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St Andrew's Healthcare - Mens Service Requires improvement

Reports


Inspection carried out on 26 to 29 March 2018

During a routine inspection

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 carried out on 9-10 and 16 January 2018

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

We did not rate this service.

We carried out this inspection to check compliance following the warning notice issued after the focused inspection in May 2017.

We found the following areas the provider needs to improve:

  • Seclusion records reviewed did not always include sufficient recording to demonstrate that all of the safeguards under the Mental Health Act code of practice had been met. Medical and nursing staff had not always completed reviews in line with the Mental Health Act Code of Practice. Staff had not always fully completed seclusion documentation.
  • Managers were not supervising staff in line with the providers management supervision policy introduced in November 2017. Data provided by the service as of the 30 November 2017, evidenced a management supervision compliance rate of 20% overall for forensic and rehabilitation wards. Three wards reported compliance rates of 0%.

We found the following areas of good practice:

  • Managers and staff ensured that wards were clean, maintained and well furnished.
  • Staff had completed risk assessments for all patients and full physical health assessments for 95% of patients on admission. Patient records had evidence of ongoing physical health care.
  • The provider had addressed the issue of staff being trained in two types of restraint technique. At the time of our visit, 91% of staff in the men’s service had completed Management of Actual and Potential Aggression training.
  • Staff demonstrated a good understanding of safeguarding practices. The provider reported that 94% of staff had completed level 1 and 2 safeguarding training. Staff were able to describe action they would take if they had safeguarding concerns.
  • Governance and monitoring processes had improved. The service director and clinical director chaired weekly governance meetings with consultants, ward managers, multi-disciplinary leads, modern matron and compliance manager.

Inspection carried out on 15 to 19 May and 1 June 2017

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

We rated St Andrew’s men’s services as inadequate because:

  • The provider had not addressed the issues identified in the June 2016 inspection whereby staff were trained in two types of managing aggression and restraint. It was still the case that staff were trained in two different types of managing aggression and restraint. This posed a risk to staff and patients if staff were following two different approaches. In the May 2017 inspection we identified the following concerns.
  • Some of the wards were not clean or safe. Ferguson ward was dirty and had plaster falling off the walls. This posed an infection control risk. The standards of cleanliness were poor on three wards and the issue had not been identified through the provider’s own monitoring system. In addition, the provider’s ligature audits had not identified how to mitigate risks posed by potential ligature anchor points. This problem was compounded by the fact that staff did not always update the risk assessments of individual patients following an incident.
  • Staffing levels were poor in most clinical areas. Although staff establishment numbers were met at the beginning of a shift, they were not increased when more staff were needed to undertake patient observations or because staff were required to help out on other wards. Staff shortages meant that patient activities and leave were sometimes cancelled. Also, shifts often had one qualified member of nursing staff, especially at night, which meant that staff could not take breaks. Agency nurses employed to make up the shortfall did not all have access to the electronic prescribing system to administer medicines. This meant that a member of staff from another ward had to come to assist.
  • There was a high turnover of staff indicating staff retention as a problem. Turnover was 32% in one forensic ward, 22% in the psychiatric intensive care unit, and 20% on a rehabilitation ward.
  • The standard of record keeping was poor in forensic and rehabilitation services. We identified that retrospective entries had been made in a seclusion record. We brought this to the attention of a manager. Handovers in forensic and rehabilitation services were poor. There was no structure, pieces of paper were used to write on and patients were not discussed in handover until the inspection team pointed this out. Records did not always document discussion around a patient’s capacity. Record entries in the learning disabilities service were sometimes punitive in nature. Records of ongoing physical healthcare monitoring were poor in all but older people’s and learning disabilities services. Risk assessments did not identify all risk factors.
  • The long term segregation policy did not meet the Mental Health Act code of practice in respect of review requirements. For example, the long term segregation policy allowed for the nurse in charge, rather than an approved clinician, to review the patient daily, and allowed for another division of the hospital (rather than an external hospital) to undertake the three monthly reviews. We found that staff were confused about what constituted seclusion and long term segregation. Many staff described patients as being in ‘extra care’ when in fact they were either secluded or in long term segregation.
  • A theme from discussions with all staff groups, including medical, nursing, social workers, and psychology staff, was that admissions were not always clinically led. We were given examples of when a clinician’s decision had been overridden by non clinicians. This posed a risk of inappropriate admissions.
  • From information given to us on inspection, both in groups and individually, we formed the view there was an oppressive culture in these services. Different staff groups, including nursing staff, medical staff, psychologists, and social workers, reported a fear of speaking up in case of reprisals.

