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St Andrew's Healthcare - Mens Service Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 June 2018

We rated Men’s services as requires improvement because:

  • Seclusion practices were not compliant with the Mental Health Act code of practice. Medical and nursing reviews had not taken place as required in 36% of records checked. Staff had not completed seclusion care plans for patients in 70% of records checked.
  • Doctors advised that they were not always able to complete seclusion reviews within the timescales required by the Mental Health Act code of practice. We reviewed data for weekend on call provision, which evidenced that the demands on doctors providing this support exceeded available on call medical staffing.
  • Managers had not identified all environmental risks in patient areas on forensic, learning disabilities and older adult’s wards. We found unidentified ligature risks and blind spots.
  • The provider had not ensured that all risk assessments and care plans were in place and updated consistently in line with changes to patients’ needs or risks.
  • The provider had not ensured that patients’ physical healthcare needs were met in accordance with care plans. There was no out of hours physical healthcare provision on site.
  • Managers had not ensured that all patients requiring observation had appropriate care plans.
  • Staff had not created personal emergency evacuation plans for patients with restricted mobility on the older adult’s wards. Staff had limited access to specialist equipment for moving patients with restricted mobility down stairs in the event of a fire.
  • Staff had not followed safe procedures for the recording of medicines administration on one forensic ward.
  • We found issues with cleanliness and maintenance on the forensic and learning disabilities wards.
  • The provider had not ensured all medical equipment was regularly tested to check it was in working order. On upper Harlestone ward, we found staff had not regularly tested the oximeter and blood pressure machine.
  • The decor and furnishings on Foster ward were poor.
  • There were insufficient numbers of staff to provide safe care, treatment and access to leave and activities on the forensic, older adults and learning disabilities wards.
  • There was a lack of consistent management on Foster and Harlestone wards.
  • The provider had implemented changes to staff roles without fully assessing the impact and had not communicated the changes effectively.

However:

  • Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw that staff were responsive to patient's needs.
  • Staff were open and transparent and would explain to patients and carers when things went wrong.
  • Staff knew what constituted a safeguarding, and could explain the process of reporting and escalation to senior staff. Staff put protection plans in place for patients when required.
  • Staff had access to appropriate alarms and radios to call for help in the event of an emergency.
  • Staff reported incidents in line with policy. Senior staff cascaded information about lessons learnt to staff at ward level.
  • Staff were aware of the provider’s whistleblowing policy and were confident they could raise concerns without fear of reprisals. Staff spoke positively about the support received from managers.
  • Ward managers were able to adjust staffing levels to meet the changing needs of patients requiring high levels of monitoring linked to individual patient risks.
  • Wards had fully equipped clinic rooms with access to resuscitation equipment, which was regularly checked and maintained.
  • Staff had a good knowledge of the Mental Health Act and Mental Capacity Act.
  • Wards had a variety of rooms for patients to use including quiet, therapy, fitness and activity rooms.
  • Staff had good access to training and received the necessary specialist training for their roles.
  • The provider held regular governance meetings to monitor the service. Managers used key performance indicators to monitor their wards performance.
Inspection areas

Safe

Requires improvement

Updated 6 June 2018

We rated safe as requires improvement because:

