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Inspection carried out on 23 May 2017

During an inspection to make sure that the improvements required had been made

We found the following issues that the provider needs to improve:

  • The provider did not have effective systems and processes to identify issues in infection control and incident management. Staff displayed poor hand hygiene and infection control practices. They had not identified all risks in an infection control risk assessment and this did not contain sufficient information to manage and mitigate risks.
  • The provider had not taken timely and reasonable steps to assess, monitor and mitigate the risks to the physical health of a patient. Care and treatment records did not contain mental capacity assessments when making decisions about some aspects of physical health.
  • The patient risk assessment did not identify all risks and the risk management plan did not address and mitigate risks. Staff did not discuss risks at staff handover.
  • Care plans did not contain enough detail to reflect the care required and staff had not involved the patient in their development. Staff did not always follow the patient’s communication care plan. They did not have immediate access to the patient’s records, as these were stored in an office away from the suite.
  • In over half of the incidents of restraint used, it was not proportionate or in response to risk. Staff that reviewed incidents did not make recommendations, record actions or lessons learnt after incidents. The provider did not have effective systems to have oversight of incident management and did not identify these issues.
  • Not enough dedicated staff were available when needed and this meant that the patient had to wait staff to be available to enter the suite or get items that they needed. There continued to be limited input from some disciplines of the multi-disciplinary team.
  • The patient did not have privacy and dignity when using the bathroom or holding telephone calls.
  • The secure garden did not contain a shelter from adverse weather.
  • Senior management staff lacked understanding about the use and application of positive behavioural support. They acknowledged that they did not currently have any expertise in adaptive behavioural scales, applied behaviour analysis or positive behaviour support within their substantive staff.
  • The registered person did not speak respectfully when they described a patient and their needs.
  • Training in learning disability and personality disorder was not up to date.

However, we found the following areas of positive practice:

  • Since our last inspection in February 2017, the provider had installed a handwashing sink and a drain in the suite. They had arranged for an external hospital to review the long-term segregation every three months.
  • Staff entered the suite more frequently and for longer duration and the suite was more personalised and contained some furniture.
  • The provider had commissioned a sensory integration assessment.
  • Staff who regularly worked with the patient knew the patient well, treated them with respect, praised and encouraged them.

Inspection carried out on 6 February to 9 February 2017

During a routine inspection

We are placing Cheswold Park Hospital in 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 Cheswold Park Hospital as inadequate because:

