All inspections: St Andrew's Healthcare - Essex

St Andrew’s Healthcare Essex is situated in North Benfleet, Essex.

The registered location at Essex provides men’s services and women’s services. This location consists of 3 core services:

• Acute wards for adults of working age and psychiatric intensive care units

• Long stay rehabilitation mental health wards for working age adults

• Forensic inpatient or secure wards

Our rating of this location improved. We rated it as requires improvement because:

Danbury ward and all acute wards for adults of working age and psychiatric intensive care units were tired and in need of redecoration.

Managers did not always ensure there were enough staff on shift to meet minimum planned numbers, on long stay rehabilitation mental health wards for working age adults. Training figures on some wards were below what we would expect for a safe service. Some staff were not up to date with mandatory training. 

Patients on Tiptree ward were not accessing and participating in, education and work opportunities in the wider community.

The service had not reviewed its recovery model of care, expected length of stay and did not have clear discharge pathways for patients at admission.

Staff did not always record observations in line with the providers policy. We reviewed 16 observation records during inspection, 12 of the observation records we reviewed had delays in the time of the observation being uploaded on to the providers electronic recording system.

Patients from Benfleet ward requiring seclusion were taken to Tiptree ward through the ward area to access seclusion, potentially not maintaining privacy and dignity.

However:

The ward environments were safe. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.

Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.

The ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.

Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.

Patients had access to a nurse call system, so patients could summon help if required.

Observations were being completed at unpredictable intervals which was an improvement from the last inspection and staff were following policies and procedures. The hospital had installed a new observations system for staff to record observations in real time and managers had oversight.

Following this inspection, requirement notices were issued for:

Regulation 9 HSCA (RA) Regulations 2014 Person-centred care
Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment
Regulation 15 HSCA (RA) Regulations 2014 Premises and equipment

At St Andrew’s Healthcare Essex, the services provided include patient centered care for both men and women with a personality disorder and/or mental health issues in both a low secure and locked environment.

St Andrew’s Healthcare Essex location has been inspected 8 times.

The location has a registered manager and a controlled drugs accountable officer.

St Andrew’s Healthcare Essex location is registered to provide the following regulated activities:

• Treatment of disease, disorder or injury

• Assessment or medical treatment for persons detained under the 1983 Act.

St Andrew’s Healthcare Essex location is situated in North Benfleet, Essex. St Andrew’s Healthcare also have locations in Northampton and Birmingham.

At St Andrew’s Healthcare Essex, the services provided include patient centered care for both men and women with a personality disorder and/or mental health issues in both a low secure and locked environment.

St Andrew’s Healthcare Essex location has been inspected 7 times.

St Andrew’s Healthcare Essex location is registered to provide the following regulated activities:

Treatment of disease, disorder or injury
Assessment or medical treatment for persons detained under the 1983 Act

Our rating of this location went down. We rated St Andrew’s Essex as inadequate because:

The service did not always provide safe care. Patients had no access to nurse call systems so that patients could summon help if required.
The service did not ensure staff had easy access to resuscitation equipment. We were not assured that staff could access resuscitation equipment in a timely way in an emergency.
Patients were not always removed from seclusion at the earliest opportunity. The seclusion room on Danbury ward was out of use due to a broken monitor.
Staff did not always follow the National Institute for Health and Care Excellence guidance when using rapid tranquillisation.
Observations were happening at predictable intervals and staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk of harm to themselves or others.
Managers did not ensure a rehabilitation model was embedded on Maldon ward. Staff were not aware of a rehabilitation model and managers acknowledged changes were required to embed a model of rehabilitation on the ward. Patients on Maldon ward did not have access to employment and educational opportunities and did not receive regular psychology sessions to support them in their recovery. The service managed activities offered by occupational therapists and technical instructors across the whole service to ensure activities were available to patients according to individual need and presentation. However, activities offered on some wards were limited. Patients could not all access the kitchen on the wards, could not independently access drinks and relied on staff to provide these.
Not all staff we spoke with on the forensic ward could demonstrate a good understanding of the Mental Capacity Act and at least the 5 principles.
Staff did not always support, inform or involve families and carers in patients’ care and treatment or give feedback on the service. Staff did not give carers information on how to find the carers' assessment. Relatives and carers did not all know how to complain or raise concerns. Managers did not always share outcomes from complaints with staff. Staff did not produce holistic, recovery orientated care plans that included goal setting and co-production with patients. Managers audited care plans, but this did not ensure improvements were made to the quality of care plans.

However

Staff on Maldon ward assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
Staff on the forensic wards developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
Managers ensured staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
Staff planned and managed discharge well and liaised with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.

We issued the provider with a warning notice telling the provider they had breaches of regulation in the following areas: no call bells in patient bedrooms for patients to alert staff in an emergency, staff were not complying with completing enhanced patient observations safely or in line with their policy, managers did not ensure a rehabilitation model was embedded on Maldon ward, patients on Maldon ward did not have access to employment and educational opportunities and did not receive regular psychology sessions to support them in their recovery.

