The Care Quality Commission
  • Mental Health
  • Independent mental health service

Archived: Bloomfield Court and 5,6 Ivy Mews

Overall: Inadequate read more about inspection ratings

69 Bloomfield Road, London, SE18 7JN (020) 3260 3099

Provided and run by:
Liaise (London) Limited

All Inspections

3 and 4 August 2016

During an inspection looking at part of the service

The previous comprehensive inspection of Bloomfield Court and 5, 6 Ivy Mews took place on 29 September and 1, 7, 8 and 15 October 2015. CQC rated the service as inadequate overall. We told the provider, Sequence Care Limited, to make immediate improvements and the provider agreed not to admit any new patients.

We published the report of that inspection in April 2016 and placed the service in special measures. The aim of placing a service in special measures is to ensure significant and timely improvements are made to the quality of the service in order to reduce risks to patients. The provider developed an action plan to improve the service. The CQC has worked in partnership with stakeholders to oversee the implementation of the action plan.

CQC carried out this unannounced focused inspection to check if the provider has made sufficient improvements to the service and whether further action was required in line with our enforcement powers. As this was a focused inspection we did not rate the service.

At this inspection, we found the provider had made some improvements to the service in response to our previous findings. However, overall these changes were not sufficient for CQC to take the service out of special measures. We were concerned that the provider’s governance arrangements were not sufficiently robust to independently identify risks and act swiftly to make improvements.

Since the last inspection, commissioners had arranged for several patients to be discharged from the service. At this inspection the number of patients using the service had reduced to seven from the 15 who were using it at our last inspection. The provider had not significantly reduced staffing levels. Consequently, there was now a higher ratio of staff to patients. Staff had the opportunity to get to know patients better.

Since the last inspection, the provider had made some changes to the premises and improved the appearance of communal areas. However, at this inspection we found that patients’ bedrooms and bathrooms were not well maintained or kept clean.

Since the last inspection the provider had undertaken an active programme of recruitment. However, some recently recruited staff, such as a registered manager and a clinical psychologist had since left the service. There was evidence of more consultant psychiatrist input to the service in the two months before this inspection and the frequency of multidisciplinary meetings had increased.

At this inspection we found some evidence that overall staff were responding more appropriately to incidents of challenging behaviour. However, there were inconsistencies in relation to record keeping about incidents of challenging behaviour. This meant we were unsure about the actual frequency of incidents.

There had been improvements in the completion of training at the service with rates of staff completing courses in managing restraint at 85%, understanding the Mental Capacity Act at and DoLS at 91% and adult safeguarding at 92%. There were sound arrangements to track the progress of safeguarding referrals and the take up of training. Handover arrangements between shifts had improved and records of these showed key issues were noted and acted on. The meals on offer to patients had improved and included healthy options.

Record-keeping processes were complex. There were inconsistencies in the way information was recorded which meant it was unclear what the actual facts were in relation to patients’ physical health. Although a GP was now undertaking physical health checks we could not be certain from the information available that these checks were appropriately tailored to each patient and sufficiently comprehensive. Care plans did not always include goals for patients which could be easily measured so it was difficult to monitor patients’ progress in the service. The provider had ensured that patients now had discharge plans.

We have taken action in relation to the breaches of regulations found at this inspection.

29 September, 1, 7, 8 and 15 October 2015

During a routine inspection

The CQC is placing the service into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made, and there remains a rating of inadequate overall or for any key question, we will take action in line with our enforcement procedures. We will begin the process of preventing the provider from operating the service. This will lead to cancelling the providers' registration at this service, or varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration

We rated Bloomfield Court and 5, 6 Ivy Mews as inadequate because:

  • There were a high number of incidents of violence in the service that staff did not always report. There were also a high number of patient restraints. Fewer than half of the staff had undertaken training in approved restraint techniques.
  • There were not enough qualified nurses on duty in the service. The provider had not filled a significant number of bank and agency shifts. Forty percent of staff had left the service in the previous year.
  • Most care plans were not specific or detailed, and did not meet all of the patients’ needs. Patients were not involved in the development of their care plans. Staff did not support patients appropriately to make decisions about their care or treatment.
  • There were low completion rates of staff training. Staff did not have the skills needed to meet patients’ needs.
  • The wards, and Ivy Mews, were not clean or well maintained and appeared institutional. The environment did not promote comfort and recovery.
  • There were no ligature-free fixtures in some patients toilets and bathrooms. The entrance gate and doors to the service were not secure.
  • Some staff did not know how to respond if they observed or heard about poor care, neglect or abuse. Referrals to the local safeguarding team were delayed by staff.
  • One patient had been deprived of their liberty without lawful authority for almost 18 months. Another patient’s care constituted long-term segregation. This patient did not have multidisciplinary reviews in accordance with the Mental Health Act Code of Practice.
  • Two patients had been in the service for four years. There was little progress in their care and treatment and no clear discharge plans.
  • The systems and processes in the service were not effective. They did not effectively assess, monitor and improve the safety and quality of the service.
  • The service had five managers or acting managers in the three years before the inspection. There was a lack of clinical and non-clinical leadership in the service.
  • The management team were out of touch with day-to-day events in the service. There was little understanding of the extent of the improvements needed.
  • We informed the provider of our serious concerns regarding the safe care and treatment of patients - Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider voluntarily made a commitment to stop all admissions of patients to the service immediately until all areas of non-compliance had been resolved. The provider also produced an action plan. The Care Quality Commission will monitor the progress of the action plan closely.
  • We identified concerns regarding other areas of the service. We have taken action regarding these concerns.

