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St Andrew's Healthcare - Womens Service Good

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

Inspection Summary


Overall summary & rating

Good

Updated 7 August 2017

We rated St Andrew’s as good because:

  • Care plans were comprehensive and holistic, and contained a full range of patients’ needs. Staff completed patients risk assessments in a timely manner and updated these after incidents.
  • Wards had adequate space for delivering care and treatment of patients, with appropriate seclusion rooms, low stimulus rooms, and extra care suites for patient use. All patient bedrooms had ensuite facilities.
  • Managers ensured that staff had received training in safeguarding and made appropriate referrals.
  • A range of psychological therapies recommended by the national institute for health and care excellence was available for patients.
  • Patients had access to independent mental health advocacy.
  • St. Andrews Hospital had its own physical healthcare team who saw patients on the wards.
  • Staff cared for patients who presented with behaviour that challenged. Managers and staff worked extra shifts to support the wards, which showed resilience and commitment toward delivering patient care.
  • Wards had family friendly visiting rooms along with policies and procedures for children visiting.
  • Staff received regular supervision and had received annual appraisal.
  • Senior staff monitored incidents and discussed outcomes and learning from them in team meetings.
  • There were robust systems in place for reporting and investigating incidents and complaints. 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.

However:

  • Staffing numbers did not meet establishment levels. There were high numbers of vacant posts. Whilst managers booked agency staff to cover vacancies at short notice this resulted in staff who were often unknown and unfamiliar with the wards and the patients. In particular high numbers of registered agency nurses had been booked for night duty, many of whom were male, and not known to the female patients. Agency staff did not have access to all of the systems, adding additional responsibilities onto the permanent staff.
  • The provider had not addressed the issue identified in the June 2016 inspection whereby staff were trained in two types of managing aggression and restraint. Fifty one percent of staff had received Management of Actual and Potential Aggression (MAPA) training and 47% of staff were trained in Prevention and Management of Aggression and Violence (PMAV). The remaining staff (2%) were out of date with training. This posed a risk to staff and patients if staff were following two different approaches.
  • Staff were unclear about the definitions and terminology relating to de-escalation, restraint, seclusion, segregation and extra care. Policies for seclusion, long term segregation and enhanced support were confusing and the long term segregation policy did not meet the Mental Health Act code of practice in respect of review requirements. Staff did not fully complete seclusion records, including physical healthcare monitoring during an episode of seclusion.
  • There was insufficient medical cover for overnight on call and emergencies.
  • Managers and medical staff told us that in recent months they had felt pressurised into accepting patients, who in their clinical opinion, were not suitable. Medical staff told us clinical decisions were made at a senior level without any evidence based rationale or consultation at a clinical level.
  • Feedback from focus groups and information received through CQC also reported a bullying culture in some parts of the organisation. However, the provider does have various avenues through which staff can raise grievances and concerns. There were no formally reported cases of bullying or harassment when we visited the service.
  • Seacole ward had outstanding maintenance issues. The heating was not working properly. We had identified a similar issue in the June 2016 inspection. Staff and patients reported a smell of sewerage in the ensuite bathrooms of some rooms. Sunley ward was not clean, bed linen was stained and smelly, and dirty linen was stored with clean linen.
Inspection areas

Safe

Requires improvement

Updated 7 August 2017

We inspected this key question for forensic services and the learning disabilities service. We also identified some issues in other services that we did not plan to inspect in this key question.

We rated safe as requires improvement because:

  • Staffing numbers did not meet establishment levels. The provider had high staff vacancy rates. The provider used unfamiliar bank and agency staff to fill vacant shifts. Staff told us they were moved between wards to meet patient need, although the provider advised that this was done to cover unforeseen events such as staff sickness or escorts.

  • Nurse managers covered two wards, sometimes leaving nurse clinical leads to run the shifts. Junior staff reported this put more responsibility on to them as they had to step up to carry out nurse clinical lead tasks. Not all agency staff had access to all of the systems, adding additional responsibilities onto the permanent staff.