  • Seclusion practices were not compliant with the Mental Health Act code of practice. Medical and nursing reviews had not taken place as required in 36% of records checked. Staff had not completed seclusion care plans for patients in 70% of records checked.
  • Doctors advised that they were not always able to complete seclusion reviews within the timescales required by the Mental Health Act code of practice. Demand on doctor’s time outstripped supply. They provided additional data relating to weekend on call cover for 30 weekend days from August 2017 to March 2018. In total 368 tasks were provided over 88 hours. Of these 212 (58%) were seclusion tasks which in themselves equated to 88 hours.
  • We identified three blind spots in seclusion facilities on the forensic and learning disability wards. On Naseby ward there was a blind spot between the seclusion and en-suite area. We identified blind spots in the en- suites of both seclusion rooms on Robinson ward.
  • Managers had not identified all environmental risks in patient areas. These included ligature risks in the secret garden shared by Fairbairn and Prichard wards. The extra care suite on Prichard ward had a sharp door fitting on the door to the living area on which patients may harm themselves. On Foster ward staff were unaware of the ligature risk audit. The audit was incomplete and did not include all rooms. On Foster, we found equipment, which displayed stickers with safety testing dates of 2016. There were exposed electrical cables behind the door leading to staff offices. On Foster, handrails to help prevent patients with mobility problems from falling were not in all communal areas of the ward.
  • The provider had not ensured that all risk assessments were in place and updated consistently in line with changes to patients’ needs or risks.
  • Foster ward was based over the first and second floors of the building. Staff had not created personal emergency evacuation plans for patients. The provider had a limited amount of specialist equipment (slide slings but no evacuation chairs) for moving patients with poor mobility down the stairs in the event of a fire. Staff did not have a clear understanding of fire processes and procedures. Access to the ward for people with reduced mobility was via a lift, which was not working during the inspection.
  • On Foster ward, staff used plastic bags to line rubbish bins on the ward. We found a roll of large orange plastic bags on a shelf in the corridor area. Plastic bags were not allowed on the wards as they presented a risk to patient’s safety.
  • Staff were not always following the provider’s policy for observing patients on the forensic and learning disabilities wards.
  • We observed a medication round on a forensic ward using the electronic prescribing system. The registered nurse did not sign for each individual patient following administration of their medication and instead signed the electronic administration record for all patients having completed the round. This meant there was a delay and could have led to errors in the signing for medication that had been given.
  • The provider had not ensured all medical equipment was regularly tested to ensure it was in working order. On upper Harlestone ward, we found staff had not regularly tested the oximeter and blood pressure machine.
  • We identified issues with cleanliness on Prichard, upper Harlestone and Watkins House. The therapeutic kitchen on Prichard ward was dirty with paint flaking from the windowsill, the laminate coating had come off the worktop and there was perishing food in the fridge. Kitchen surfaces, fridges and the freezer on upper Harlestone, and the fridge, toilet and shower at Watkins House were not clean.
  • We identified issues with maintenance on Prichard and Foster wards. The toilet on the bedroom corridor on Prichard ward had a leak under the sink and the laminate floor was stained. On Foster, curtains were hanging off the rail in the main lounge area. Paint was peeling in the dining area. There was a burst pipe in the kitchen that had burst previously. A bucket was placed underneath to catch the water.
  • Foster ward’s décor and furnishings were poor. The ward and one bedroom had an underlying unpleasant smell.
  • The kitchen fridge on each of the rehabilitation wards contained open items of food. Labels were not in place indicating when the food had been opened and when it should have been consumed by.
  • There were insufficient staff to facilitate patients section 17 leave on forensic, learning disabilities and older adult’s wards.
  • We reviewed the provider’s incident database. As of 28 March 2018 there were 360 incidents awaiting review, of which 263 were overdue.
  • Staff turnover on Foster ward, including management positions over the past 12 months was high.

However:

  • Staff observed areas of the ward that were not in direct lines of sight as part of routine ward observations. There were convex mirrors and closed circuit television in areas such as the bedroom corridors where there were blind spots in order to mitigate against incidents.
  • Each ward had a fully equipped clinic room with access to resuscitation equipment.
  • There was clear signage reminding staff to adhere to infection control principles including handwashing.
  • Staff had access to appropriate alarms and radios to call for help in the event of emergency.
  • Staff had a good understanding of the safeguarding reporting process. Staff put protection plans in place as required. There were safe procedures for families and carers including children to visit the hospital.
  • Ward managers were able to adjust the staffing levels to take account of case mix. We saw examples of shifts where staffing had been increased to take account of patients who required increased observation. When bank and agency staff were used, they were primarily sourced through the provider’s bank bureau, agency staff were used as a last resort.
  • Qualified nurses were available in communal areas of the ward at all times.
  • All permanent and bank staff were trained in the management of actual or potential aggression. Staff told us that they used restraint as a last resort.
  • Staff reported incidents appropriately. Lessons learnt from incidents were cascaded to staff. Staff we spoke with said they received a debrief following serious incidents and felt well supported by their manager and the team.
  • Staff were open and transparent and would explain to patients and carers when things went wrong.

