Archived: Mundesley Hospital

CQC first inspected Mundesley Hospital in September 2016. Following that inspection, we rated the service as inadequate. Due to our concerns, we issued the hospital with a warning notice and placed it into special measures. CQC carried out a focussed, unannounced inspection of the hospital in January 2017 to check on progress against the warning notice and to look at some additional concerns that were raised with CQC.

In June 2017, we carried out a further announced, comprehensive inspection to reassess the service six months after we decided to place it into special measures. During this inspection we reviewed progress against the warning notice and the requirement notices. Although we found that the service had addressed some of our previous concerns, we have once again rated Mundesley Hospital as inadequate. This is because:

• We identified a serious incident where staff did not report an incident of restraint through the hospital reporting system.
• This matter was also not reported to safeguarding. We could not be assured that staff were transparent in alerting the hospital’s management or external bodies about incidents.
• We saw evidence of a culture where staff did not always respond to patients’ needs. For instance, we saw several staff eating breakfast whilst a patient waited to enter the dining area. We saw several different staff ignore a patient who knocked at the office door.
• The hospital had an informal feel and staff spoke of a family environment. There was some evidence that the informality bordered on poor conduct, with some staff lacking a professional approach. Some patients complained of staff gossiping about each other in front of them.
• Some patients commented on the difference between the care they received during the day and the night. They reported that at night, staff were not as caring and were less approachable.
• Four patients reported that staff sometimes fell asleep on duty when they were meant to be observing the patient.
• We saw inconsistencies in documentation of enhanced observations on the recording sheets. This meant we could not be sure that the staff carried out observation entries in a timely manner. This also fuelled concern that observations may not have been carried out according to policy. Failure to carry out observations could result in harm to the patient. We raised this with senior managers following the second part of the inspection.
• We found one box of medication that staff had not labelled correctly. Staff had written the name of the medication on the box stating the tablet strength was 2.5mg. We checked the contents and the box held 5mg tablets. This may have resulted in an administration of medication error. This box had been in use for a period of time and this had not been identified through audit. We raised this concern with the provider immediately for investigation and action.
• We saw that staff requested all patients complete a permission form to carry out a body search regardless of their individual risk at admission and following leave from the hospital.This practice meant staff searched patients without considered reason of individual circumstance or risk. Following a serious incident the hospital advised the inspection team of a change of process to ensure only patients with known risk were searched following leave.  Patient records did not clearly state if searches carried out were due to known risk. The provider continued to carry out body searches at admission.
• There was no access to any kind of psychology service. We did not see evidence of any other psychology support such as staff trained in DBT (dialectical behaviour therapy), art therapy or psycho-educational therapies.
• The provider failed to provide CQC with accurate pre inspection information about staffing. For example, the provider submitted information that there was a vacancy rate of just under 2% for registered nurses. During inspection we saw a vacancy rate of over 80%.  
• During inspection the hospital provided figures of 90% compliance of supervision. Staff records we reviewed did not support this.
• There was a serious incident of self-harm on the ward. This incident was reported by front line staff. The detail within the verbal account provided during the inspection was misleading. We challenged the provider who acknowledged that incorrect information had been given.
• Areas of risk to patients were not being managed effectively by the organisation. For example, the provider had not proactively identified areas of poor practice identified throughout this report. Internal audit and management systems had not identified areas of poor practice and how the service could improve.

However:

• The hospital had addressed most of the concerns raised in the warning notice issued following the inspection in January 2017.
• Admission paperwork was completed, physical health needs were assessed, identified and plans were in place to address patients’ needs.
• We saw evidence of contingency and crisis planning with most patients.
• Contemporaneous notes were in order, mostly legible and showed patient progress.
• We saw an excellent handover. The staff conducted it in a careful and considered manner, identified patient need and highlighted areas of risk while describing the management plan.
• Managers had introduced a system to ensure that staff reviewed incidents and learned lessons.

CQC carried out a focussed unannounced inspection of Mundesley hospital on 12 to 13 January 2017. This inspection concentrated on reviewing progress against a warning notice and requirements notices following a comprehensive inspection of the service in September 2016.

At this inspection we found that:

• The risk management process remained incomplete. Staff did not identify all risks; therefore, not all risks were addressed in the care plans.
• Staff did not routinely carry out assessments on admission and this meant that staff did not identify all the physical health needs of patients.
• Where a patients physical or mental health needs changed there was limited evidence of review.
• Where staff identified the need to monitor a patient’s food or fluid intake, there was a lack of review of the information or subsequent action taken.
• There was limited evidence of individual risk assessment taking place prior to a patient going on Section 17 leave.
• Rapid tranquilisation forms were in place but one was missing. Staff had not noticed this when using the provider’s own internal audit.
• Staff did not always record physical health observations following rapid tranquilisation. A patient’s physical health can deteriorate following this treatment and it is essential to monitor patients’ physical observations to detect any deterioration in health.
• We identified that contemporaneous records were not accurate, and did not evidence patients’ progress. Information lacked detail and at times was repetitive.
• It was not clear from daily entries if the patient was detained or informal. There was no evidence of how staff implemented care plan goals. Staff did not record decisions regarding a patient being on enhanced observations nor was there a daily review of enhanced observations by the doctor. Enhanced observations are designed to increase support to the patient in acute times of distress where staff have assessed that the patient is at increased risk of harm to self or others.
• There was no audit in place to monitor the quality of entries in patient records. However, the manager did evidence plans for staff to receive training regarding record keeping.
• Managers were developing audits of clinical systems. However, we identified several issues that had not been highlighted through audit.

However:

• We saw an improved system in place for reporting of incidents, restraint and rapid tranquilisation. Managers had begun to deliver training to staff on how and what to report as an incident. We saw evidence of improved reporting of incidents. The provider had introduced a system for capturing information from adverse events and had begun to use the information to learn lessons.
• 67% of staff had completed basic life support training that included the use of the defibrillator (AED). The provider had also identified intermediate life support training and had a plan for implementation.
• Gaps in signatures on medication charts had greatly reduced. We identified three gaps in administering creams, however the pharmacy had identified the errors, and the hospital had investigated.

• Managers had updated the hospital environmental risk assessment to include the identification and management of potential ligature risks. Further work was planned to continue to improve the safety of the environment.
• We identified a significant improvement in mandatory training figures. 84% of staff were compliant with their mandatory training.
• The provider had delivered training in the Mental Health Act and Mental Capacity Act. 72% of staff had received training in the Mental Health Act and 87% had completed training in the Mental Capacity Act. This was an improvement and further sessions were booked.
• Managers had updated the risk register, which now reflected clinical as well as business risks. Managers provided information on further planned improvements to procedures to manage organisational risk.
• During this inspection, we found that managers had implemented a system to ensure that staff reported notifiable promptly.

CQC will continue monitor the service whilst in special measures and a further comprehensive inspection will take place to assess all areas identified at the previous comprehensive inspection.