  • Staffing levels at night were particularly low. There was often only one registered agency nurse on duty, with little or no knowledge of the ward or the patient’s needs.

  • There was insufficient medical cover for overnight on call and emergencies.

  • Staff were trained in different methods to manage violence and aggression. Fifty one percent of staff had received Management of Actual and Potential Aggression (MAPA) training and 47% of staff were trained in Prevention and Management of Aggression and Violence (PMAV). The remaining staff (2%) were out of date with training. Due to low staffing levels managers could not be assured that there were enough trained staff on duty for each ward, or that these staff had enough experience.

  • Staff were unclear about the definitions and terminology relating to de-escalation, restraint, seclusion, segregation and extra care. Policies for seclusion, long term segregation and enhanced support were confusing and the long term segregation policy did not meet the code of practice in respect of review requirements. For example, the long term segregation policy allows for the nurse in charge rather that an approved clinician to review the patient daily and allows for another division of the hospital (rather than an external hospital) to undertake the three monthly reviews. An approved clinician is a mental health professional approved by the Secretary of State to act as an approved clinician for the purposes of the Mental Health Act.Terminology was used interchangeably throughout the policies. Many staff described patients as being in ‘extra care’ when in fact they were either secluded or in long term segregation.

  • Staff did not fully complete seclusion records, including physical healthcare monitoring during an episode of seclusion.

  • Seclusion records were difficult to follow. We could not identify the official start time of one seclusion episode and the end time was not completed. We reviewed a mixture of documents for seclusions in patient records, and could not locate some medical reviews for patients during seclusion.

  • Seacole ward heating was not working properly. We found some areas of the ward were uncomfortably cold. Patients complained of sewage and smells coming from the waste pipe in some of the ensuite bathrooms. Staff had not cleaned the seclusion room after use the previous evening and the toilet was damaged.

  • Sunley ward was not clean and the bedlinen was stained and smelly. Clean linen had been stored with dirty linen.

  • On Seacole ward, managers had identified the door handles on the locked laundry cupboards as ligature risks, but two patients had unsupervised access to this room. 

  • We could not be sure that rapid tranquilisation was being used in accordance with national institute of health and care excellence guidance because records were incomplete.

  • The area at Springhill House used daily by all patients did not provide adequate seating or dining space.

However:

  • Managers had mitigated identified ligature points by using nursing observations and individual risk assessments. Staff had quick access to ligature cutters and pocket masks in different areas of the ward. Staff completed environmental risk assessments daily and kept accurate records.

  • During our inspection, we were given information about which patients on the ward may be distressed to see us. Staff and managers were clear on how we should respond to patients in this situation. This demonstrated safe management for patients, visitors and staff and effective management of de-escalation.

  • Staff completed the Short Dynamic Risk Scale (SDRS), which allowed staff to assess risks for patients with learning disabilities. Risk assessments were reviewed at the patient’s monthly multidisciplinary team meetings.

  • The provider had ongoing recruitment and retention programmes to attract new staff, and was supporting healthcare assistants to undertake nurse training.

  • Staff completed patients risk assessments in a timely manner and updated these after incidents.

  • Staff received training in safeguarding and made appropriate referrals.

  • The provider had good medicines management processes and medication was stored and administered correctly.

  • The provider had family friendly visiting rooms along with policies and procedures for children visiting.

Effective

Good

Updated 7 August 2017

We inspected this key question for all services.

We rated effective as good because:

  • Care plans were comprehensive and holistic, and contained a full range of patients’ needs. Care records included positive behaviour support plans and my shared pathway. There was evidence in the care records that physical assessments had taken place at the time of admission and periodically thereafter.
  • A range of psychological therapies recommended by the national institute for health and care excellence was available for patients. A psychology team, with learning disabilities expertise worked with patients’ education and social needs. Interventions were adapted based on comprehensive assessments to meet the needs of the patient group.
  • Staff involved individual patients in reviewing their good behaviours. They would identify patterns and score these behaviours, helping patients to build awareness of when good behaviours occur.
  • Staff used recognised rating scales, for example health of the nation outcome scores and discussed these in multidisciplinary meetings.
  • The multidisciplinary team worked well together for benefit of patients.
  • Staff received regular supervision and had received annual appraisal.
  • Patients had access to independent mental health advocacy.