However:

  • In older adults there was effective provision of physical healthcare. Staff had received specific training to carry out their role, such as dementia training and end of life care. Staff received regular supervision and appraisals.
  • The provider had taken action to address the shortage of staff. It had run many recruitment fairs in an attempt to attract staff to work at St Andrew’s and staff were being recruited. The Aspire programme enabled healthcare assistants to become qualified nurses with a bursary provided by St Andrew’s Healthcare.
  • There was an emphasis on positive behaviour support planning and a continued move to reduce the use of restraint, including prone restraint. The use of restraint was monitored by the restrictive practice monitoring group which met monthly to review the use of restraint in all services. Data showed a downward trend in the use of restraint, with the provider reporting a reduction in restraint by 32%, and a reduction in the use of prone restraint by 38%. According to the provider, the use of seclusion had decreased by 17%. Staff in learning disabilities completed detailed positive behavioural support plans with patients that included triggers and ways in which staff and patients could reduce negative behaviours.
  • Patients knew how to make a complaint and there were effective systems in place to support managers to investigate complaints and identify an outcome.
  • Staff supported patients with physical health issues. Staff completed annual healthcare assessments with patients and supported access to specialist services, where required.
  • There were weekly manager and matron meetings to review issues, monthly quality and safety meetings which included the managers, clinicians, and compliance manager. There were weekly bed management meetings to review bed numbers.
  • At the time of the inspection, a new leadership team for the service had just been put in place who were actively addressing the concerns within the service. The recently appointed service director had identified and understood the improvements which were required in the men’s pathway. They had introduced a local audit two weeks before the inspection and piloted on one ward. The aim of this was to have more immediate action taken when issues were identified.

Inspection carried out on 7,8,10 February 2017

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

We did not rate this service.

We found:

  • The provider had strengthened the implementation of positive behaviour support (PBS) planning since the last inspection in June 2016.
  • Staff we spoke with were knowledgeable about using least restrictive practices for restraint and positive behaviour support planning, a recommended approach to managing patients challenging behaviour.
  • Staff were caring and keen to do their best for the patients. They were respectful in their approach.
  • Care plans and data supported what staff had told us about the use of restraint as a last resort and only after staff had tried to de-escalate and divert patients who were becoming distressed or agitated.
  • Data provided showed a downward trajectory in the use of restraint and in the use of prone restraint.

We also found:

  • The electronic system was difficult to navigate to find key documents such as positive behaviour support plans. Staff saved some documents on a shared drive rather than in the electronic system. Staff we spoke with knew where to find the information they required, however, information was not consistently in the same place for each record.
  • The behaviour observations sheets used codes for behaviour and it was not always clear which exact behaviour related to which code. This meant staff may not be clear what behaviour was expected in certain situations.
  • Some seclusion records were missing and staff could not find them.
  • Medical staff raised an issue about completing medical reviews for seclusion at night with only one doctor on duty for the site, and a second doctor available until midnight.

Inspection carried out on 13 - 16 June 2016

During a routine inspection

We rated St Andrew’s Healthcare Northampton as requires improvement because:

  • Not all seclusion rooms considered the privacy and dignity of patients. Staff used closed circuit television (CCTV) to monitor patients. However, monitors were visible to staff from the office and to patients on entering or leaving the adjacent low stimulus room. In adolescent services, one seclusion room had a faulty two-way intercom system. Care records confirmed that the room was used regularly and recently. In older adults services the provider did not always reduce the risk from blind spots.