  • When we inspected the hospital in August 2015, we found breaches of four regulations and rated it overall as ‘requires improvement’. Although the hospital had made some efforts to improve services, not enough had been done to remedy the breaches and to maintain improvements in the long term. We also found new problems that the hospital needs to put right, which resulted in our lower rating of ‘inadequate’.
  • Staff did not monitor patients’ physical health regularly and effectively and the hospital still did not have an effective system for monitoring patients’ physical health. Staff had not assessed all risks to patients with long-term health conditions and those self-medicating. They had not prepared comprehensive care plans to ensure that they received the right support, care and treatment to meet their physical health needs, enable safe self-medication and keep them safe.
  • Staff did not manage medicines correctly. They did not ensure that all medication was stored appropriately or securely. They did not keep records on stock acquired from other wards and so might not have been able to identify any stock discrepancies. Staff did not always ensure that patients took the medication they were given.
  • Records to ensure that patients were kept safe and to manage and mitigate risks to them did not contain sufficient information or all of the relevant information. Positive behavioural support plans did not contain information to enable staff to de-escalate incidents. Environmental risk assessments did not always identify risks or contain plans to manage or reduce them. One audit of ligature anchor points (places to which patients intent on self-harm could tie something to strangle themselves) was inaccurate and some staff were unaware of ligature risks.
  • Staff did not follow safety procedures. This included observation of patients, checking electrical equipment and contents of first aid boxes. The provider had not ensured that environmental risks of ligature points in communal bathrooms had been reduced or removed and had not improved the ability for staff to see patients in their bedrooms.
  • The hospital imposed a number of blanket restrictions on patients’ freedom when restrictions should be based on individual risk assessments. Staff on Brook and Don Wards restricted shaving times. Some staff and patients on Don Ward told us that punitive measures were used for patients deemed not to conform to behavioural rules. Staff used physical and mechanical restraint to control and restrict a patient that was not always proportionate to the harm or risk of harm posed by the patient. This was not in line with the Mental Health Act and the code of practice.
  • Staff searched all patients on return from section 17 leave (granted to patients detained for treatment).
  • The provider did not ensure that areas of the hospital were clean or well maintained. Areas of the hospital were visibly unclean, with debris on floors and surfaces. Ward kitchens were worn and tired.
  • The Isle Suite used for long-term segregation did not promote recovery, comfort, dignity and confidentiality, and did not meet the requirements of the Mental Health Act code of practice. The suite was not clean and contained debris and stains in all areas. There was no cleaning schedule for the suite and there were no hand washing facilities for staff. The suite did not have any furniture except a mattress. It did not contain the patient’s personal items, except for stickers on the walls and curtains and the patient was unable to make telephone calls in private. The hospital had not sought an external review of the patient’s circumstances and records did not show evidence that staff had informed the local safeguarding team of the commencement of long term segregation. Documentation of some multidisciplinary reviews contained language relating to continuing seclusion; it was not clear on one record whether an approved clinician had completed the review. Records did not show input of any structured programmes of therapy and activity.
  • The care and treatment records for one patient did not show how staff had assessed the patient’s capacity to make decisions not applicable to their detention under the Mental Health Act. The provider’s policy did not clearly explain the rights of the Lasting Power of Attorney or the scope of their role.
  • Staff prescribed medications for mental disorder for some patients that did not match those stated on consent to treatment forms. This was not in accordance with the Mental Health Act and code of practice. Reviews completed by a community pharmacy identified 47 errors in relation to Mental Health Act paperwork and prescribed medicines between July and September 2016.
  • Some patients raised concerns about their experience of using the service. They had concerns about the quality and variety of food provided, did not like the way that staff treated them, and were not happy with their involvement in meetings about their care and treatment. Some carers raised concerns about communication and their involvement in meetings. Over half of patients’ care plans reviewed did not show evidence of patient involvement or reflect the views of patients. Twenty five percent of patient care plans contained vague and ambiguous statements. Observations showed some staff did not maintain professional boundaries with patients. Community meeting minutes for some wards showed mainly information that staff communicated to patients and not the involvement and views of patients.
  • The hospital’s leadership and governance structure was unclear and complex. Governance committee meeting minutes did not provide assurance that actions were completed. The provider’s systems and processes did not ensure that staff carried out their responsibilities. Staff, including senior managers, did not understand the duty of candour. The records of investigations and serious incidents records did not show evidence of the duty of candour being applied. Staff investigating serious incidents did not follow the provider’s policy and investigations completed did not show evidence of lessons learned. The registered person did not submit notifications to the Care Quality Commission of statutory notifiable incidents in five cases and a further two incidents were submitted with delays.
  • Systems and processes were ineffective and did not ensure that the provider had oversight to ensure that staff files were up to date with the required registrations, qualifications, references, and disclosure and barring service checks to ensure they were fit and proper to carry out their roles. Staff did not receive the necessary training to meet the care certificate standards and not all staff received regular supervision and appraisal.
  • The provider had not obtained the required information to meet the requirements for the fit and proper persons for the organisations directors.
  • The paper-based system for patient care and treatment records was cumbersome. This meant that staff could not easily access records when needed.
  • The provider had not updated some of its policies to reflect changes in the organisation.
  • Team meeting minutes did not contain sufficient information to be an accurate record of meetings and the minutes for Don Ward did not promote morale and engagement of staff.
  • The hospital audit programme was not fit for purpose. Staff had not completed actions including re-auditing later, not all audits had action plans and those that had did not all have timescales.
  • Staff did not uphold the privacy and dignity of patients as they administered patients’ medication through a hatch from clinic rooms; other patients and staff could see patients taking their medication.

However:

  • The provider had reduced the number of restraint and seclusion episodes significantly since the introduction of a No Force First approach.
  • The hospital provided a range of psychological therapies. Dedicated trained staff ran a dialectical behavioural therapy based helpline.
  • Patients participated in providing positive behavioural support training to staff.
  • An occupational therapy activity timetable and a dedicated recovery college provided a range of activities and courses.
  • Senior managers in the organisation were visible and accessible to patients and staff. Ward representatives attended weekly meetings to report ward performance to the senior management team.