However:

  • There was not always sufficient numbers of skilled and experienced staff on duty to meet the complex and often specialised needs of patients. Managers and medical staff told us that in recent months they had felt pressurised into accepting patients, which in their clinical opinion were not suitable for the ward environment or accepted establishment of nursing staff.
  • Not all Mental Health Act paperwork had been scanned to the electronic record and not all patients had been given copies of their section 17 leave plans. We could not locate a clear contingency or crisis plan for staff to follow during a patients leave on the learning disability wards.
  • Handover records were not always kept in a clear location for staff to review. Staff said they did not always record what is said when a handover took place and they were compromised when shifts were short staffed. Records did not show regular effective handovers took place or included handovers for external teams.

Caring

Good

Updated 7 August 2017

Following our inspection in June 2016, we rated the services as good for caring. Since that inspection we have received no information that would cause us to re-inspect this key question or change the ratings for forensic and rehabilitation wards.

We only inspected this key question in learning disabilities.

We rated caring as good because:

  • Across both learning disability wards, we observed different disciplines of staff to be caring, and engaging with patients. Staff were caring and respectful in their approach to patients and showed an understanding of individual need.
  • Patients were involved in their care planning unless they had declined. Care plans evidenced that patient preferences had been included and were individualised. Care plans were available in easy read format.
  • Patients were positive about the psychology team and the group work on offer. One patient explained some of the mindfulness skills they had put into practice and another said they were pleased they had learnt skills.
  • Both learning disability wards had some challenging patients, managers and staff worked extra shifts to support the wards, which showed resilience and commitment toward delivering patient care.

However:

  • Four patients on the learning disability wards said staff could be snappy when they are under pressure and some staff were rude.

Responsive

Good

Updated 7 August 2017

Following our inspection in June 2016, we rated the services as good for responsive. Since that inspection we have received no information that would cause us to re-inspect this key question or change the ratings for forensic and rehabilitation wards.

We only inspected this key question in learning disabilities.

We rated responsive as good because:

  • The provider had investigated complaints and learnt lessons from them and had apologised when required in line with the Duty of candour.
  • There was a full range of rooms available within the hospital. Patients from both learning disabilities wards could attend the gym, art room and separate kitchen if they wished to engage in activities and learn to cook.
  • Spencer North ward had a separate lounge where patients could watch a film or TV. There was a dedicated visitors’ room off the wards.
  • There was a chaplaincy service and access to spiritual leaders for other faiths.

  • Sitwell had a patient admission that was unsuitable for that mental health ward. However, we were advised that a more suitable placement was being sought and that Sitwell was the best place for the patient whilst this was being arranged.

Well-led

Good

Updated 7 August 2017

We inspected this key question for all services.

We rated well-led as good because:

  • Nurse managers told us their line managers and service directors were supportive.
  • Staff said although morale was low, they felt they got on well as a team and supported each other when needed. Staff liked working with each other and with the management team on their ward.
  • There were robust systems in place for reporting and investigating incidents and complaints. Managers fed back the outcomes and findings from these investigations to staff through team meetings and communication. Staff learned from incidents, complaints and service user feedback.
  • Multidisciplinary teams worked well together across all wards, for the benefit of patients.
  • All staff we spoke with were aware of their duty to be open and honest with patients when things went wrong. We saw examples where staff had explained to patients when something had gone wrong.
  • Managers ensured that staff had access to regular clinical supervision and yearly appraisals.
  • The provider used key performance indicators and other indicators to gauge the performance of the team. The measures were in an accessible format and used by the staff team who developed action plans when there were issues.
  • Staff told us that there were opportunities available for developing leadership skills within St Andrews Healthcare.

