generally comfortable, decorated and furnished well. We observed records showing that staff completed and regularly updated thorough risk assessments of all wards areas and removed or reduced any risks they identified. The ward complied with guidance and there was no mixed sex accommodation. Male and female patients were on different wards. We observed ligature points which staff were aware of. Managers ensured the service had a ligature audit and map identifying and mitigating these. We observed staff having easy access to, and using, alarms and patients had easy access to nurse call systems in their bedrooms. Clinic rooms were clean, fully equipped, with accessible resuscitation equipment and emergency drugs.

Managers were completing refurbishment works due to plans to change the remit of the hospital and to improve the environment. However, this had impacted peoples experience at the service. Visitors did not have access to all facilities when visiting the service and the works limited the accessibility for some patients. However, the provider managed the environment well to ensure these were safe for people using services. The provider completed regular and up to date environmental, health and safety risk assessments and ligature audits. Managers ensured risk assessments for fire safety, water monitoring, electrical installation and calibration of equipment were up to date. All actions as a result of assessments and audits were monitored and completed. Managers ensured maintenance checks were reported and completed within reasonable timeframes. Managers ensured cleaning checks and handwashing and infection control audits were regularly completed.

Two patients on enhanced observations shared concerns with having to wait for female staff to support them with their immediate needs. Some patients and carers said there had been occasions when staff were observed to have fallen asleep whilst observing patients on enhanced observations which managers were addressing. Feedback from some patients during the assessment told us that staff were speaking in their own language in front of them, which they did not understand. Several patients we spoke with said there were not enough activities in the evenings or at weekends. However, patients and carers we spoke with did not raise any concerns with the numbers of staff available at the service. Patients generally said staff were available, kind and knew how to meet their needs.

Staff we spoke with told us that there was appropriate staffing levels to make sure patients received consistently safe, good quality care. However, some staff told us that they would have to swap staff around to manage the gender mix of staffing to meet patients needs. Managers confirmed they would move staff around to meet female patients needs as they sometimes had more male than female staff on shift. Managers reported current staffing establishments as having 9 registered mental health nurses, 2 staff nurses and 1 preceptee nurse in post. They also reported 32 support workers, 2 bank support workers and 1 physical health nurse. Managers reported vacancies of 3 registered nurses and 4 support workers, with 10 support workers currently in the process of onboarding or induction. The service had 2 consultants and a ward doctor. Staff reported having enough daytime and nighttime medical cover and a doctor available to go to the ward quickly in an emergency. Managers reported that staff worked with a minimum of 2 nurses and 4 support workers, but this increased with every patient on enhanced observation. Staff reported receiving reflective practice, regular supervision, and appraisals. Staff reported receiving mandatory and specialist training to enable them to have the knowledge and skills to meet patients' needs. Staff reported receiving an induction when they commenced employment at the service. Staff reported there had been quite a few staff leavers due to the changeover of provider. Managers reported a reducing turnover rate. Between August 2023 and January 2024, the turnover rate was 24% and reduced further between November 2023 and January 2023 to 11%. Managers reported no long-term sickness. Staff reported that bank and agency staff were used regularly, and block booked.

We carried out an observation of the service using the Short Observational Framework for Inspection (SOFI) tool. The observation showed generally positive staff interactions with patients of a relaxed, inclusive, facilitative, and warm nature. 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.

Managers had not ensured the gender mix of staff consistently enabled female patients to have their immediate needs met. There were some complaints about delays to the availability of female staff to meet female patients’ immediate needs. Managers confirmed they would move staff around to meet female patients needs as they sometimes had more male than female staff on shift. As the hospital was changing its remit to become a female only service, managers must ensure the gender mix of staff is sufficient to meet patients' needs. We reviewed nursing rotas and spoke with staff and managers about staffing levels at the service. Staff and leaders, we spoke with said there were enough staff at the service. Rotas we reviewed demonstrated safe staffing levels. Managers ensured staff received mandatory and specialist training. Overall, mandatory training rates for staff were 93%. Managers limited their use of bank and agency staff and requested staff familiar with the service. Managers made sure all bank and agency staff had a full induction and understood the service before starting their shift. Managers reported staff supervision rates at 87% and appraisal rates at 93%.