St Andrew's Essex provides care for both men and women with a personality disorder and/or mental health issues in a low secure and locked environment.

We carried out this inspection in response to concerning information received through our monitoring processes.

We did not rate this service on this inspection. We found the following areas the provider needs to improve:

Patients were at risk of avoidable harm. Staff did not always assess and manage patient risks. Multidisciplinary teams were not always reviewing patient observation levels following risk incidents. Staff did not record all risks on one patient’s risk log. Staff did not always report incidents appropriately. We reviewed an incident where a patient had tied a ligature which was reported inappropriately.
The service did not have enough registered nursing and support staff to keep patients safe. Managers had not filled a third of registered nurse shifts and 15% of support staff shifts. Shift leads allocated staff to multiple roles, which impacted on staff’s ability to keep patients safe. Both staff and patients told us they didn’t feel safe.
Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk of harm to themselves or others. Staff were not completing intermittent observation records in line with the provider’s policy and procedures.
Staff did not always follow the Mental Health Act Code of Practice in relation to seclusion. Staff did not record the levels of observation accurately for a patient who was secluded for a long time. Staff had not completed the section on informing family, carers or advocacy about the seclusion and had not completed the seclusion room checklist prior to seclusion commencing.
Staff did not always treat patients with dignity and respect. We were concerned by some of the language used by staff in patient records. Staff recorded information that was judgemental and not a factual account. For example, following an incident involving a staff member being racially abused, it was recorded in the progress notes that the staff told the patient to ‘behave yourself’ and staff recorded that they told another patient to “stop playing up”. In addition, in response to an incident of self harm staff recorded in notes that they had told a patient “you’re an adult, deal with it”. The provider took appropriate action to deal with this incident.
The leadership, governance and culture did not always support the delivery of high quality, person centred-care. The provider’s governance processes had not addressed staff failures to follow the provider’s procedures on enhanced observations and allocation of staff tasks. Managers did not have sufficient oversight of key elements of the service that related to patient safety.
Managers did not always make notifications to the Care Quality Commission when safeguarding incidents occurred. We reviewed a random sample of six safeguarding incidents, involving physical abuse between patients and managers had failed to notify any to CQC.

However:

Staff and patients told us they had been offered support and debriefs following a recent serious incident.
Staff reported that learning from incidents was shared through ‘red top alerts’. Managers displayed hard copies in the ward offices.

We rated St Andrew’s Essex as good because:

All ward areas were clean and well maintained; equipment was well maintained and safety tested, cleaning records were up to date and demonstrated regular cleaning of ward areas.

There were designated quiet areas on all wards and there was a visitor’s room near the hospital entrance that could be used for patients to meet with family and friends.
There was a phone room on all wards to facilitate patients making calls in private.
Patients were given a welcome pack on the psychiatric intensive care wards, which contained essential items for hygiene and enhanced their wellbeing.
Shifts were covered by sufficient numbers of staff with the right grades and experience.
Staff told us that morale had improved recently and attributed this to new members of the leadership team.
Staff told us they felt well supported by managers.
There were flexible working arrangements available for staff.
Staff and visitors had access to personal alarms. The provider had simplified their staff recording system since the last inspection and for the majority of shifts; staffing numbers matched those on the rota. Shifts were covered by sufficient numbers of staff with the right grades and experience. Staff told us that they were able to maximise their time on direct care activities as opposed to administration duties. There was a full range of mental health professionals available to deliver care.
Staff we spoke with knew what incidents to report and used electronic recording system to report incidents. Staff were open and transparent and explained to patients when things went wrong. Staff told us they received feedback from investigation of incidents at team meetings and in managerial supervision. There was evidence that changes had been made as a result of feedback.
Patients we spoke with told us staff were kind and treated them with dignity and respect. Carers we spoke with told us that they were pleased with the care their relative received.
Care records were up to date, personalised, with holistic recovery-orientated care plans.
Prescription charts showed that staff followed National Institute for Health and Care Excellence guidance for prescribing medication. The pharmacist had written the percentage of medication prescribed to help staff remain within British National Formulary limits and reduce the risk of multiple medications being prescribed for the same problem.

However we found the following areas that the provider needs to improve:

There were high levels of the use of prone restraint across the hospital, particularly in the psychiatric intensive care services. Whilst the provider had set out measures to reduce levels of seclusion and restraint these measures had not yet had significant effect.
The external door to the garden from the extra care suite on Audley ward was clear glass and therefore visible from the garden. This compromised patients’ privacy and dignity. This was raised with the provider who agreed to address the issue.
The fridge lock in the clinical room on Audley ward had been broken. The provider had sourced a new lock and was awaiting fitting of the new lock at the time of the inspection.

For two of the seclusion records reviewed the front sheets were incomplete. The nurse in charge had not signed them before uploading to the electronic record.
For one patient the gap between medical reviews whilst in seclusion was longer than the four hours recommended by the Mental Health Act 1983: Code of Practice.