  • In forensic services, the receptionist controlled access to three buildings from one reception area and used CCTV monitors to control access. When reception staff were away from their desk, access to the building was delayed for patients.
  • On Seacole ward there were issues with controlling temperatures on the ward. This was because of the air exchange system sending columns of cold air directly downwards when the ward gets above 28 degrees. The provider told us they were going to fit a safe diffuser over all of the ducts to try to diffuse the cool air over a larger area. On Seacole ward, the furniture in the night lounge was torn and dirty. In the psychiatric intensive care unit (PICU) some bedrooms, bathroom and shower areas were dirty and carpets were not clean. We could detect a strong smell of urine in some bedrooms. The shower areas upstairs did not provide comfort or promote dignity and privacy. There was a shower curtain on some, but not all showers. The door to the room did not lock and patients needing the toilet could enter. We observed staff searching patients in communal areas on two wards. One ward lacked appropriate signage and other relevant information for patients with neuro rehabilitation needs. Staff restricted access to patients wishing to use their bedrooms, and this was not individually risk assessed.
  • There were ligature points in the psychiatric intensive care unit and the provider did not ensure all patients’ risk assessments and care plans included the management of specific environmental ligature risks. There was no recorded evidence of staff and patients having an immediate debrief following an incident. A debrief is an opportunity for staff to reflect on the incident, review what action was taken, any immediate lessons learned and to offer support to patients and staff.
  • The provider had high vacancy rates in forensic, neuropsychiatry, older adults and rehabilitation services. This was particularly high for registered nurses. The provider used bureau (St Andrew’s bank staff) and agency staff to fill vacant shifts. However, a significant number of shifts remained unfilled. Staff told us when shifts were not filled, staff moved between wards to meet patient need or wards worked short of staff. Staffing levels at night were particularly low.
  • In rehabilitation, adolescent and forensic services, staff did not always complete physical healthcare monitoring following administration of rapid tranquilisation or commencement of seclusion. Staff did not always complete physical healthcare monitoring for patients prescribed specific medications and staff did not complete the relevant chart regularly or appropriately. Staff in forensic services did not always document fully what patients had been offered or received. There were gaps in records where staff had not signed the entries. In rehabilitation services, staff did not always respond appropriately to a decline in a patient’s physical health and did not use observation tools to review and assess the response needed.
  • Not all staff had completed training in the Mental Health Act (MHA) or the Mental Capacity Act (MCA). Staff did not receive annual MHA training and the provider could not demonstrate that staff had received training in the revised MHA code of practice. This meant that staff were not working to the most recent guidelines. Staff did not read patients their rights under section 132 of the Mental Health Act in some wards. If patients did not understand their rights, staff did not always make further attempts. On PICU, forensic, rehabilitation and older adult’s wards staff had not uploaded the MHA legal detention papers in full to the electronic system. Some records had part of the paperwork uploaded.
  • In some services staff did not assess patient’s capacity to consent to treatment appropriately. Staff documented patients did not have capacity but did not give a rationale as to why they had made this decision nor document any discussion. Mental capacity assessments were not decision specific. Consultants did not always accurately complete medication consent paperwork (T2 and T3 forms). Staff kept some information in paper format.
  • The provider did not have an effective management supervision structure. Supervision was highlighted as an issue in learning disabilities, older adults and rehabilitation services. Supervisions occurred monthly by peers rather than line managers in some areas. We saw that some staff had different supervisors each month. This meant there was no consistency and managers could not be sure that supervisors were addressing performance issues.
  • Not all groups of staff felt engaged with the developments and changes to the service.

However:

  • There had been improvements since the last inspection. Leadership had been strengthened and new ways of working implemented to improve the patient experience. The provider had improved governance systems and carried out recruitment drives to attract staff. There had been an overall decline in the use of agency staff over the preceding 12 months.
  • Most wards were safe, visibly clean, homely and well furnished. Patients could access garden areas and open spaces. Patients held their own mobile phones wherever possible and had private access to a landline telephone that had direct lines to advocacy and other services. Wards had a range of rooms for care and treatment and rooms for patients to meet visitors in private. Wards had seclusion rooms, low stimulus rooms and extra care suites for patient use. Patients could personalise their bedrooms and had lockable spaces to secure possessions. The provider had procedures for children visiting. Staff provided a range of activities for patients and activities were available seven days a week.
  • On most wards, staff updated patients’ risk assessments regularly and included patients’ individual needs. Staff in forensic services completed regular ligature risk assessments and wards contained very few ligature risks. Staff managed known risks with nursing observations and individual risk assessments. Staff had quick access to ligature cutters and pocket masks (for use in mouth to mouth resuscitation) in different areas of the wards. Staff used positive behavioural support plans with patients effectively.
  • Staff undertook comprehensive assessments and developed care plans that were thorough, holistic and patient centred. With the exception of rehabilitation, adolescent and forensic services, staff monitored the physical health of patients regularly and developed physical health goals and treatment for patients. Staff used outcome measures such as health of the nation outcome scale and specific tools for acquired brain injury patients. Physical healthcare services included dentistry and podiatry. Practice nurses from the GP surgery attended the wards to address patients’ physical healthcare needs. Staff made prompt referrals for any further specialist physical healthcare input.
  • Staff were passionate about their job and knew patients well. Patients told us staff worked hard and were kind to them. Most staff treated patients with dignity and respect and were responsive to patients’ individual needs.
  • We saw leadership at ward manager level. Managers said they felt supported and staff said they felt valued. Senior staff monitored incidents and discussed outcomes in team meetings. Some senior staff gave examples of learning from incidents for their ward. Staff told us morale was increasing following a period of change over the last two years and told us their managers were supportive. Multidisciplinary teams worked effectively across all wards.
  • The provider had ongoing recruitment and retention programmes to attract new staff. Staff received training in safeguarding and made appropriate referrals. There was a range of psychological interventions available for patients which patients were encouraged to attend. Staff trained in British sign language (BSL) were available to patients on Fairbairn ward. The provider had an induction programme for new staff and was supportive of further learning opportunities for all permanent staff. Staff received annual appraisals and most staff received regular supervision. Staff attended regular team meetings and recorded any actions and outcomes from these.
  • In some wards, Mental Health Act 1983 (MHA) paperwork was in order and stored securely. MHA administrators had a thorough scrutiny process. Some staff used the Mental Capacity Act to assess capacity for individual decisions. There were appropriate systems for managing and recording complaints. Patients had access to independent advocacy services. This meant that they were able to receive independent support to help them express their views and assist with any appeal against their detention under the MHA if they so wished.
  • Managers had access to dashboards for their teams, which gave details of staff compliance with mandatory training. Nurse managers reported they received prompts from the provider’s training department when staff’s mandatory training or refreshers were due.
  • The provider managed quality and safety using a variety of tools. There was a dashboard for monitoring ward performance, quality and safety against agreed targets. There was a monthly lessons learnt bulletin for staff. Staff told us they knew the whistleblowing policy and felt they could raise concerns without fear of victimisation. Managers were visible on the wards and staff felt supported by operational managers and clinical nurse leads.
  • The managers told us, and we saw the documents to show, they were offering an ‘Aspire campaign’, which supported healthcare support workers to undertake their nurse training. The provider would pay these staff a bursary to support their training, following which they would return to work at St Andrew’s for a minimum of two further years. The provider had plans to support 20 staff a year in this scheme.

