Enhanced Observation
Summary
London North West University Healthcare NHS Trust has introduced Enhanced Therapeutic Observations and Care (ETOC) to strengthen safety and therapeutic support for vulnerable patients across its three hospital sites. The programme improves oversight, consistency, and quality of care through structured governance, skilled workforce deployment, and real-time visibility of staff movements. By embedding this patient-centred model, the Trust has enhanced patient experience, reduced length of stay, improved productivity, and created a sustainable framework for therapeutic care in complex settings.
The Challenge
The Trust previously lacked a clear and consistent framework for Enhanced Therapeutic Observations and Care. Wards often managed enhanced care locally without central oversight, creating risks for patients and leaving gaps in assurance. Records of substantive staff redeployment were kept retrospectively, meaning leaders had limited visibility in real time. This reduced confidence in governance and risked inefficiencies such as double bookings. In addition, not all redeployed staff had the appropriate training in mental health or de-escalation, increasing risks to both patients and staff. These challenges were compounded by financial pressures caused by inefficient workforce deployment.
The Solution
Under the leadership of the Deputy Chief Nurse, the programme was delivered by the Lead Nurse Workforce, the E-Rostering manager, and the Lead Nurse for Enhanced Care in partnership with clinical teams. HealthRoster and SafeCare were configured to provide real-time redeployment visibility for senior nurses at safety huddles and out of hours. All referrals for enhanced care are now triaged by senior clinicians, with clear criteria applied to distinguish between patients needing ward-managed 1:1 support and those requiring ETOC. The ETOC team includes Registered Mental Health Nurses and unregistered staff, with the RMN assessment service expanded to seven days. Substantive RMNs have been appointed to Emergency Departments, reducing reliance on agency cover. Only staff with appropriate skills and training are allocated enhanced care shifts, creating a skills-based roster that prioritises safe and therapeutic support.
Results & Next Steps
The programme has significantly improved safety, governance, and patient care. Senior nursing teams now have full visibility of staff redeployment across all sites, reducing duplication and ensuring assurance in the event of incidents. Patients consistently receive support from appropriately trained staff, improving therapeutic engagement, patient experience, and continuity of care. Staff benefit from transparent redeployment processes, improving morale and confidence. The expansion of RMN services has reduced agency use and strengthened quality. Enhanced care now spans 71 wards across three sites, supported by acuity scoring and data reporting for NHSE requirements and national benchmarking. Future work will focus on addressing unfilled shifts and linking workforce shortfalls with Datix to provide further assurance and oversight.
