We undertook this inspection to check whether improvements had been made since our last inspection in April 2013. At the inspection in April 2013 we found many care plans had not been reviewed within expected timescale and there was a risk that care plans did not address patients’ current needs. In addition, information recorded in patients’ electronic records sometimes conflicted with information given to staff about their care needs and status under the Mental Health Act 1983.

At this inspection we found that improvements had been made. We reviewed the health care records of eight young people admitted to the adolescent unit and found that most care plans and risk assessments were up to date and had been reviewed in accordance with specified dates. This ensured care plans reflected the current needs of patients. Patient records were accurate and fit for purpose.

During this inspection we visited the adolescent unit and the addictions treatment programme. We spoke with several young people who were admitted to the adolescent unit. Most patients were satisfied with the care and treatment provided. One patient told us that their care was “good” and staff were “nice.” Comments from patients who had completed patient satisfaction questionnaires on the adult ward and from those taking part in the addictions treatment programme included “I felt safe, secure and cared for” and “very caring and committed staff.”

Patients were satisfied with the environment in which they received care, although the adolescent ward was described as generally quite hot and lacking ventilation. Appropriate arrangements were in place to ensure that medicines were managed safely. Complaints about the service were investigated and managed appropriately.

However, we found that not all care plans and risk assessments were reviewed in line with specified review dates in order to ensure that patients’ individual needs were being met. Records kept in respect of patients’ care and treatment were not always accurate and could not always be located promptly. Information provided to staff about patient care, legal status and capacity to give consent was sometimes contradictory or was not always immediately available to them.

We carried out this unannounced inspection to check if the provider had made improvements on the adolescent unit following an inspection of the service in May 2012. There were 13 young people admitted to the unit on the day of our visit.

During this inspection we observed that the young people on the unit were provided with education, individual and group therapy and recreational activities throughout the day and evenings. These mostly took place as planned. However, one young person told us, “weekends are long and boring; those are the two days I hate.”

Staff received appropriate training and support to enable them to deliver the care to the young people that they needed. Most staff we spoke with demonstrated a detailed understanding of the individual needs of the young people they supported. There were sufficient numbers of staff available to care for the young people on the unit.

A detained patient we spoke with understood their legal status and rights under the Mental Health Act 1983 and records pertaining to their detention were located promptly and were accurate.

During our visit to The Priory Hospital North London we visited the adolescent unit. We spoke to four of the 18 young people who were patients on the unit at the time. The young people said they did not feel safe or protected particularly from some of the other young people. Staff were described as ‘not in control’ of the unit and they felt that concerns for their personal safety were not taken seriously by staff. The young people told us there were not enough activities provided for them, particularly at the weekends. Those that were scheduled often did not take place. One young person described the weekends as ‘awful’.

Three of the young people we spoke with told us there were usually not enough staff on duty to meet their needs. This meant that they were often unable to go outside for a walk. Those not receiving one-to-one care had little time with staff and their needs were not always met.

We found that agency staff did not always receive an adequate induction when they came to the ward. An agency nurse induction checklist had been prepared by managers but was not yet in use. A typical comment we received from one young person was, ‘agency staff don’t know about young people’. This meant there was a risk that agency staff were not appropriately supported to enable them to deliver care to the young people safely.

Evidence of the legal detention of one young person in the hospital could not be located on the day of our visit. This could have resulted in a failure to uphold the person’s rights under the Mental Health Act 1983.

Patients told us that they were happy with the care they received at the hospital. Group and individual therapy was provided on a regular basis. Staff were described as ‘sincere, kind-hearted and genuine’. Young people on the adolescent unit took part in regular activities and school work and were enabled to keep in contact with their families. Plans of care and treatment were individualised and patients were agreed their weekly programme of activity with staff. Treatment, including medication, was explained in ways that could be easily understood by patients. Patients felt that staff had time for them. One comment we received typified this: ‘staff always want to know how you are doing; they stop and ask you how you are feeling’.

We visited two wards in the hospital, the adult Ward and the adolescent Ward. Young people on the adolescent Ward told us they took part in a range of therapies and activities. One said they had found the therapy ‘very helpful’ and commented that ‘staff don’t push too much and also don’t let me sit back either’. They said that therapy had helped them to express their feelings more and they liked the support they got from other young people. One said ‘it feels like being part of a family’. They told us that a community meeting was held every morning for staff and young people and that at the meeting the ‘young people can have their say’ and their views are ‘taken on board by staff’.

Negative comments we received from the young people included ‘we don’t get talked to enough’ by staff and some staff interact with the young people whilst others do not. One young person said that they sometimes found it hard to approach staff directly and would like staff to take the initiative more in approaching them. One young person said that staff ‘say they can’t take you out because they are too short staffed’; and another told us ‘when things get out of control there are never enough staff’

The patients we spoke to on the adult Ward told us that ‘staff are responsive’ and ‘it is like a hotel here.’ They also said they had regular sessions with a psychologist and that staff ‘are knowledgeable and capable’ and ‘there are loads of activities’ including meditation and board games. Patients said staff were respectful and sensitive in their approach towards them and took notice of patient preferences. Patients on both wards described having a choice of food at meal times including a salad bar and said the food was generally, ‘good’ and ‘properly prepared’

As this was a focused inspection, the provider’s overall inspection rating or core service ratings were not altered.

