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St Andrew's Healthcare - Mens Service Requires improvement

We are carrying out a review of quality at St Andrew's Healthcare - Mens Service. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 November 2021

Our rating of this location stayed the same. We rated it as requires improvement because:

Following our inspection we took urgent action because of immediate concerns we had about the safety of patients on the learning disability and autism wards. Conditions were placed on the provider's registration that included the following requirements; that the provider must not admit any new patients without permission from the CQC; that wards must be staffed with the required numbers of suitably skilled staff to meet patients’ needs; that staff undertaking patient observations must do so in line with the provider’s policy; that staff must receive required training for their role and that audits of incident reporting are completed. The provider is required to provide CQC with an update relating to these issues on a fortnightly basis.

Whilst the CQC acknowledge the impact of the COVID-19 pandemic on staffing across the health and social care sector, we had identified staffing issues at this location at our previous inspection. Our assessment process for rating services requires previous breaches to be considered.

  • Senior managers and staff on the learning disability and autism wards did not always treat patients with compassion and kindness and did not always support, inform and involve families or carers. Staff at the learning disability and autism wards were unable to define a closed culture or describe how they ensured patients were protected from the risks associated with a closed culture developing. Staff on the learning disability wards and forensic wards did not always treat patients in seclusion with dignity and respect.
  • The psychiatric intensive care ward, forensic wards and learning disability and autism wards did not always have enough nursing and support staff to keep patients safe and the wards were regularly short staffed. Patients regularly had their escorted leave, therapies or activities cancelled or cut short because of staff shortages.
  • Staff did not manage risks to patients and themselves well. Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk harm to themselves or others. This happened on the psychiatric intensive care ward, forensic wards and learning disability and autism wards. Staff did not always know what incidents to report and how to report them at the forensic wards, long stay rehabilitation wards and learning disability and autism wards. Staff were not always updating patient risk assessments and care plans at the forensic wards, long stay rehabilitation wards and learning disability and autism wards. Staff did not always ensure patients’ physical healthcare needs were met at the forensic wards and learning disability and autism wards. Staff were not always following systems and processes when administering, recording and storing medicines on the learning disability and autism wards. Not all ward areas at the long stay rehabilitation service and learning disability and autism service were safe, clean and well maintained.
  • Seclusion rooms did not meet all the guidance in the Mental Health Act Code of Practice on the forensic wards, long stay rehabilitation wards and learning disability and autism wards. When a patient was placed in seclusion, staff did not always follow best practice guidelines on the forensic wards and learning disability and autism wards. When a patient was placed in long term segregation, staff on the forensic wards and learning disability and autism wards did not always follow best practice guidelines in the Mental Health Act Code of Practice.
  • Managers did not ensure all staff had the right skills, qualifications and experience to meet the needs of the patients in their care on the forensic wards and learning disability and autism wards. Staff did not always provide a range of care and treatment suitable for the patients in the long stay rehabilitation wards and learning disability and autism wards. The service had not fully responded to the needs of patients with autism at the learning disability and autism service.
  • Leadership and governance arrangements across all core services had not addressed previous issues or ensured concerns were identified and acted on. The provider’s data was not always accurate. Not all leaders had a good understanding of the services they managed. Not all staff felt respected, supported and valued by senior managers. Not all staff felt they could raise concerns without fear of retribution from senior managers. Senior managers are managers above ward manager level.

However:

  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff liaised well with services that would provide aftercare and were assertive in managing care pathways for patients who were making the transition to another service. As a result, discharge was rarely delayed for other than clinical reasons.
  • The provider had a care awards initiative to celebrate success and improve the quality of care across services. Staff engaged in local and national quality improvement activities. The provider reported involvement in various research projects.
Inspection areas

Safe

Inadequate

Updated 10 November 2021

Effective

Requires improvement

Updated 10 November 2021

Caring

Requires improvement

Updated 10 November 2021

Responsive

Requires improvement

Updated 10 November 2021

Well-led

Requires improvement

Updated 10 November 2021

Checks on specific services

Child and adolescent mental health wards

Requires improvement

Updated 10 February 2015

  • There was a need to assess and treat patients based on individual risk and identified needs, rather than placing emphasis on generic, restrictive risk management processes.
  • Agency and bank staff did not have adequate information about individual patient care and any safeguarding protection plans on the wards where they are working.
  • The complaints process was not always clearly displayed on the wards in formats people can understand.
  • Feedback from the outcome of complaints was not shared with the complainant on all occasions. 
  • Seclusion facilities were being used for de-escalation and time out.