Inspection carried out on 4 - 6 August 2015

During a routine inspection

We are placing Cheswold Park Hospital in 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 Cheswold Park Hospital as inadequate because:

  • When we inspected the hospital in August 2015, we found breaches of four regulations and rated it overall as ‘requires improvement’. Although the hospital had made some efforts to improve services, not enough had been done to remedy the breaches and to maintain improvements in the long term. We also found new problems that the hospital needs to put right, which resulted in our lower rating of ‘inadequate’.
  • Staff did not monitor patients’ physical health regularly and effectively and the hospital still did not have an effective system for monitoring patients’ physical health. Staff had not assessed all risks to patients with long-term health conditions and those self-medicating. They had not prepared comprehensive care plans to ensure that they received the right support, care and treatment to meet their physical health needs, enable safe self-medication and keep them safe.
  • Staff did not manage medicines correctly. They did not ensure that all medication was stored appropriately or securely. They did not keep records on stock acquired from other wards and so might not have been able to identify any stock discrepancies. Staff did not always ensure that patients took the medication they were given.
  • Records to ensure that patients were kept safe and to manage and mitigate risks to them did not contain sufficient information or all of the relevant information. Positive behavioural support plans did not contain information to enable staff to de-escalate incidents. Environmental risk assessments did not always identify risks or contain plans to manage or reduce them. One audit of ligature anchor points (places to which patients intent on self-harm could tie something to strangle themselves) was inaccurate and some staff were unaware of ligature risks.
  • Staff did not follow safety procedures. This included observation of patients, checking electrical equipment and contents of first aid boxes. The provider had not ensured that environmental risks of ligature points in communal bathrooms had been reduced or removed and had not improved the ability for staff to see patients in their bedrooms.
  • The hospital imposed a number of blanket restrictions on patients’ freedom when restrictions should be based on individual risk assessments. Staff on Brook and Don Wards restricted shaving times. Some staff and patients on Don Ward told us that punitive measures were used for patients deemed not to conform to behavioural rules. Staff used physical and mechanical restraint to control and restrict a patient that was not always proportionate to the harm or risk of harm posed by the patient. This was not in line with the Mental Health Act and the code of practice.
  • Staff searched all patients on return from section 17 leave (granted to patients detained for treatment).
  • The provider did not ensure that areas of the hospital were clean or well maintained. Areas of the hospital were visibly unclean, with debris on floors and surfaces. Ward kitchens were worn and tired.
  • The Isle Suite used for long-term segregation did not promote recovery, comfort, dignity and confidentiality, and did not meet the requirements of the Mental Health Act code of practice. The suite was not clean and contained debris and stains in all areas. There was no cleaning schedule for the suite and there were no hand washing facilities for staff. The suite did not have any furniture except a mattress. It did not contain the patient’s personal items, except for stickers on the walls and curtains and the patient was unable to make telephone calls in private. The hospital had not sought an external review of the patient’s circumstances and records did not show evidence that staff had informed the local safeguarding team of the commencement of long term segregation. Documentation of some multidisciplinary reviews contained language relating to continuing seclusion; it was not clear on one record whether an approved clinician had completed the review. Records did not show input of any structured programmes of therapy and activity.
  • The care and treatment records for one patient did not show how staff had assessed the patient’s capacity to make decisions not applicable to their detention under the Mental Health Act. The provider’s policy did not clearly explain the rights of the Lasting Power of Attorney or the scope of their role.
  • Staff prescribed medications for mental disorder for some patients that did not match those stated on consent to treatment forms. This was not in accordance with the Mental Health Act and code of practice. Reviews completed by a community pharmacy identified 47 errors in relation to Mental Health Act paperwork and prescribed medicines between July and September 2016.
  • Some patients raised concerns about their experience of using the service. They had concerns about the quality and variety of food provided, did not like the way that staff treated them, and were not happy with their involvement in meetings about their care and treatment. Some carers raised concerns about communication and their involvement in meetings. Over half of patients’ care plans reviewed did not show evidence of patient involvement or reflect the views of patients. Twenty five percent of patient care plans contained vague and ambiguous statements. Observations showed some staff did not maintain professional boundaries with patients. Community meeting minutes for some wards showed mainly information that staff communicated to patients and not the involvement and views of patients.
  • The hospital’s leadership and governance structure was unclear and complex. Governance committee meeting minutes did not provide assurance that actions were completed. The provider’s systems and processes did not ensure that staff carried out their responsibilities. Staff, including senior managers, did not understand the duty of candour. The records of investigations and serious incidents records did not show evidence of the duty of candour being applied. Staff investigating serious incidents did not follow the provider’s policy and investigations completed did not show evidence of lessons learned. The registered person did not submit notifications to the Care Quality Commission of statutory notifiable incidents in five cases and a further two incidents were submitted with delays.
  • Systems and processes were ineffective and did not ensure that the provider had oversight to ensure that staff files were up to date with the required registrations, qualifications, references, and disclosure and barring service checks to ensure they were fit and proper to carry out their roles. Staff did not receive the necessary training to meet the care certificate standards and not all staff received regular supervision and appraisal.
  • The provider had not obtained the required information to meet the requirements for the fit and proper persons for the organisations directors.
  • The paper-based system for patient care and treatment records was cumbersome. This meant that staff could not easily access records when needed.
  • The provider had not updated some of its policies to reflect changes in the organisation.
  • Team meeting minutes did not contain sufficient information to be an accurate record of meetings and the minutes for Don Ward did not promote morale and engagement of staff.
  • The hospital audit programme was not fit for purpose. Staff had not completed actions including re-auditing later, not all audits had action plans and those that had did not all have timescales.
  • Staff did not uphold the privacy and dignity of patients as they administered patients’ medication through a hatch from clinic rooms; other patients and staff could see patients taking their medication.