Effective

Good

Updated 6 June 2018

We rated effective as good because:

  • All information needed to deliver care was stored electronically and was available to staff when they needed it. There were also paper copies of personal behavioural support plans available in each ward office.
  • The multidisciplinary team included the full range of mental health disciplines to provide care to this patient group and included occupational therapists, psychologists, social workers, nurses, health care assistants, activities coordinators, activity nurses and pharmacists.
  • Staff used recognised rating scales to assess and record severity and outcomes including the Health of the Nation Outcome Scales. Robinson ward was a centre of excellence for the use of the Vona du Toit Model of Creative Ability.
  • Patients accessed psychological therapies in line with the National Institute for Health and Care Excellence guidance; these included cognitive behavioural therapy, dialectical behavioural therapy and sex offender treatment programmes. There was reference made to the National Institute for Health and Care Excellence guidelines for patients with positive behaviour support care plans.
  • Staff we spoke with said they had good access to training for their role and the provider had a programme for training healthcare assistants to become registered nurses.
  • Staff had a good knowledge of the Mental Health Act and the Mental Capacity Act. Where patients were subjected to the Mental Health Act, staff protected their rights. The completion rate for Mental Health Act and Mental Capacity Act training was at 85%. There was a Mental Health Act office on site to help staff deal with any queries.

However:

  • Patient records showed gaps in the recording and management of ongoing physical health problems. We found that staff had not always completed food and fluid balance charts for a patient with diabetes on Prichard ward. On the learning disabilities wards we found a number of gaps in the recording of patients’ baseline observations, an example of a patient with asthma whose peak flow reading had not been recorded in line with the plan of care and a patient who had become hard of hearing who was not referred for an audiology appointment.
  • There was no out of hours physical health care provision on site.
  • Staff had not always ensured patient records were complete or accurate and had not always updated them following incidents. Care plans were not available in an accessible form, for example in pictorial form for those patients who did not want or were not able to understand a lengthy paper document.
  • Staff we spoke with said that there had been a reduction in the number of social workers and occupational therapists available to the forensic and older adult’s service meaning that social workers were now providing support to more than one ward. One occupational therapist covered both Cranford and Foster ward. Patients said they had less access to occupational therapy sessions.
  • Whilst the provider had made considerable progress in delivering supervision, they had not achieved their target of 85% of staff having regular clinical and managerial supervision. Staff on Foster ward had not received regular management supervision due to high rates of management turnover.
  • In the older adults service, the conditions of section 17 leave did not always state if it was being granted as part of a rehabilitation plan or as a routine requirement to enable the patient to access fresh air. Staff did not consistently record when patients declined Section 17 leave.

Caring

Good

Updated 6 June 2018

We rated caring as good because:

  • Staff treated patients with kindness, compassion and respect. We observed interactions between staff and patients during the inspection and saw that staff were responsive to patient's needs, discreet and respectful.

  • Most patients we spoke with told us that they felt safe and that staff took the time to listen to them when they had a problem.

  • Carers we spoke with felt that they were appropriately involved in their relative’s care. One carer praised the service saying their son was the best he has been since being on Prichard ward.

  • The admission process informed patients about their care and orientated them to the wards and the service.

  • Patients were involved in their care and treatment. We saw staff explaining to patients about aspects of their care and treatment. Patients signed care plans, where appropriate, to show their agreement. Patients were actively encouraged to be involved in their ward round and were offered a copy of their care plan. Patients said staff took into account their personal, cultural and social needs especially when planning activities.

