Archived: Tesito House

Updated 27 February 2019

Tesito House opened in March 2017 in the Ardwick district of Manchester, as a 24-bedded, high dependency, treatment and mental health recovery centre for women from the city. The service aim was to provide treatment and support for adult women with complex mental health problems by supporting and developing their skills, working through their rehabilitation and recovery pathway in a safe and comfortable environment. It was managed by Alternative Futures Group Limited. Tesito House at the time of inspection was registered for the following regulated activities:

• assessment or medical treatment for persons detained under the Mental Health Act 1983
• diagnostic and screening procedures
• treatment of disease, disorder or injury.

The service is developed around a patient’s prospective rehabilitation journey through the service’s three distinct eight-bedded clinical units. These were named after well-known local personalities. The admissions ward, Carol Ann Duffy ward, was the stabilisation ward. The recovery and therapy ward was Erinma Bell ward. The step-down unit, Marie Stopes, was made up of a series of eight self-contained apartments.

The Care Quality Commission last carried out a comprehensive inspection of this service in March 2018. At this inspection, we rated the service as ‘inadequate’ overall with ratings of inadequate for safe, effective and well led key questions and requires improvement for caring and responsive key questions. Following the inspection, we placed the service into special measures. Since then, the service had not been accepting any further admissions.

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.

At the March 2018 inspection, it was found that the provider was in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took regulatory action in line with our enforcement powers by issuing warning notices in relation to:

• Regulation 12; safe care and treatment because the service did not have appropriate management plans in place for managing risk to all individual patients.
• Regulation 17; good governance; because the systems and process in place did not ensure the provider could assess, monitor and improve the quality of care and treatment it delivered. Not all patients had an up to date care plan or physical health monitoring, and all patients did not have the correct legal documentation attached to their medication records.

We also issued four requirement notices advising the provider of a number of improvements we required it to make.

During this inspection it was found that some of the regulatory breaches identified during the last inspection had been addressed. However, a number of breaches and areas for improvement which we had also highlighted at the time of that inspection continued to be reviewed and developed by the service.

At the time of the inspection there were eight patients at the service of whom seven were detained under the Mental Health Act and one was an informal patient. Tesito House works in partnership with the local NHS Trust who provide Mental Health Act administrative support, therapy and pharmacy support, the consultant psychiatrist and the out of hours service.

Updated 27 February 2019

We rated Tesito House as Inadequate because:

• In 2018, we placed the service into special measures because the provider did not ensure patient care was being delivered to the highest standard possible, patient assessments were not complete, shortcomings were not promptly identified and rectified. At this re-inspection we found a number of areas of concern raised in our previous inspection had not improved.
• Safety was not a sufficient priority. Measurement and monitoring of safety performance with regards to the use of restrictive practices and the safe proper management of patient medication was poor.
• Systems, processes and standard operating procedures were not robust and regularly reviewed to keep patients safe.
• Staff did not have access to training and development to enable them to meet the needs of patients. The learning needs of staff were not understood. Staff were not supported to participate in training and development or the opportunities that were offered did not meet their learning needs.
• Patients were not supported to understand information they were given about their care and condition. Staff did not consistently provide clear information to patients or give them time to respond.
• Discharge and transition planning was not timely, was not done in partnership with patients and did not consider all of the patient’s needs.
• Governance systems and processes were not effective and did not give the service oversight to ensure the standard of care and treatment was maintained. There was no process in place to review key items such as the strategy, values, objectives, plans or the governance framework. The impact of service changes on the quality of care was not understood.
• Notifications were not submitted to external organisations in a timely manner.
• There was no evidence of learning and reflective practice. When concerns were raised or things did go wrong, the approach to reviewing and investigating causes was insufficient or too slow. There was no evidence of learning from events or action taken to improve safety.
• The service operated with a number of blanket restrictions in place which were not individually risk assessed or care planned.

However:

• Patients were regularly being assessed and their individual strengths, problems and needs were being identified and documented.
• The service kept detailed risk assessments and management plans which were updated when patients’ presentations changed and actions taken accordingly.
• Comprehensive physical health provision was available to patients to monitor and review their physical health and wellbeing.

Updated 27 February 2019

See detailed findings.