All patient and carers we spoke with said the service was regularly cleaned and maintained.

Staff and leaders, we spoke with said they made sure the service was regularly cleaned and cleaning records were up to date. Staff said they followed infection control policies, received infection prevention control training, and had appropriate protective personal equipment to keep themselves and patients safe. Staff followed hand hygiene guidelines and regularly completed hand hygiene audits.

We conducted a tour of the service and found it to be visibly clean. We observed staff cleaning the service and reviewed cleaning records which demonstrated staff regularly cleaned the service.

Managers held regular cleaning and infection prevention control audits of the service to ensure processes were in place to maintain the cleanliness and infection control standards of the service. Staff followed infection control policies, including handwashing. Managers ensured staff received appropriate personal protective equipment and infection control training with a compliance rate at 96%.

Prior to our on-site assessment, some patients and carers described concerns about potential errors with administration of their medicines, which they had spotted before taking these. They described a few occasions where medicines had been potentially administered that were prescribed for other patients. However, patients feedback indicated that they were supported with medicines appropriately, were provided with relevant information about their treatment and were given opportunities to discuss this in their care and treatment review meetings. Most patients were satisfied with the staff support provided with their medicines and opportunities to develop self-medication skills. Staff provided opportunities for patients to self-medicate at the service and 1 patient was self-medicating at the time on our on-site visit which we observed.

Managers told us of, and we reviewed, a medicine errors protocol so that they knew how to assess, categorise, and take action on any medication errors at the service. However, this had not been fully applied to a recent medicines error we had identified, until we raised it again with managers on our second visit. We spoke with registered nurses administering medicines and doctors who prescribed medicines at the service. We reviewed 8 patient medicine prescriptions charts and found people’s medicines were appropriately prescribed. Ninety percent of staff completed medicine management training. However, staff confirmed that there had been a recent error in recording administration of rapid tranquilisation, and that stock records were not accurate at the time of the inspection visit.

During our first on-site visit, we observed one patient’s information on display in the clinic room. This was removed by staff during our second on-site visit, after being raised for the second time. However, the clinic room was clean, tidy, and well arranged. There was a couch for examination of patients and appropriate equipment for staff to be able to conduct physical health checks of patients. All equipment was calibrated.

We found a breach of the legal regulation in relation to safe care and treatment. We were not assured that managers had embedded systems in place, to ensure issues with medicines storage and recording were managed. Although staff generally administered medicines correctly, there was an error in recording the route of administration for rapid tranquilisation for a patient who had received oral medication. We raised this with staff who stated that the patient had requested this to be administered orally but the administration route was incorrectly recorded by staff as being given intramuscularly. We had to raise this again during our second visit as this had still not been corrected. Despite staff recording that they had checked equipment and medicine storage, staff had incorrectly stored adrenaline in the fridge when best practice suggest this should be stored at room temperature. Staff had not recorded the stock level of 34 ampules of the medicine lorazepam which is a controlled drug that is liable for misuse. We found expired medicines in the emergency bag in the clinical room where adrenaline had expired in December 2022. The recorded amounts of medicines in the emergency bag were not accurate. Staff had recorded the emergency bag as holding 5 salbutamol ampules when there were in fact 10. However, we reviewed patient medicine prescriptions charts and found people’s medicines were appropriately prescribed. Doctors monitored high dose antipsychotics. Nurses conducted post rapid tranquilisation monitoring of patients which included a doctor’s review. Managers ensured people’s behaviour was not controlled by excessive and inappropriate use of medicines, and followed NICE guidance to ensure that patients' physical health needs were monitored.