We undertook this focused inspection of the child and adolescent wards to check the progress the provider had made in addressing the breaches of regulation identified at the previous inspection in April 2018.

At this focused inspection on 23 and 24 October 2018, we found the provider had made good progress regarding our concerns identified in the April 2018 inspection. The provider had made improvements in all 14 areas we asked them to address. We also report on additional concerns found with the safety of the clinic room.

We previously inspected this service in April 2018 as part of our on-going comprehensive mental health inspection programme. As a result of our findings at the inspection in April 2018, we provided feedback to the provider regarding our serious concerns of young peoples’ safety on the child and adolescent wards.

The provider immediately transferred an experienced child and adolescent service manager to provide leadership to the child and adolescent wards. The provider also developed a detailed action plan to address our concerns. We were assured that the action plan demonstrated risk was either removed or was being removed in a timely manner to ensure people’s safety on the on the child and adolescent wards.

At the April 2018 inspection, we found the following concerns on the child and adolescent wards:

• Ligature risks were present on all of the wards, including high risk ligatures in young people’s bedrooms.
• Young peoples’ risk assessments were not detailed and risk management plans did not always identify how staff could minimise risks effectively.
• Young people did not always have a full physical health assessment on admission to the hospital.
• Emergency alarms and call buttons were not always responded to in a timely manner.
• Paediatric early warning scores were not completed correctly. Possible deterioration in a young person's physical health may not have been escalated appropriately.
• Staff on the child and adolescent wards did not understand what constituted restraint. There was inconsistent recording of restraint of young people, and a lack of planning of how to support young people in the least restrictive way possible.
• The out-of-hours doctor did not carry an alarm or pager. Staff may not have been able to contact the doctor in an emergency.
• The prescription of 'as required' medicines on the child and adolescent wards did not always clearly describe the route for administration. There was not always a recorded rationale for the administration of 'as required' medicines.
• The provider did not ensure that appropriate medical equipment was within its expiry date and was suitable for the client age group.
• Young peoples’ care plans did not always reflect their needs. Care plans were not always personalised, holistic or recovery-orientated.
• Young people told us that some staff did not treat them with respect and dignity. They found some staff patronising and unsympathetic.
• The governance and risk management systems and processes had not been effective. Potential risks to young people had not been proactively identified and addressed. Monitoring of the quality of care on the child and adolescent wards had been ineffective.
• Staffing levels for nursing on the child and adolescent wards were not safe. On a number of day shifts, there was one registered nurse rather than the minimum of two. Young people did not always receive one to one nursing sessions and their escorted leave was sometimes cancelled due to staffing levels on the wards.
• Staff had not received suitable training to meet the specific needs of young people in their care. Nursing staff on the child and adolescent wards had not received specialist training in epilepsy, autism or eating disorders.

At this inspection, we found that the service had made the following improvements:

• Leaders had a good understanding of the child and adolescent wards and had improved governance systems. An experienced child and adolescent service manager provided supernumerary support to the wards, and senior managers had a good oversight of the wards. There were improved systems in place to identify potential risks and to monitor the quality of care on the wards. However, the provider needed to ensure that the quality of the leadership was maintained and the implementation of the new governance systems was embedded.
• Staff completed risk assessments that were detailed and risk management plans identified how staff could minimise risks effectively.
• Staff completed a full physical health assessment for patients on admission to the hospital.
• The provider regularly tested response times to emergency alarms and call buttons via a rolling programme of staff emergency scenario drills.
• Staff completed paediatric early warning scores correctly, which ensured they were able to identify and escalate deterioration in a young person’s physical health.
• Staff understood what constituted a restraint and they used verbal de-escalation techniques first to ensure young people were supported in a least restrictive way. Staff completed restraint records to a good standard.
• The out of hours doctor carried a pager to ensure they could be contacted in an emergency.
• The prescription of 'as required' medicines clearly described the route for administration. Staff always recorded a rationale for the administration of 'as required' medicines.
• Staff ensured that young people’s care plans reflected their needs, were personalised, holistic and recovery orientated.
• Staffing levels for the children and adolescent wards were safe. The provider had processes in place to ensure the correct number of registered nurses was on each shift.
• Nursing staff on the CAMHS wards had received specialist training required to deliver their role safely. For example, staff had received suitable training to meet the specific needs of young people in their care, which included epilepsy, autism and diabetes.

We also found that the service needed to continue to make the following improvements:

• The provider had addressed our previous concerns regarding the clinic room. Staff checked medical equipment was within its expiry date and was suitable for the client age group. However, we found additional concerns with the clinic room. The provider did not have a robust system in place to ensure that all clinic rooms items were within its expiry date or to ensure that the clinic room environment was cleaned regularly.

• The provider needed to complete its planned work to reduce potential ligature anchor points. Since our last inspection, the provider had removed high-rated risks, but they still had environmental work to complete to minimise all of the ligature points. The provider needed to ensure that they met the timescales for this work.
• Young people told us that agency staff did not always treat them with dignity and respect, but told us permanent and bank staff were caring and understanding. At the last inspection, young people told us that staff did not always treat them with respect and dignity. At this inspection, all six patients were positive about how permanent and bank staff treated them. However, three out of six patients told us that agency staff did not always treat them with dignity and respect. Particularly agency staff did not always knock on their toilet door before entering.
• The provider needed to ensure that staff worked with young people to understand their rights as an informal patient.