Inspection carried out on 16, 17 January 2014

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

The purpose of the follow up visit was to check whether the provider had made improvements to areas found non-compliant during our last visit in August 2013.

We also looked at seclusion facilities and seclusion records, as concerns had been identified at a Care Quality Commission Mental Health Act seclusion monitoring visit on 22 November 2013.

The inspection team consisted of one CQC compliance inspector and a mental health specialist advisor. We visited Bradlaugh, Ferguson and Fairbairn wards. We spoke with staff, patients and the ward managers.

We found the provider had made improvements to the décor on Bradlaugh ward, although the replacement of the worn chairs on the ward was still outstanding.

We also found that improvements were needed to meet full compliance with the regulations in relation to the use of seclusion.

Inspection carried out on 1, 2 August 2013

During a routine inspection

We visited Cranford, Rose, Grafton and Bradlaugh wards, which provided treatment and support for males with mental health needs, acquired brain injury and learning disability. Within medium and low secure and locked ward environments.

We spoke with 22 people who used the service and asked them about their experience of using the service. Quotes received from people are included throughout the report.

We saw that each ward had a team of staff involved in people's care and treatment, which included psychiatrists, psychologists, nurses, occupational therapists, qualified mental health nurses and health care assistants. This meant that arrangements were in place to ensure people were supported by appropriately qualified and skilled staff.

We saw that St Andrew’s Healthcare had an on-going staff recruitment programme and on the first day of our visit we saw that staff interviews were taking place. The main area of dissatisfaction from the majority of people we spoke with was about restrictions to activities and outings brought about through having limited staff resources on the wards.

We found that people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Inspection carried out on 13 December 2012

During a routine inspection

We visited Harlestone ward which is a low secure ward situated over two floors (Lower Harlestone and Upper Harlestone) and is part of St Andrew’s Healthcare Men’s Service.

We spoke with seven patients and they all expressed satisfaction with the care and treatment they received at the hospital. They told us that the staff treated them with respect. We found that each patient had a daily schedule of therapeutic activities. We saw that records were kept of when patients had engaged in scheduled activities and also when patients had declined to carry out their activity. Patients told us that they had access to escorted leave. One person said sometimes their escorted leave had been cancelled due to staff shortages. The staff confirmed that leave had been cancelled on some occasions, due to staff shortages, but was not a regular occurrence. During our visit we saw that six patients from Upper Harleston ward were out on escorted leave to Milton Keynes shopping centre to do some Christmas shopping.

Patients told us they had opportunities to use the on site gym, but were dissatisfied with the limited space within the secure courtyard facility. An example was given as there not being enough space to run and kick a football.

Inspection carried out on 17 August 2011

During a routine inspection

We visited two wards within the Men’s service: Foster low secure ward that provides forensic treatment for men and Ferguson a low secure ward that provides rehabilitation and recovery. We interviewed seven detained patients and asked questions in relation to their care.

Patients said they had a “good rapport” with staff, and confirmed there were good links with the advocacy service. They said there was good access to the medical team and opportunities to discuss their ongoing care and treatment with the psychologists’ at St Andrew’s Healthcare.

All of the patients we spoke with told us they participated in one to one and group activities. These included using the on site gym and swimming facilities, going on bike rides, playing squash and badminton, and shopping. Some patients spoke of taking part in an allotment and music group. Some people spoke of attending social events held within St Andrew’s grounds and some said that they enjoy their escorted visits into town.

One person said “St Andrew’s has a lot to offer; they are helping me to move on”.

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.