We rated St Andrew’s Essex as ‘requires improvement’ because:

The provider had not included all ligature points in their ligature risk assessments.
Staff did not always record or manage seclusion and long term segregation in accordance with requirements of the Mental Health Act (MHA) code of practice.
The provider had limited rooms or quiet areas on some wards for care and treatment. Staff regularly transferred patients between wards in order to access safe areas to manage disturbed behaviour. Staff transferred patients between wards via lifts or staircases during periods of agitation. This was a risk to patients and staff.
Wards had limited space for patients to meet visitors in private.
There was a delay in replacing curtain rails and other repairs on wards, affecting patients’ privacy and dignity.
Staff had not fully completed an evacuation care plan for a disabled patient and the required evacuation chair, for use in an emergency, was not available.
Medication management/prescribing was not always reviewed in a timely manner.
Staff were not always aware where to find information in electronic patient records. This meant there may be a delay in finding up to date information.
The provider had discrepancies in their staff rotas. Records did not always accurately reflect the staffing on duty.
The provider did not have consistent records of management supervision. Management supervision records were inconsistent and poorly documented.
Some staff had reported experiencing racial abuse and felt that managers had not responded appropriately to their concerns. However, the provider was able to demonstrate issues of racial abuse were investigated. The provider supplied data that showed from 01 April to 21 September 2016, there were seven recorded accounts of verbal racial abuse. The data also showed that managers addressed incidents at a local level in discussion with staff, with peer support and through reflective meetings. Staff were encouraged to report these incidents to the police. The provider’s workforce race equality standard (WRES) action plan provided showed the provider monitored incidents of verbal abuse of staff through the electronic reporting system.

However:

Patients spoke positively about staff and told us they felt safe on the ward and staff were available to support them. We saw good rapport between staff and patients, positive staff and patient interaction and individual support.
The provider supplied specific ‘yellow boxes’ for staff use in an emergency, for example, ligature cutters. This ensured staff could respond quickly to patients in an emergency.
The provider operated a ‘safewards’ initiative on Hadleigh Ward. We saw this had a positive impact on patient care.
Staff were aware of their individual responsibility in identifying safeguarding concerns and reporting these promptly.
Staff kept accurate and detailed patient records. Care plans were detailed and showed both patient and multidisciplinary team (MDT) involvement.
There was effective MDT working. Patients had opportunities to get involved in hospital governance for example in the monthly patients’ forum.
Cleaning records were up to date and we saw evidence that regular cleaning and audits were taking place.

We carried out an unannounced focused inspection of St Andrews Healthcare, Maldon Ward, on 31 March 2015 due to concerns that were raised with the Care Quality Commission. During the inspection we found that:

The provider had high levels of staff vacancies. This meant the provider used a high rate of bank and agency staff. The provider did not employ regular bank and agency staff to ensure continuity of care for patients. A patient told us the permanent staff treated them with kindness, consideration, and compassion. However, the agency staff did not always treat them with dignity and respect

The provider did not keep accurate or accessible duty rotas. Duty rotas were duplicated in three different records, some of which were not accessible to ward staff. This meant staff could not be sure who was expected on duty or whether shifts had sufficient staff for safe care and treatment for patients.
Staff cancelled patient’s section 17 community leave due to staffing shortages. Section 17 leave is a controlled, discretionary period of leave given to a person detained in hospital under the MHA. Medical staff granted leave to patients to allow them to access activities, and appointments, and to support their recovery.
Staff did not always update risk assessments following incidents. Staff recorded incidents on the electronic record system but did not update risk assessments and care plans when risk changed. This meant that staff did not have up to date information to provide safe care for patients. The provider had carried out an environmental risk assessment. However, this did not fully address risks presented by blind spots where staff could not observe patients

The seclusion room was located on the first floor, which meant that staff have difficulty safely accessing this facility in an emergency.

However

Patients had access to an advocacy service. There was information about the advocacy service displayed on posters in the ward area.
Staff managed seclusions in line with The Mental Health Act code of practice. Doctors were attending within an hour to review patients.
Patients were involved in developing their care plans. A patient told us they attended regular review meetings where their care plan was reviewed. They had received a copy of their care plan.
The ward environment was clean and tidy and the furnishings were in good condition. Staff completed cleaning audits that were up to date.

Overall we found that improvements were required as the services provided were not always safe. Actions from ligature audits were not followed through on one ward and care and treatment records were incomplete in respect of one person’s physical healthcare needs. This meant that people may be at risk of unsafe care and treatment.

There were systems in place to ensure an effective service. Surveys and audits measured the quality and effectiveness of systems.

The services provided were caring. This was confirmed by our observations of the care and treatment being provided and subsequent discussions with staff.

The services provided were responsive. Evidence was seen that demonstrated to us that the provider encouraged feedback from people and staff to influence the running of the service.

The services provided were well led. Most staff told us that they felt supported. Staff across all of the wards inspected told us that there were difficulties with the recruitment and retention of staff. We found that there was widespread use of bureau (St Andrews healthcare staff) and agency staff on the wards inspected.

Easton Lodge