However:

  • During the last comprehensive inspection in July 2016, some staff said senior management do not attend the wards and they were unfamiliar with who the senior team were. During this inspection, some staff still did not know who some of the hospitals most senior managers were, and felt they were not visible on the wards. Other staff told us they no longer knew who the most senior managers were as there had been so many recent changes at that level.
  • Nurse managers for all wards were responsible for two wards each. This meant clinical nurse leads had to act up in their absence putting additional pressure on less experienced and unqualified staff. Sitwell ward did not have a manager in post.
  • Managers had not ensured that all mandatory training compliance rates were above 75%. Managers did not ensure they had the right levels of suitably trained staff on the wards to meet the individual needs of the patients.
  • Staff we spoke with were unclear as to why some new procedures and paperwork had been introduced and how to implement them.
  • Staff told us clinical decisions were made by managers at a senior level without any evidence-based rationale or consultation at a clinical level.
  • Staff morale was not good on most wards, while most staff said they felt supported by their colleagues they felt they spent most time managing challenging behaviour rather than supporting patients in their recovery.
  • Managers had not ensured that all restrictions in place were justified, regularly reviewed or based on individual patient needs.
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.

Wards for people with learning disabilities or autism

Requires improvement

Updated 10 February 2015

  • The information about the complaints process was not clearly displayed on the wards in formats people can understand.
  • Agency and bank staff did not always have adequate information about individual patient care.
  • Seclusion facilities were being used for de-escalation and time out.
  • Not all of the staff could demonstrate an understanding about appropriate use of the seclusion facilities.
  • The CQC have not been sent notifications relating to incidents affecting service or the people who use it, in line with requirements.
  • Not all wards had resuscitation equipment. There were a number of locked doors, stairs and potentially an unpredictable patient group, which may impact how quickly the equipment arrived where it was needed. The provider must ensure that lifesaving equipment is available without delay.

Forensic inpatient or secure wards

Requires improvement

Updated 10 February 2015

  • Patient’s views were not always documented in care plans
  • On Fairbairn ward there were not always staff available who were trained in British Sign Language.
  • Patient reviews of restraint and seclusion were not always being undertaken and documented fully
  • Not all of patients are assisted to understand their rights
  • Not all medication administration is accurately recorded.
  • All paperwork was of high standard including that for the Mental Health Act.
  • Reviews of care within the multi-disciplinary team were thorough and capacity was assessed regularly.
  • Within in the Women’s service, the documentation of restraint and seclusion was detailed with timings and we saw learning from incidents had occurred

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.

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

Good

Updated 10 February 2015

  • We observed and staff reported good and supportive multi-disciplinary team working.
  • Additional systems were in place to review enhanced support and seclusion/segregation, such as arranging for doctors across wards to give a second opinion/ independent review on the management of these incidents.
  • Robust systems were in place for the management and auditing of medicines.
  • We found that the monthly patient safety and experience group held at St Andrew’s Healthcare Essex was an effective forum for managing and learning from patient safety incidents that took place in the hospital.
  • We identified good examples of the provider supporting staff to attend additional training to prepare them to care for people with specific mental healthcare needs.

Wards for people with a learning disability or autism

Good

Updated 7 August 2017

  • Spencer North is a low secure ward.
  • Sitwell is a medium secure ward.

Forensic inpatient or secure wards

Good

Updated 7 August 2017

  • Seacole is a medium secure ward.
  • Stowe is a medium secure ward.
  • Sunley is a medium secure ward.
  • Elgar is a low secure ward.
  • Spencer South is a low secure ward.
  • Sinclair is a low secure ward.

Long stay or rehabilitation mental health wards for working age adults

Good

Updated 7 August 2017

  • Thornton is a locked rehabilitation ward.
  • Hereward Wake is a locked rehabilitation ward.
  • Spring Hill is a locked rehabilitation ward.

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 older people with mental health problems

Good

Updated 16 September 2016

  • O’Connell ward is a locked ward for male older adults.

  • Compton is a locked ward for male and female older adult patients.

  • Foster is a locked ward for male older adults.

  • Cranford is a medium secure ward for male older adult patients.

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

Requires improvement

Updated 16 September 2016

  • Sherwood ward is the psychiatric intensive care unit.