However:

  • The provider had reduced the number of restraint and seclusion episodes significantly since the introduction of a No Force First approach.
  • The hospital provided a range of psychological therapies. Dedicated trained staff ran a dialectical behavioural therapy based helpline.
  • Patients participated in providing positive behavioural support training to staff.
  • An occupational therapy activity timetable and a dedicated recovery college provided a range of activities and courses.
  • Senior managers in the organisation were visible and accessible to patients and staff. Ward representatives attended weekly meetings to report ward performance to the senior management team.

Inspection carried out on 26 March 2014

During an inspection in response to concerns

During this inspection we visited Gill and Hebble wards, which are for patients with learning disabilities. We also visited Foss ward, which is for patients with a diagnosis of mental illness and personality disorder type illness. We spoke with six patients about their experiences of living in the hospital.

We carried out this inspection because concerns were identified to us by a whistle blower, in relation to care and welfare of people who use services, safeguarding people who use services from abuse, staffing and supporting workers.

At this inspection we found that people experienced care, treatment and support that met their needs and protected their rights. Most patients said their named nurses and key workers were helpful and supportive.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Most patients we spoke with told us that they felt safe. One patient said they didn't feel staff cared. However, they acknowledged that staff intervened to keep them and others safe.

There were enough qualified, skilled and experienced staff to meet people’s needs and staff received appropriate professional development and support.

Inspection carried out on 9 January 2014

During an inspection to make sure that the improvements required had been made

We carried out an inspection of Cheswold Park Hospital in October 2013. At that time we found the patients did not always experience treatment and support that met their needs and protected their rights. This was because there were some restrictions and interventions that were imposed on patients that were not based on individual risk assessments. We made a compliance action, which required the provider to make improvements in this area.

We undertook this inspection to review the provider's compliance with the compliance action made at the last inspection. At this inspection we found that improvements had been made and the provider had appropriate arrangements in place to ensure patients experienced treatment and support that met their needs and protected their rights.

Inspection carried out on 24 September 2013

During a routine inspection

We visited Brook and Foss wards, which are for people with mental health issues, Hebble ward, which is for patients with learning disabilities and Calder ward, which is for patients with a diagnosis of personality disorder type illness. We spoke with 12 patients about their experiences of the hospital. Comments included, “There is always plenty to do and staff around to talk to.”

Patients expressed their views and were involved in making decisions about their care and treatment. Patients said there were lots of opportunities for them to make choices and have a say in how their care and treatment was delivered.

There were some restrictions and interventions that were not based on individual risk assessments, such as monthly room searches, so patients did not always experience treatment and support that met their needs and protected their rights.

Patients were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Patients said staff helped to keep them safe.

There were enough qualified, skilled and experienced staff to meet people’s needs.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

Inspection carried out on 13 September 2012

During an inspection to make sure that the improvements required had been made

We visited two wards and we spoke with four patients. The patients we spoke with gave positive feedback about their experiences of the hospital. They praised the staff and said they were treated well.