12 November 2014

During a routine inspection

During our visit we spoke with six people who use the service and a minimum of ten staff of different disciplines which included the hospital manager, deputy and assistant managers, nurses, occupational therapist, healthcare assistants (known as rehabilitation facilitators) and psychology assistants. We also received feedback from some external health and social care professionals involved with people who use the service.

The majority of people who use the service said they liked the hospital and that the staff were kind and caring. The staff conveyed a thoughtful and empathetic approach when they spoke about peoples needs and the support they required.

The care plans were individualised to each person and took into account their needs and any safety concerns. However, we found there was a lack of discharge planning with some people identified to move on from the service.

People were supported to prepare and eat a variety of foods that they enjoyed, and which took into account their different needs.

The use of space within the hospital was limited and did not encourage individual work with people who use the service. Some health and safety checks were carried out, but the lack of frequent and consistent checks of the fire systems put people who use the service at risk.

Staff did not receive appropriate training and supervision in their work, which put people who use the service at risk of being inappropriately supported by staff.

24 January 2014

During an inspection looking at part of the service

We found the provider had made improvements to ensure that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. The provider had made improvements to ensure that people's medication was appropriately agreed, administered and checked. Complaints were properly recorded and appropriate action was taken to investigate, and where required make changes to improve the service. Record keeping was well managed, with appropriate records of involvement of people and their representatives in their care and treatment being maintained.

20, 21 June and 2 July 2013

During an inspection looking at part of the service

This inspection was supported by colleagues from the Mental Health Act Commission and the Care Quality Commission pharmacy inspection team.

15 people lived at the hospital and three people told us staff were respectful of people's rights. For example two people explained that staff listened to them and respected their privacy, supporting them to go out and sometimes getting voluntary employment. People were involved in day to day activities, for example in making snacks, planning shopping and doing their laundry. There were activities for people to do and people were encouraged and supported to take exercise and work towards going out independently.

People were not fully supported to be supported to consent to care and treatment for example in agreeing to some behavioural control medication.

Care planning and reviews took place regularly with involvement from people who used the service and care plans were agreed by people who used the service or their representatives. Five people we spoke with who lived at the home confirmed this to be the case. The staff understood people's care needs and how to protect them from risk and harm, however monitoring and logging of medication was not appropriately managed.

Appropriate accommodation was provided. People understood their rights to make complaints but these were not always responded to appropriately. Care records for people who used the service could not always be located promptly when needed.

15 March 2013

During a routine inspection

We visited three units at the hospital during our inspection and spoke with four people who use the service. People using the service told us they were happy with the care and treatment they received. One person said: "Things have gotten better for me in the past year and I am able to go out more and do things I like to do". People using service said there were enough staff and they were available and helpful. Staff did activities with people such as going out in the community, cooking and sport and exercise, and gaining work experience. Three people said there were activities regularly available that they liked.

People were involved in planning their care and where necessary the code of practice for depriving people of their liberty was followed. Staff we spoke with understood people's care needs and how to protect them from risk and harm.

We found that staff had adequate training and were supported by the management to do their job. Staff we spoke with said the management were supportive and the training was good. Staff supervision and training was up to date. The provider used effective systems to regularly check that care was being provided safely and appropriately. However all of the documentation about people's care was not always up to date and accurate.

The Mental Health Act Commissioner had visited the service on 21 February 2013, and produced a separate report which focuses on the experiences of people detained at the service.

19 April 2012

During an inspection looking at part of the service

Some patients told us that they had been asked about things they liked to do by staff and their views were included in their care plan. Three patients told us that they had copies of their care plans and that they were able to talk about things they wanted to do at meetings they attended.

Some patients told us that they understood that the hospital was locked and they could ask to go out when they wanted to with staff.

We saw patients speaking freely with staff and with each other in a relaxed manner in communal areas and in the new activities room.

20 October 2011

During a themed inspection looking at Learning Disability Services

There were six patients at the hospital when we visited. We met and introduced ourselves to all six patients and spoke in more depth to three patients to get their views of the service.

A patient told us that they were bored and that they wanted to go out of the hospital more often and be more involved in activities such as cooking meals. The patient told us that staff treated him like a child. He was not happy about this.

A patient told us that they had missed a dental appointment because there had not been enough staff on duty to take them. This could have negative impact on their oral health.

The relatives we spoke with told us that they were satisfied with the service and were pleased to have their relatives closer to home. One relative told us that they find the manager approachable.