At this inspection we visited Tennyson and Byron wards. We spoke with ten patients admitted to those wards on the day of our visit. Most patients were positive about the care and treatment they were receiving. For example, one patient said, “the care is fine.” Everyone told us they took part in a range of groups and activities both inside and outside the hospital. Several patients said the groups were helpful for their recovery. Many patients on Tennyson ward prepared their own meals in shared flats within the ward. We saw staff interacting with patients in a caring and compassionate way and responding to their needs. The mental and physical health needs of patients were addressed.

Patients were provided with opportunities and support to increase their independence and become involved in the local community. For example, some patients went swimming at a local leisure centre or took up volunteering opportunities in the community as part of their rehabilitation. Some patients were supported to purchase food and prepare their own meals as they progressed towards discharge from the hospital.

Patients we spoke with understood their rights under the Mental Health Act 1983 and an informal patient was clear about their right to leave the hospital.

There were systems in place to ensure the hospital was clean and to reduce the risk of infection. These were mostly effective.

We carried out this unannounced inspection to check whether the provider had complied with two warning notices served after the last inspection of the service in February 2013. At the last inspection we had found that emergency resuscitation and first aid equipment was not properly maintained and not suitable for its purpose. The system in place to identify, assess and manage risks did not protect patients against the risks of inappropriate or unsafe care in an emergency.

During this inspection we found that improvements had been made. We checked all of the emergency equipment and found it was suitable for its purpose and being properly maintained. A system of regular checks had been implemented. Senior managers regularly monitored the implementation of checks to ensure they were taking place. Systems in place reflected guidance from expert bodies and were effective in managing risks to patients and others in an emergency.

We spoke with six patients detained under the Mental Health Act 1983. Patients confirmed they were able to raise their concerns with the manager, although they did not think these were always promptly addressed. Patients had mixed views about the quality of care and treatment they had received during their admission. For example, one patient said, “the staff are like family to me” and another told us “staff are fine, most are polite.” However, two others were less positive and considered they received little help from staff.

We carried out this inspection to see whether the provider had made improvements to the systems in place to medically review patients held in seclusion and to follow up on concerns arising from recent incidents that had occurred at the hospital.

There were 49 patients admitted to the hospital at time of our inspection. We spoke with four patients on Coleridge and Tennyson wards. They told us they were satisfied with the care and treatment provided by the service. Staff received appropriate training to enable them to provide the care and treatment that patients needed.

However, emergency resuscitation and first aid equipment was not properly maintained and not suitable for its purpose. As a result the provider had not made suitable arrangements to protect patients and others from the risk of using unsafe equipment in emergency situations.

Although the provider had a system in place to assess and monitor the care and treatment provided to patients and to identify, assess and manage risks relating to their health, welfare and safety, this was not effective. The system in place did not protect patients against the risks of inappropriate or unsafe care in an emergency. We have taken action to address these concerns.

We carried out a joint visit to the service with a mental health act commissioner who reviewed the provider's arrangements for the seclusion of patients.

There were 41 patients admitted to the hospital on the day of our visit. We spoke with four patients on Keats Ward and Byron Ward. Patients confirmed that therapeutic groups and activities usually took place as outlined on their individual timetables. Most had found their admission to the service helpful. For example one patient told us “it is helping being here” and another said, “I’ve come a long way”.

Patients described most staff as “good” or “very good”. A typical comment we received was “staff are helpful”. Some patients told us they wanted to have more time to speak with the consultant psychiatrist in the monthly ward round. One patient told us that five minutes of discussion with their consultant was “not enough”.

There were generally enough staff on duty and staff had undergone a range of training to help them meet the needs of patients. Patients knew how to make a complaint and one patient told us their complaint had been resolved satisfactorily. However, the provider did not have an effective system in place to regularly assess and monitor the care and treatment of patients in seclusion and protect them against the risks of inappropriate or unsafe care.

The patients we spoke to during our visit to the hospital told us that they were generally happy with the care provided to them. Patients told us they met regularly with their primary nurse and one person said, ‘we have good therapeutic input, it has made such a difference to my life’. Patients were able to receive visits from family and friends and increased facilities had been made available for this. There were usually enough staff on duty to ensure that patients could go out on escorted leave when this was agreed as part of their care plan. Patients told us they took part in a range of activities and were able to go outside in the secure compound several times during the day.

Patients told us that they were happy with the care and treatment they received at The North London Clinic. They were involved in planning their care and could raise collective issues of concern through the patients’ representatives meetings. Typical comments we received included: ‘I’ve got involved in my care plan. I see my primary nurse regularly and talk through my care plan’; and ‘there is a planning meeting every day to discuss what there is to do. Staff involve us in this and give you a choice of activities’. Everyone told us they were treated well by staff and their dignity was respected. One patient commented that ‘you can approach staff if you are unhappy about anything’. Patients were concerned about the limited space available for seeing visitors and the impact on other patients who were unable to access activity rooms during visits. They were also concerned about the cost of telephone calls and some types of postal costs. There were mixed views expressed on the food provided with most patients describing it as acceptable. Everyone said they were given a choice of meal and individual needs and preferences were catered for.

We rated The North London Clinic as requires improvement because:

• The senior leadership team of the hospital had been unstable since the hospital’s merger with another provider in December 2016, which meant there had been inconsistent leadership. Although there was a governance framework in place, new systems and processes had not yet been fully embedded since the merger, and staff could not always find key information to help them deliver their role effectively.

• There had been a high turnover of ward managers, which meant there was a lack of leadership and experience at ward level. Most deputy ward manager posts were vacant, which meant ward managers did not always have sufficient leadership support on the wards. Staff morale was low.

• There was a high vacancy and turnover rate for the nursing teams across the hospital. This had led to an over reliance on bank and agency staff.

• Physical healthcare monitoring was not being carried out consistently to meet the individual needs of patients. There was no effective oversight of physical health monitoring systems within the hospital.

• The hospital did not have enough personal alarms for all staff and external visitors, and they were not all in working order.

• The hospital did not ensure there were effective systems in place for all staff to hear about and learn from incidents and complaints. Team meeting minutes did not demonstrate that they happened every month as managers said they should. Care record audits were not being carried out.

• Patients who were detained had limited access to an Independent Mental Health Advocate.

• The wards did not always promote patient recovery. The wards were not well maintained and did not provide a therapeutic environment. The hospital did not ensure staff engaged with patients following a seclusion episode, which meant patients were not provided with a de-brief and offered any additional support they may have required.

• Carer needs were not always being met. Carers reported that communication could be improved between carers and staff at the hospital.

We found these areas of good practice:

• There was a proactive approach to anticipating and managing individual risks for patients. Up-to-date risk assessments and management plans were in place for all patients. There were systems in place for safeguarding patients.

• Patients’ needs were fully assessed. Care plans were comprehensive, holistic and person centred. Patients co-produced their care and risk management plans. The hospital provided a range of psychological therapies and interventions recognised by guidance from the National Institute for Health and Care Excellence.

• The hospital was good at involving patients in their care and treatment. There were opportunities for patients to feedback on the services they received at the hospital.

• Patients were supported with their recovery journey. There was an extensive programme of individual and group activities that reflected patients’ individual needs and preferences.

• The hospital’s risk register matched staff concerns and our concerns found during the inspection. Detailed plans were in place to make improvements and senior management discussed the risk register regularly. Leaders had recognised the recent hospital merger had been a challenging time for staff, and had been proactive in engaging with staff and working to improve morale.