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Inspection Summary


Overall summary & rating

Inadequate

Updated 21 July 2017

We are placing Watcombe Hall into special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to 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 Watcombe Hall as inadequate overall because:

  • The provider had not undertaken all of the actions that we told them take following our inspection in February 2016. It had not ensured that all staff had access to appropriate and regular supervision and appraisal. The provider had not ensured that staff were following up physical health observations systematically when young people declined physical health checks. There were gaps in recording of physical health observations and lack of monitoring. The provider did not consistently meet its own policy to respond to complaints within 25 days. Although the provider had reviewed what restrictions should be placed on all patients regardless of their individual risk, staff were still being inconsistent in applying these ‘blanket restrictions’. We found issues around section 17 leave, consent and capacity and section 62 urgent treatment orders and delays in requesting second opinion appointed doctors to review the medication of people detained under the Mental Health Act.
  • Following our inspection in February 2016, we had the rated the services as requires improvement overall but with a rating of good for caring, responsive and well led. During our follow up visit in May 2017 we were concerned enough to re-inspect all the key questions. We changed the rating in safe and effective from requires improvement to inadequate and well led and responsive from good to inadequate. The rating for caring was changed from good to requires improvement.
  • The leadership of the service was not robust. The unit manager and clinical manager were both off work and there was confusion and speculation amongst staff and young people about the long term management of the unit.
  • There were a high number of incidents in the service; including 18 serious incidents in the first three months of 2017. This has led to 38 staff injuries in the previous six months, staff feeling overwhelmed and staff leaving the service. Young people said they did not feel safe.
  • New and agency staff had not completed an induction and staff had not had regular supervision and training. Some staff said they did not feel confident to carry out their role. Stakeholders were concerned about staff training and staff consistency.
  • Young people were not attending regular education and therapy sessions. The service was ‘firefighting’ from one incident to another and as a result young people were bored and under stimulated.
  • Governance processes had not alerted the provider in a timely manner that the service was deteriorating.
  • We were concerned that the service was not meeting Regulations of the Health and Social Care Act (Regulated Activities) Regulations 2014. We issued a letter of intent to advise the provider of p
  • The provider sent an action plan within the agreed timescale.
  • The provider voluntarily closed the service to admissions in agreement with us and in liaison with NHS England on 11 May 2017.

The letter of intent identified the following issues:

  • Watcombe Hall was not safe and the impact of multiple issues had affected the safety of the unit for children and young people and the staff.

  • There were 354 incidents involving restraint in the last six months.

  • Patients were at risk when staff responded to incidents and had been left unobserved or had attended the incident with the member of staff.

  • There were 38 staff injuries in the last six months.

  • There was a lack of formal debriefing following incidents

  • Staff turnover impacted on the quality and consistency of the care being delivered to children and young people.

  • New staff were not adequately trained, inducted and supervised.

  • Access to fresh air for young people was overly restricted and some young people were not going outside on a day to day basis. There was also a lack of therapeutic activities.

We asked the service to take immediate action on the following:

  • To deploy sufficient, appropriately trained and competent staff for the safe management of the unit.

  • To ensure sufficient observations of the young people to ensure they were not left unattended or required to accompany staff attending to incidents involving other young people.

  • Ensure that the environment was safe. This included addressing the PICU fence, external doors and access to upstairs bedrooms.

  • Ensure young people had regular access to fresh air and exercise.

  • Ensure all young people to received timely appropriate care and treatment including for their physical health needs.

  • We also required the provider to send us a daily update of any incidents and to provide assurance that any staff on duty had completed an appropriate induction and training.

The provider voluntarily closed the service to admissions in agreement with us and in liaison with NHS England on 11 May 2017. On 19 May, the provider submitted an action plan which confirmed that the provider had taken action to address the immediate safety issues. The provider has submitted regular action plan updates since this inspection.

We made six requirement notices for the provider to address which are detailed later in the report.