  • Patients had access to an independent mental health advocate who regularly visited the wards.

However:

  • We observed one member of staff was rather abrupt with a patient who had requested the remote control to change the channel on the television on Fairbairn ward.

  • Not all patients had the opportunity to go into the weekly multi-disciplinary meeting to discuss their care and treatment on the psychiatric intensive care unit.

Responsive

Requires improvement

Updated 6 June 2018

We rated responsive as requires improvement because:

  • Managers advised that the service was not meeting the needs of five patients on Hawkins ward. Staff told us they had escalated this issue to senior managers.
  • Space was limited on Foster ward. Staff were using rooms for dual purposes, for example, the staff room was also an interview room. There were no designated quiet rooms.
  • We found privacy and dignity issues on Foster ward. Some bedrooms were off a corridor leading to the dining room and toilets/shower rooms. This meant other patients could see into the bedroom if the door was open as they passed along the corridor. The ward telephone was in a communal area. Patients could not make a phone call in a private area.
  • We found issues with outside space on the older adult’s wards. Foster ward was on the first floor and there was no direct access to the garden area. As a result, frail, elderly patients were reliant on staff availability to access fresh air. On Cranford ward, the outside courtyard was stark and bare.
  • On Cranford ward, bed occupancy was 100%, which was above the Royal College of Psychiatrists recommended 85% to ensure quality of care.
  • We found blanket restrictions on the older adult’s wards. Access to food and drinks was restricted to set times. Patients could request snacks and drinks outside of these times, but staff could not always facilitate this if the ward was busy. On Foster ward there was a blanket ban on all patients using paper hand towels. Patients had to use toilet roll to dry their hands.

However:

  • The service did not move patients between wards during their admission unless this was justified in their best interest. When patients were moved or discharged this happened at an appropriate time of day. Patients were discharged back to their home area, whenever possible.
  • We saw that care plans referred to identified section 117 aftercare services for patients who had been subject to section 3 or the equivalent forensic section of the Mental Health Act.
  • Patients told us the food was of good quality. Food choices included halal, kosher and vegetarian meals.
  • There were information leaflets available on treatments, how to make a complaint, the Mental Health Act and patient’s rights, and advocacy in the main hospital reception. Patients had access to appropriate religious and spiritual support, there was a multi-faith room within the hospital and patients were provided with a suitable quiet space on the ward to pray.
  • There were accessible bathrooms and toilet facilities on each ward for patients who required this. There was easy access to interpreters for those for whom English was not their first language. On Fairbairn ward, most staff were competent in British sign language or were undergoing training. There was a 50% mix of hearing impaired and hearing staff in an effort to promote the deaf culture.
  • Staff knew how to handle complaints. Patients told us they were able to raise a complaint or issue in the community meetings, these issues were recorded and highlighted to staff in team handovers and with managers. Feedback was given to the complainant at the community meeting, where appropriate or to the patient on a one to one basis.

Well-led

Requires improvement

Updated 6 June 2018

We rated well-led as requires improvement because:

  • We found a lack of leadership on some wards in the learning disability and older adult’s service. There was a lack of management support on both Harlestone wards. On Foster ward there had been eight managerial changes over the last 24 months. The interim manager at the time of the inspection had only been in post for six weeks, a new manager was starting in June 2018.
  • Staff on the learning disability and forensic wards told us that there was poor visibility of senior management. Forty percent of staff interviewed in the learning disability service told us they did not know who the senior managers in the organisation were and advised they had not seen them on the wards. Staff in the forensic service told us that senior managers rarely visited the wards.
  • Staff did not have access to regular team meetings on Prichard, Mackaness and Harlestone wards.

  • Managers had not ensured that there were sufficient numbers of staff on shift to enable patients to have regular sessions with their care coordinator. On the learning disability wards, 75% of staff interviewed expressed concerns about understaffing.