Services for older people

Good

Updated 10 February 2015

  • People’s individual needs were assessed and detailed care plans formulated to meet these. Care provision was reviewed by the multi-disciplinary team on a weekly basis.
  • Communication between staff was clear and complete including learning from incidents both within the service and from the wider organisation.
  • Mental Health Act paperwork and consent to treatment documentation was accurate and the proper procedures had been followed in all records we reviewed.
  • Patients had undergone initial capacity assessments which were reviewed regularly including assessments for specific tasks relating to their care.
  • The Deprivation of Liberties Safeguards process had been followed correctly for those patients to whom it related.
  • Practice incorporated latest research and evidenced-based guidance to ensure the most effective care was being provided.

Other specialist services

Good

Updated 10 February 2015

Neuropsychiatry

  • Strong multidisciplinary work on the wards which promoted holistic assessment and treatment of people’s needs.
  • Use of specifically developed outcome measures for people with brain injuries which informed the treatment plans and therapies used in the service.
  • Introduction of technologies on the ward such as tablet computers to improve the patient and staff experience.
  • A strong model for future plans of the service meant that at a strategic level it was clear where the development would lie
  • There were strong internal governance systems within the neuropsychiatry service which meant that managers within the service had a good understanding of the challenges and strengths within the service they were responsible for.
  • People on Tallis ward had been encouraged to write advanced statements and plan their future care should they lose capacity to make decisions regarding their care in the future.

Wards for people with a learning disability or autism

Inadequate

Updated 10 November 2021

Our rating of this service went down. We rated it as inadequate because:

  • Senior managers and staff did not always treat patients with compassion and kindness. Staff did not always support, inform and involve families or carers. Staff were unable to define a closed culture. Staff kept a patient in seclusion for longer than required.
  • The service did not have enough nursing and support staff to keep patients safe and the wards were regularly short staffed. Patients regularly had their escorted leave, therapies or activities cancelled or cut short because of staff shortages.
  • Staff did not manage risks to patients and themselves well. Staff did not always follow the provider’s policy and procedures on the use of enhanced support when observing patients assessed as being at higher risk harm to themselves or others. Staff did not always act to prevent or reduce risks despite knowing any risks for each patient. Staff did not always know what incidents to report and how to report them. Staff were not always updating patient risk assessments and care plans. Staff did not always ensure patients’ physical healthcare needs were met. Staff were not always following systems and processes when administering, recording and storing medicines. Not all ward areas were safe, clean and well maintained.
  • Seclusion rooms did not meet all of the guidance in the Mental Health Act Code of Practice. When a patient was placed in seclusion, staff did not always follow best practice guidelines. When a patient was placed in long term segregation, staff did not always follow best practice guidelines in the Mental Health Act Code of Practice.
  • Managers did not ensure all staff had the right skills, qualifications and experience to meet the needs of the patients in their care. Staff did not always provide a range of care and treatment suitable for the patients in the service.
  • The service had not fully responded to the needs of patients with autism in the ward environment. The design, layout, and furnishings of the ward did not always support patients’ treatment. Senior managers and staff were sometimes dismissive of complaints from patients with autism. Not all patients could make hot drinks and snacks at any time.
  • Leadership and governance arrangements had not addressed previous issues or ensured concerns were identified and acted on. The provider’s data was not always accurate. Leaders did not always have a good understanding of the services they managed. Not all staff felt respected, supported and valued by senior managers. Not all staff felt they could raise any concerns without fear of retribution from senior managers. Senior managers are managers above ward manager level.

However:

  • The provider evidenced sharing of national safety alerts and action taken to ensure wards acted as required.
  • Staff completed comprehensive mental health and physical health assessments of each patient either on admission or soon after.
  • Staff received and kept up-to-date with training on the Mental Health Act and Mental Capacity Act.
  • We observed staff treating patients with respect, kindness and dignity and responding to their needs during the site visit.
  • Staff engaged in local and national quality improvement activities. The provider reported involvement in various research projects

We rated this service as inadequate because it was not safe, effective, caring, responsive or well led.

