Barnet Lane Clinic

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 to patients. The provider managed the environment well to ensure these were safe for people using services. This included processes to maintain cleanliness and infection control standards.