Inspection areas

Safe

Inadequate

Updated 21 July 2017

We rated safe as inadequate because:

  • Due to recruitment challenges, staff turnover and sickness, there were significant numbers of agency staff working in the service. This meant that some staff did not know the young people well, which impacted on the consistency of care. Also young people were not all having their one to one sessions regularly with their named worker.
  • Young people did not feel safe, such as when staff left the ward to attend to incidents.
  • The environment was not safe. For example, the fence in the psychiatric intensive care unit (PICU) garden was not fit for purpose and had led to the garden not being used regularly. Young people were seen climbing over the fence during the inspection.
  • Staff injuries were high with 38 injuries in the last six months.
  • There had been a number of serious incidents which included overpowering staff to gain keys, forcing locked external doors and absconding. Staff felt very overwhelmed and young people said they did not feel safe.
  • Staff and young people did not receive a formal and timely debrief after an incident
  • There were 254 recorded incidents of restraint in the last six months. Agency staff were not trained in restraint and breakaway techniques.
  • Maintenance was not timely. For example, graffiti had been reported in the maintenance book but had not been repainted until the week before the planned inspection.
  • The rapid tranquilisation policy was out of date and did not reference National Institute for Health and Clinical Excellence guidance.
  • Room temperatures and fridge temperatures were not consistently recorded.
  • Some stock medication and syringes in the emergency equipment bag were out of date and medicines were not always ordered in a timely way, including leave medicines.
  • The dispensing of medication when young people went on leave did not comply with the service’s medicines policy.
  • Some practices were over restrictive and there were inconsistencies around blanket restrictions. For example, information given to young people about when they could go to their rooms and access to fresh air. This was a requirement notice at the previous inspection in February 2016.
  • Twenty seven staff (50% of the eligible staff) did not have up to date level three safeguarding training, which was mandatory.
  • Staff were not clear about making a safeguarding alert. This had resulted in referral delays to the lead safeguarding authority.
  • There were delays in capturing information on incidents and only 39% of staff were trained to use the electronic incident recording system.
  • There was inconsistent practice around use of personal alarms and some staff did not know how to use the alarms.

However:

  • In March 2017, the provider conducted a safe staffing review and raised the staffing levels. Numbers had recently increased to ten staff in the day and eight at night. A minimum of two qualified nurses on shift at all times supported the high level of observations.
  • The provider was working closely with the local authority and NHS England to improve safeguarding and a protocol was in the early stages of implementation.
  • The provider had increased the number of block contracts with agency staff to improve consistency.
  • Core training for agency staff had been arranged that included minimum restraint training and breakaway techniques.

Effective

Inadequate

Updated 21 July 2017

We rated effective as inadequate because:

  • Young people did not receive timely appropriate care and treatment including for physical health needs. Physical observations were not consistently recorded or monitored.
  • There were gaps in their recording of fluid and food charts for young people with an eating disorder.
  • Access to education and psychological therapies was limited and young people were frequently failing to attend these sessions.
  • The main electronic record system did not contain all the relevant information. Information was stored on paper files and some on the hospital electronic drive.
  • Comprehensive admission assessments were not completed for young people being admitted
  • Care records did not have full multidisciplinary input, including medical and psychology.
  • Newly recruited staff and agency staff had not completed induction and did not have the appropriate knowledge for working in this setting.
  • Staff had not received any specific training in the safe management of young people with an eating disorder. Staff raised their lack of knowledge about eating disorders as a concern during the inspection.
  • The multi-disciplinary team were not working well together and the communication with the education team was not effective.
  • Some staff had not received a recent appraisal or supervision. This was highlighted as an area of concern in the previous inspection.
  • Understanding of the Mental Health Act (MHA) was a requirement notice at the previous inspection in February 2016.There remained concerns in how the MHA paperwork was recorded.
  • Requests for second opinions from second opinion approved doctors (SOADs) were not always prompt. A SOAD is an MHA approved doctor qualified to give a second medical opinion for patients detained under the MHA.
  • Use of section 62 for the administration of emergency medication did not fully adhere to the MHA and MHA Code of Practice. For example, a rationale for using a section 62 for the administration of emergency medication under restraint was explained but section 62 forms also listed dosage of regular medication to be given.
  • Patients and carers were not routinely given section 17 leave forms when young people who were sectioned were given authorised leave. The management of section 17 was inconsistent. Leave was sometimes restricted or cancelled and there was confusion around ‘earning back’ leave following incidents.
  • We also found gaps in consent recording for young people who were detained. For example, out of seven records there was no documentation for patients to detail whether they had capacity to consent to their regular medication and whether they gave consent to take this medication.
  • Some staff (41%) were not up to date with Mental Capacity Act training. We found that up to date with Mental Capacity Act training. We found that u

    nderstanding of capacity and consent amongst staff was mixed.