  • Staff told us morale had been affected by reductions in the multidisciplinary team, extra kitchen duties without replacement staff and the uncertainty of what independent practice units will mean for the service and their roles. Staff had taken on the responsibility of serving meals on the wards but managers had not ensured that staff were clear about their responsibilities and had not ensured staffing levels met demand.
  • We received feedback from staff we spoke with that they had been told not to be negative at transformation meetings. Staff had therefore felt they could not express their views about service developments.
  • Whilst the provider had made considerable progress embedding the importance of regular clinical and managerial supervision, managers had not met the target for supervision.

However:

  • Staff were aware of the provider’s whistleblowing policy and were confident they could raise concerns without fear of reprisals. There was also a ‘safe call helpline’, which staff could use anonymously to express any concerns.
  • The service had governance structures in place. Monthly ward management meetings were held involving staff and patient representatives where learning was shared and there was evidence of this in meeting minutes. The provider used key performance indicators to measure the performance of the team, and monitored these in weekly governance meetings.
  • Staff said they felt supported by the ward managers and in particular, staff from Prichard ward were pleased with the recent appointment of a new ward manager. Staff told us there was a high level of mutual support within the team.
  • Staff described the provider’s vision and values and explained how they implemented these in their care and treatment of patients. An example of this was putting people first and valuing each person as an individual. Team objectives reflected the organisations vision and values.
  • Managers monitored staff compliance with their mandatory training. Compliance rates were 94%.
  • Managers addressed staff performance promptly and effectively. One ward manager gave examples of recent incidents, which had led to disciplinary proceedings for staff.
  • Managers and staff said that there were opportunities both internally and externally for training and development.
Checks on specific services

Child and adolescent mental health wards

Good

Updated 16 September 2016

  • Bayley ward is a medium secure inpatient ward that can accommodate up to 10 children and adolescent males with learning+ disabilities / autistic spectrum disorder.

  • Heygate ward is a medium secure inpatient ward that can accommodate up to 10 children and adolescent males with learning disabilities / autistic spectrum disorder.

  • Fenwick ward is a low secure inpatient ward that can accommodate up to 10 children and adolescents females with neuro-disability / autistic spectrum disorder.

  • Richmond Watson ward is a low secure inpatient ward that can accommodate up to 12 children and adolescent males with complex mental health needs.

  • Church ward is a low secure inpatient ward that can accommodate up to 10 children and adolescent males with neuro-disability / autistic spectrum disorder.

  • Boardman ward is a low secure inpatient ward that can accommodate up to 11 children and adolescent females with complex mental health needs.

  • Heritage ward is a low secure inpatient ward that can accommodate up to 12 children and adolescent females with complex mental health needs.

  • John Clare ward is a low secure inpatient ward that can accommodate up to nine children and adolescent females with complex mental health needs.

Services for people with acquired brain injury

Good

Updated 16 September 2016

  • Rose ward is a medium secure male ward.

  • Tallis, Tavener, Althorp, Berkeley Close (1st floor) are male locked wards.

  • Berkeley Close (ground floor) is a female locked ward.

  • Berkeley Lodge, 37 and 38 Berkeley Close and 19 The Avenue are locked units

  • Walton is for male patients with Huntingdon’s disease.

  • Harper – specialist ward for male and female patients with Huntingdon’s disease.

Wards for people with a learning disability or autism

Requires improvement

Updated 6 June 2018

Hawkins ward

Naseby ward

Mackaness ward

Harlestone ward

Watkins House

Garden Cottage

Forensic inpatient or secure wards

Requires improvement

Updated 6 June 2018

Robinson ward

Fairbairn ward

Prichard ward

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 6 June 2018

Ashby ward

Fenwick ward

Church ward

Wards for older people with mental health problems

Requires improvement

Updated 6 June 2018

Foster ward

Cranford ward

Acute wards for adults of working age and psychiatric intensive care units

Good

Updated 6 June 2018

Heygate ward