Forensic inpatient or secure wards

Requires improvement

Updated 10 November 2021

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Staff had not recognised or reported one safeguarding incident and we were not assured staff knew when to escalate incidents such as financial issues.
  • Only 54% of registered nurses completed immediate life support training. This posed a risk to patients who require immediate medical attention. Across the service five out twelve nurse call alarms were either not working or damaged.
  • Staff were not always completing patient’s observation records accurately. CQC reported on this at our earlier inspection. Staff did not always receive breaks between observing patients.
  • Five of eighteen care plans we reviewed were incomplete and staff had not followed up on the progress notes. Staff had not followed physical healthcare plans of two patients. We found similar issues at our inspection in March 2018. None of the care plans had clearly recorded consent to treatment.
  • Seclusion rooms on all wards met most but not all guidance in the Mental Health Act Code of Practice. There was no exit plan for a patient in long term segregation on one of the wards. Staff did not always keep clear records or follow best practice guidelines when patients were in long term segregation or seclusion. We reported on similar issues at our inspection in March 2018.
  • Staff did not always protect the privacy and dignity of a patient in prolonged seclusion.
  • Processes for recording staff supervision were not robust. We reported on similar issues at our earlier inspection.
  • The service did not have enough nursing or support staff to keep patients safe and ensure all patients care needs were met all the time. CQC reported on this at our inspection in March 2018.
  • Senior leaders were not always visible on the wards. Two managers told us they did not feel supported by senior leaders on matters such as staffing levels and recording supervision. These managers told us they felt senior managers did not fully appreciate the pressures faced by staff on the wards and their focus was on different priorities for the service.
  • Governance systems and processes were not always robust. We were not assured managers would recognise and identify all potential risk issues.

However:

  • All wards were clean, well equipped, well furnished, well maintained and fit for purpose. Cleaning records were complete and up to date.
  • Clinic rooms were fully equipped, with accessible resuscitation equipment and emergency drugs that staff checked regularly. Staff checked, maintained, and cleaned equipment.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medicines on each patient’s mental and physical health.
  • Staff involved patients in care planning and risk assessment. They ensured that patients had easy access to independent advocates. Staff informed and involved families and carers appropriately.
  • Staff planned and managed discharge well. They liaised well with services that would provide aftercare and were assertive in managing care pathways for patients who were making the transition to another inpatient service or to prison. As a result, discharge was rarely delayed for other than clinical reasons.

We rated this service as requires improvement because it was not safe, effective, caring or well led.

Long stay or rehabilitation mental health wards for working age adults

Requires improvement

Updated 10 November 2021

Our rating of this location went down. We rated it as requires improvement because:

  • Staff had not completed discharge plans for all patients. Patients were not always aware of their specific goals for discharge.
  • Clinic rooms were not adequately equipped to meet patient need. Two of the three wards did not have access to emergency resuscitation equipment on the ward. All three wards did not have oxygen signs on the clinic room door.
  • Staff had not labelled all opened food items in the fridge, which was identified as an action from the last inspection in March 2018.
  • Staff did not always report safety or safeguarding incidents. These incidents had not been reviewed effectively and patient care needs had not been updated.
  • The providers compliance with safeguarding level three training on two of the three wards was low at 60% and 63%.
  • Managers allocated therapy staff to frontline shift work due to staffing shortages which impacted on the delivery of therapies to patients.
  • Patients leave was affected by and planned around staffing levels and not around patient choice. We found therapy sessions had been cut short or cancelled due to staffing levels.
  • The seclusion rooms consisted of blind spots that the staff were not aware of increasing the risk of patients harming themselves without staff knowing when using the facilities. We found blind spots in the garden that the staff were not aware of.
  • Staff did not always learn lessons from incidents and follow processes put into place after incidents.

However:

  • Staff monitored and supported patients' physical health.
  • Staff treated patients with compassion and kindness. They respected patients’ privacy and dignity. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition.
  • All ward teams included or had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

We rated this service as requires improvement because it was not safe, effective or well led.

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

Requires improvement

Updated 10 November 2021

Our rating of this service went down. We rated it as requires improvement because:

  • The ward was regularly short staffed because managers moved staff to other wards to cover shortfalls.
  • Staff undertook patient observations for long periods of time without a break. This impacted on staff well-being, morale and patient care. Observations were not completed in line with policy and guidelines by the National Institute for Health and Care Excellence.
  • We were not assured staff knew the individual risks for patients which meant they might not be able to identify a deterioration in patients mental health, which may put staff and patients at risk.
  • The manager did not share lessons learned with the whole team when things went wrong. Improvements were not always identified or shared within the team.
  • The leadership, governance and culture for the ward did not always support the delivery of high-quality person-centred care. Staff did not always raise concerns as they felt they were not always taken seriously, appropriately supported, or treated with respect when they did.
  • Not all leaders had the necessary experience, knowledge, capacity, capability or integrity to lead effectively.
  • Staff did not understand how their role contributed to achieving the service strategy.
  • Staff did not always feel respected, supported or valued.

However:

  • The ward environments were clean. Staff minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by comprehensive patient assessments. The ward had access to the full range of specialists required to meet the needs of patients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity. Patients’ comments were overwhelmingly positive. A patient told us the staff aided their management of anxiety and reduced incidents.
  • Staff planned and managed discharge well and liaised well with services that would provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The provider had a care awards initiative to celebrate success and improve the quality of care across services.

We rated this service as requires improvement because it was not safe or well led.

Wards for older people with mental health problems

Requires improvement

Updated 20 September 2019

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.