However:

  • The provider had introduced a new multi-disciplinary model of care to help ensure that all members of the multi-disciplinary team could work together with young people to meet their needs.
  • The provider had recognised the lack of engagement in therapy and low attendance at schools. A seven day weekly planner was in the early stages of implementation to improve compliance with therapy and school.
  • A staff supervision and appraisal plan to ensure regular supervision was in the early stages of implementation.

Caring

Requires improvement

Updated 21 July 2017

We rated caring as requires improvement because:

  • Young people told us they were concerned about their lack of privacy and dignity during bathroom support observations.
  • Young people told us they did not always feel involved in their care. A recent independent patient survey in January 2017 found that only 44% of young people felt involved in their care.
  • Carers reported a lack of involvement in their child’s care and communication issues, such as a lack of response to communications at times.

However:

  • Most carers and young people reported that staff were friendly, kind and respectful.
  • All young people said they saw their advocate regularly and knew about how to access advocacy services.

Responsive

Inadequate

Updated 21 July 2017

We rated responsive as inadequate because:

  • The service did not clearly identify when it was unable to meet the needs of young people referred to the service. This was due to them not receiving accurate information when the young person was referred, not undertaking their own robust assessments and not feeling they could refuse to accept a young person. This had resulted in them struggling to care for young people whose needs could not be met within that environment.
  • The service had a range of facilities that were under used. For example, the purpose built gymnasium had not been used since August 2016.
  • Staff and young people told us that young people did not have access to fresh air and to the garden on a regular basis. Staff did not record when the garden was used.
  • There was a lack of activity and a recent independent survey found that only 11% were happy with level of activity at weekends.
  • All the young people we spoke with told expressed dissatisfaction with the meals and the choice of meals provided.
  • Young people told us that they were bored and did not have enough to do particularly during the evening and weekends.
  • Not all carers knew how to complain and one carer told us that when they contacted staff to ask how to complain they were not responded to.

However:

  • Young people were aware of how to complain and the advocate supported young people to make complaints.

Well-led

Inadequate

Updated 21 July 2017

We rated well-led as inadequate because:

  • At the time of the inspection the service did not have a stable leadership team although interim arrangements had been put into place.
  • Governance processes had not been sufficient to alert the provider in a timely manner of the serious concerns and provider action through the improvement team had only recently been taken.
  • Staff morale was low. There was uncertainty around the arrangements for the management of the service. The absence of the registered manager and nurse manager had exacerbated this.
  • Recent high levels of incidents, staff injuries, sickness and turnover had left staff with little job satisfaction and feeling of empowerment.
  • Governance systems were not working effectively and results of audits were not followed up. For example, no action had been taken from medication audits that showed issues in ordering leave medicines, checking equipment and recording temperatures.
  • Clinical governance was not effective in monitoring adherence to agreed plans. For example, reviews of the recording of vital patient observations did not regularly take place so it was not clear how often some young people were eating and drinking.
  • Policies were out of date, such as the rapid tranquilisation policy.

However:

  • Staff and management were open and transparent about where things had gone wrong and were working hard to improve. We received assurance that the improvement team had taken immediate action and improvements included an increase in staffing, staff supervision and appraisal and training for the staff following our inspection.
  • A full time interim manager was in position and was receiving an induction. Staffing levels had been increased to safe levels.
  • The improvement team was working closely with the safeguarding authority to improve safeguarding.
  • Staff knew how to whistle blow and were able to raise concerns without fear of victimisation.
Checks on specific services

Child and adolescent mental health wards

Inadequate

Updated 21 July 2017