Inspection carried out on 1 August 2012

During an inspection in response to concerns

We spoke with 17 patients on the eight wards and on one ward we sat in on a patients’ meeting that five patients attended. On five of the eight wards patients gave very positive feedback about their experiences of the hospital. They praised the staff, said they were involved in their care plans and said there were lots of activities. On Esk, Don and Calder wards five of the nine patients we spoke with expressed concern about there being staff vacancies. They said this had led to them missing out on activities. They said they found it unsettling that the agency staff who were used to cover staff vacancies were not familiar with their needs and preferences, particularly at night. One patient said there had been a lack of qualified staff on the wards on a number of occasions in recent months and this had an unsettling effect on the patients.

Inspection carried out on 10 May 2012

During a routine inspection

We visited Gill and, Hebble wards, which are for patients with learning disabilities. We also visited Calder ward, which is for patients with a diagnosis of personality disorder type illness. We spoke with six patients about their experiences of living in the hospital. Comments included, “The staff here are well trained” and “The staff are very pleasant.”

Patients said staff helped to keep them safe. They told us that there were lots of opportunities for them to make choices and have a say in how their care and treatment was delivered. We observed that there were lots of activities for patients; one patient told us there was always something going on.

Inspection carried out on 20 May 2011 and 16 January 2012

During a themed inspection looking at Learning Disability Services

There were 21 in-patients on the medium secure learning disability wards when we visited Cheswold Park Hospital. Gill ward is an assessment unit and there were nine inpatients on the ward. Hebble ward is a rehabilitation unit and there were 12 in-patients on the ward at the time of our inspection.

We met and introduced ourselves to the patients using the service. We spoke with six patients at the hospital from these wards. We spoke to four patients in more depth to get their views of the service.

Overall, patients told us they were satisfied with the care and treatment at the hospital. Patients told us the staff supported them to be involved in devising care plans, person centred plans and they regularly attended review meetings. One patient said, “My (care) plan is kept in the office, but I can have mine when I want it.” And “My named nurse goes through mine all the time.”

Patients told us they were satisfied with the activities and occupational opportunities available to them. They told us, “I have loads to do; I take part in badminton, football and art.” Another patient said, “I take part in activities around the hospital, there are choices and I can do what I want, art, cooking, gym.”

Most patients told us they felt safe at the service and knew who to speak to if they were unhappy with aspects of their care or support. Patients said, “Yeah, I feel safe; they have done wonders for me.” And, “If I don’t feel safe, like my illness is getting worse, I talk to staff if I start to feel unsafe or threatened.”

However, one patient told us they had been `hurt’ during a physical restraint, had made a complaint about this and was dissatisfied with the provider’s response to their complaint.

Inspection carried out on 6 December 2011

During an inspection to make sure that the improvements required had been made

To carry out this follow up inspection we did not seek the views of patients, however, we saw that they benefited from high quality facilities within the hospital. This included a well stocked shop which provided work opportunities for patients, a gym, recreational facilities and newly developed outdoor areas. When we inspected the hospital in September 2011 patients we spoke with told us that staff were “good” to them, although some told us that they were unhappy about being detained in hospital. They told us that when they had planned leave from the hospital this was important to them and they said that on the whole it took place as arranged.

Inspection carried out on 4 September 2011

During an inspection in response to concerns

People we spoke to told us that staff were “good” to them, although some told us that they were unhappy about being detained in hospital. People told us that when they have planned leave from the hospital this is important to them and they said that on the whole it takes place as arranged. Some people told us that they do not feel they have the opportunity to carry out spontaneous activities within the hospital due to them needing staff support to do so.

Inspection carried out on 20 May 2011

During an inspection in response to concerns

When we have visited this hospital prior to this review, patients have been extremely positive about their experience of Cheswold Park Hospital. They told us that they felt involved in decisions about their care and treatment, and that they felt staff gave them the support they needed.

Inspection carried out on 4 April 2011

During a routine inspection

Patients were extremely positive about their experience of Cheswold Park Hospital. They told us that they felt involved in decisions about their care and treatment, and that they felt staff gave them the support they needed. Patients told us that they could participate in decision making about how the hospital, and some patients who had experienced treatment in other hospitals told us that this was the best hospital they had experienced.

Reports under our old system of regulation (including those from before CQC was created)


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.